The distinguishing traits of CLI: what makes it so different? Roberto Ferraresi Cardiovascular CathLab

Transcription

1 The distinguishing traits of CLI: what makes it so different? Roberto Ferraresi Cardiovascular CathLab

2 Potential conflicts of interest Roberto Ferraresi, MD I have the following potential conflicts of interest to report: consulting, travel reimbursement, teaching courses, training: 1. Abbott 2. Ev3 3. Medtronic/Invatec 4. Biotronik No conflict with this lecture

3 Coronary Artery Disease Critical Limb Ischemia

4 Length of the treatable vessels cm cm cm (X 2)

5 Disease distribution Heart My last 1000 CORO vs 1000 ANGIO CLI FemPop - 70 % LM or TPT 7 % 39 % 1 vessel 35 % 10 % 2 vessel 31 % 20 % 3 vessel 34 % 70 %

6 Atheromatous disease pattern

7 62 % of the diabetic patients with CLI have a previus history of coronary artery disease

8 Coronary Artery Disease Vessel length is limited and one single plaque of atherosclerosis can have a precocious and dangerous clinical manifestation Critical Limb Ischemia CLI is the clinical expression of a diffuse multivessel disease, generally more late and advanced than what we found in ischemic coronary disease

9 Coronary Artery Disease Critical Limb Ischemia

10 Acute coronary syndromes UA, NSTEMI, STEMI An unstable plaque problem leading to stunned myocardium, necrosis & death

11 Critical limb ischemia Is tissue necrosis a foot infarct syndrome, an unstable plaque problem like ACS? Pathophysiology: CLI ACS? à NO!!! =?

12 Pathophysiology: CLI ACS In diabetic pts the onset of CLI is often a mechanical trauma due to sensory neuropathy, not a pure ischemic event No pain = no problem

13 Pathophysiology: CLI ACS In diabetic pts the onset of CLI is often a mechanical trauma due to sensory neuropathy, not a pure ischemic event Infection is the main cause of amputation in ischemic diabetic foot: abscess, phlegmon, necrotizing fasciitis, osteomyelitis. Infection means: increased tissue O2 consumption reduced O2 extraction due to tissue/ perfusion mismatch (arteriolar microthrombosis & A-V shunts)

14 Pathophysiology: CLI ACS 1. Chronic subcritical ischemia: a low blood flow is sufficient to keep the limb asymptomatic 2. Tissue lesion and infection: healing needs a high blood flow because healing is a blood flow dependent phenomenon In animal models femoral artery blood flow increases 3-7 times in infected limbs

15 Coronary Artery Disease Arterial disease alone is sufficient to develop symptomatic disease Critical Limb Ischemia CLI in diabetics is expression of a complex interaction between PAD, infection, microrcirculation and tissue metabolism

16 Coronary Artery Disease Critical Limb Ischemia

17 Time is muscle About 35 years ago, Eugene Braunwald, postulated a revolutionary hypothesis: time is muscle. He proposed that acute MI is a dynamic process and that its clinical outcome is determined largely by infarct size.

18 Time is brain In 1996, stroke treatment changed dramatically when the FDA approved the use of a new drug called tissue plasminogen activator, or tpa, to treat stroke

19 Time is muscle Time is brain We make the diagnosis of heart and brain ischemia quickly clearly knowing that time is a key point for treatment

20 Time is not foot These feet have an history of weeks/months of ulcer, infection, pain, inability to walk, misdiagnosis In the majority of the cases they arrive to our foot clinic without a diagnosis of CLI

21 Time is not foot These feet have an history of weeks/months of ulcer, infection, pain, inability to walk, misdiagnosis Today this is our goal!

22 Time is foot!!! Can we postulate that early ricognization and treatment could avoid major and minor amputations in diabetics CLI??? Can we hope that if time is foot this could be our new target?

23 Coronary Artery Disease Fast, sure & operative Critical Limb Ischemia Late, uncertain & passive

24 Coronary Artery Disease Critical Limb Ischemia

25 CLI treatment protocol (Rutherford 5-6) INFECTION TREATMENT RIVASCULARIZATION FINAL TREATMENT PTA/Bypass are not the first line therapy in Texas C wounds (infection+ischemia)

26 CLI treatment protocol (Rutherford 5-6) 1 INFECTION TREATMENT ULCER DEBRIDEMENT & URGENT SURGERY (GANGRENE/ABSCESS/ PHLEGMON) METABOLIC & CARDIOLOGIC TREATMENT PRE-MEDICATIONS The goal of emergency surgery in infected ischemic diabetic foot is the control of local and systemic infection. Surgery has to be performed as soon as possible: any delay in treating an acute lesion will reduce the possibility to save the limb. PVD doesn t modify the timing of emergent surgery in infective ischemic foot Faglia et Al. J Foot Ankle Surg. 2006;45(4):220-6.

27 CLI treatment protocol (Rutherford 5-6) Timing of treatment Heart Brain Foot (Texas C) 1 Rivascularization 2 Other therapies 1 Other therapies 2 Revascularization

28 CLI treatment protocol (Rutherford 5-6) INFECTION TREATMENT RIVASCULARIZATION FINAL TREATMENT PTA/Bypass are not sufficient to gain healing!!!

29 CLI treatment protocol (Rutherford 5-6) Revascularization alone Heart Brain Foot success failure

30 CLI treatment protocol (Rutherford 5-6) An aggressive surgical treatment (VAC therapy, tissue engineering etc.) is essential to achieve a definitive foot healing after revascularization The goal of surgical treatment is to reconstruct a stable foot in terms of Skin integrity Structural stability Suitability for prosthesis Ability to walk 3 FINAL TREATMENT - MEDICAL - SURGICAL - ORTHOPEDIC - REHABILITATION

31 Philosophy of crossreferral Probability of healing based on toe pressures Rogers LC, Armstrong DL:Podiatry Care, Chapter 113, Rutherford's Vascular Surgery, 7th Edition. Elsevier Inc, 2010

32 Philosophy of crossreferral Probability of healing based on toe pressures Rogers LC, Armstrong DL:Podiatry Care, Chapter 113, Rutherford's Vascular Surgery, 7th Edition. Elsevier Inc, 2010 The vascular team improves flow and pushes the wound up the curve

33 Philosophy of crossreferral Probability of healing based on toe pressures When flow is adequate, the podiatry team manages wound healing, offloading, reconstruction, prevention. Rogers LC, Armstrong DL:Podiatry Care, Chapter 113, Rutherford's Vascular Surgery, 7th Edition. Elsevier Inc, 2010 The vascular team improves flow and pushes the wound up the curve

34 Philosophy of crossreferral Probability of healing based on toe pressures When flow is adequate, the podiatry team manages wound healing, offloading, reconstruction, prevention. Patients falling in the middle of the curve are managed simultaneously by combined efforts Rogers LC, Armstrong DL:Podiatry Care, Chapter 113, Rutherford's Vascular Surgery, 7th Edition. Elsevier Inc, 2010 The vascular team improves flow and pushes the wound up the curve

35 Coronary Artery Disease Flow team is sufficient Critical Limb Ischemia Flow & Toe team

36 Revascularization evolution in CAD Drug Eluting Balloon Decreasing incidence of restenosis Bare Metal Stent Drug Eluting Stent POBA Decreasing invasiveness of surgical procedure CABG Evolution fuel

37 CLI: a coronary-like Evolution? Decreasing incidence of restenosis Balloon PTA Decreasing invasiveness of surgical procedure ByPass Evolution fuel

38 CLI: a coronary-like Evolution? Decreasing incidence of restenosis Drug Eluting Balloon Bare Metal Stent Atherectomy Decreasing invasiveness of surgical procedure ByPass Balloon PTA Drug Eluting Stent Laser/crioplasty Evolution fuel

39 CLI race score Political organization (money) Medical knowledge industry

40 CLI race score Brain evolution The only way to win CLI race is to connect medical knowledge evolution with the evolution of devices and sanitary system DEB DES BMS "the sleep of reason produces monsters Francisco Goya ( ) CABG POBA Devices evolution