Critical Limb Ischemia A Collaborative Approach to Patient Care Christopher LeSar, MD Vascular Institute of Chattanooga July 28, 2017
Surgeons idea
Surgeons idea
represents the final stage of peripheral vascular disease progression
Clinical Responsibility
WOUND GRADE AMP ISCHEMIA INFECTION
QUESTION #1 How Threatened is the Limb?
Which Foot Is Ischemic? Right: Pain Worse at Night / Rubor Left: Sudden Onset Pain In the Good Leg
Which Foot Is Ischemic? Right: Chronic Ischemia Left: Acute Ischemia
CLI Clinical Assessment ACUTE ISCHEMIA
Pulse Exam
Neuromotor Exam 1x Speed 56 y/o Female < 24h Sudden Pain in Left leg Poor movement of toes on Left
Neurosensory Exam 4x Speed 56 y/o Female < 24h Sudden Pain in Left leg Poor Sensation from Left Knee to Toes
Severity of Limb Ischemia Class 1: The limb is viable even without therapeutic intervention. Class 2: The limb is threatened and requires revascularization for salvage. Class 3: The limb is irreversibly ischemic and salvage is not possible. Rutherford RB, J Vasc Surg. 1997; 26: 517-538.
Severity of Limb Ischemia Class 1: The limb is viable even without therapeutic intervention. Class 2: The limb is threatened and requires revascularization for salvage. Class 3: The limb is irreversibly ischemic and salvage is not possible. Rutherford RB, J Vasc Surg. 1997; 26: 517-538.
Severity of Limb Ischemia Class 1: The limb is viable even without therapeutic intervention. Class 2: The limb is threatened and requires revascularization for salvage. Class 3: The limb is irreversibly ischemic and salvage is not possible. Rutherford RB, J Vasc Surg. 1997; 26: 517-538.
Algorithm Clinical Ischemia Class 1 Class 2A Class 2B Class 3 Revascularization Elective Therapy Semi-Elective Therapy Urgent Therapy Major Amputation
Which Foot Is Ischemic? Right: Pain Worse at Night / Rubor Left: Sudden Onset Pain In the Good Leg
CLI Clinical Assessment CHRONIC ISCHEMIA
WOUND GRADE AMP ISCHEMIA INFECTION
PI-69207-AA March 2012 Page 22 of 55 Severity of Limb Ischemia: Fontaine and Rutherford Classification Schemes Circulation 2006;113;e463-e465
ischemia. Limb salvage is depend damage and angiosomal perfusion Rutherford 4
Rutherford 5
Rutherford 6
WOUND GRADE AMP ISCHEMIA INFECTION
WOUND GRADE AMP ISCHEMIA INFECTION
WOUND GRADE AMP ISCHEMIA INFECTION
WOUND GRADE ISCHEMIA AMP DIABETES INFECTION
QUESTION #1 How Threatened is the Limb?
QUESTION #1 How Threatened is the Limb? Degree of Ischemia and Infection!
QUESTION #2 What determines limb salvage in CLI?
Amputation First? 417 patients in a Medicare population with lower leg CLI evaluated for amputation Primary Amputation 67% Infrainguinal Bypass 23% Angioplasty 10% Complications: 80% wound, 78% MI, and 81% Stroke: Primary Amputation Only 16% had an Angiogram prior to Primary Amputation Allie DE, et al. EuroIntervention. 2005;1:75-84.
Compartmentalized Pedal Flow Stenosis Images courtesy of Peter Schneider
Angiosome Perfusion
BTK Today: The Angiosome Concept An angiosome is an anatomic unit of tissue fed by a source artery Six angiosomes feed the foot Targeted therapy of the artery to the ischemic wound. Maximize ulcer/wound healing Sometimes there is Isolated Arterial Perfusion Dean SO. Defining Angiosome Anatomy for Reperfusion Decisions. (VIVO, Chalk Talk). Wednesday, October 20, 2010.
Lateral Plantar Artery Attinger CE, et al. Plast Reconstr Surg. 2006;17(7 Suppl):261S-293S.
Medial Plantar Artery Variability Attinger CE, et al. Plast Reconstr Surg. 2006;17(7 Suppl):261S-293S.
WOUND GRADE AMP ISCHEMIA INFECTION
WET GANGRENE 12 HOURS LATER
65 y/o WF with Rapid progression of Gangrene Right Foot PMH: DM, HTN, CAD Rutherford 6 Wet Gangrene
No Surgical Bypass Options Classic Answer: BKA (Life Saving) Subintimal Dissection PTA Surgical Debridment of Infection
MICRO PUNCTURE ACCESS OCCLUDED POSTERIOR TIBIAL
Tibial Retrograde Transluminal Angioplasty
PI-69207-AA March 2012 Page 50 of 56
PI-69207-AA March 2012 Page 51 of 56
RECONSTRUCTION OF BOTH ANTERIOR AND PORTERIOR CIRCULATIONS OF THE FOOT
RECONSTRUCTION OF BOTH ANTERIOR AND PORTERIOR CIRCULATIONS OF THE FOOT ANGIOSOME CONCEPT
TWO WEEKS SIX WEEKS
WOUND GRADE ISCHEMIA AMP PREVENTION INFECTION
Case 1 65 y/o Ischemic ulceration Right foot PMH: HTN, CAD, Dyslipidemia Left AKA SH: Former significant smoking PE: Palp Fem pulse, no pop or tibial
Distal SFA 95% Stenosis Primary Angioplasty And Stent
Atherectomy Angioplasty 2.5 x 150 EN-1262.A
EN-1262.A
EN-1262.A
Orbital Atherectomy 1.25 Micro Crown Angioplasty 2.0 x 150 mm
Final Final
Healing wounds Two weeks post op
Four Weeks
CRITICAL LIMB SPECIALIST HISTORY & PHYSICAL (PULSE EXAM) LIMB SALVAGE ANGIOSOME CONCEPT ANGIOGRAM CAPABILITY
Case 2 59 y/o WF with distal embolization Left 1 st, 2 nd, 3 rd toes x 6 months PMH: HTN, PVD, S/P bilateral kissing iliac stents 12 months prior SH: Significant continued smoking ½ pack/day PE: Palpable Left Fem, Pop, PT, DP
1 Week Post Op Embolization Syndrome S/P Bilateral Kissing Iliac Stents Painful Blue Toes
EN-1262.A
3 Months Post Op Embolization Syndrome Intense Fire-Like Pain with Rubor Pain Worse at Night
AP VIEW LEFT LATERAL OBLIQUE TIBIALS
LEFT LATERAL OBLIQUE TIBIALS RIGHT LATERAL OBLIQUE FOOT
AP/CRANIAL VIEW FOOT
Orbital Atherectomy 1.25 Micro Crown Angioplasty 1.5 mm x 10 cm
EN-1262.A
EN-1262.A
CRITICAL LIMB SPECIALIST HISTORY & PHYSICAL (PULSE EXAM) LIMB SALVAGE ANGIOSOME CONCEPT ANGIOGRAM CAPABILITY
Case 3 The Test 47 y/o WM with Pain and Numbness in Right Toes x 2 Months PMH: PVD, Aortic Occlusion S/P Aorto-Bi-Fem Bypass SH: Significant former smoking PE: Palpable Right Fem, Pop, PT, DP LAB: Zero Toe Pressure
Rest Pain with Numbness of Toes Critical DPA Stenosis with a weak LPA
LATERAL VIEW AP/CRANIAL VIEW
Co-Dominant Flow Immediate Pain and Numbness Improvment
CRITICAL LIMB SPECIALIST HISTORY & PHYSICAL (PULSE EXAM) LIMB SALVAGE ANGIOSOME CONCEPT ANGIOGRAM CAPABILITY
Case 4 69 y/o White Female Gangrene L 2 nd toe PMH: HTN, CAD, Dyslipidemia SH: Former significant smoking PE: Palp Fem pulse, pop, no tibial pulses
CSI 1.25s PTA 3 x 4
CSI 1.25s
PTA 2 x4
Two weeks post-op Four weeks post-op
CRITICAL LIMB SPECIALIST HISTORY & PHYSICAL (PULSE EXAM) LIMB SALVAGE ANGIOSOME CONCEPT ANGIOGRAM CAPABILITY
Pedal Retrograde Subintimal Angioplasty
REST PAIN NEAR CONSTANT INABILITY TO SLEEP RUTHEFORD 4
PERONEAL OUTFLOW ONLY Two weeks post-op Four weeks post-op POOR CONNECTION PEDAL ARCH
RETROPEDAL ACCESS ONLY OPTION
ULTRASOUND ACCESS
SUBINTIMAL DISSECTION Two weeks post-op Four weeks post-op RETROPEDAL ANGIOGRAM
Angioplasty 2.5 x 3 x 210 PI-69207-AA March 2012 Page 101 of 56
Vascular Surgery Options
Endovascular Options
Hybrid: Surgical Bypass
79 y/o WM with Pain and Numbness in Feet x 2 months R>L PMH: DM, HTN, CAD c CABGx5 Rutherford 4 Rest Pain
POPLITEAL OCCLUSION
ATHERECTOMY ANGIOPLASTY STENT REPAIR
TP TRUNK OCCLUSION RETROGRADE PTA ACCESS
PTA DOMINANT OUTFLOW NOTED PUNCTURE
NEW WOUND FROM TEGADERM DRESSING PUNCTURE POST OP DAY 3 NOW RUTHERFORD 5!
INCISION RIGHT KNEE
S/P CABG with Bilateral GSV Harvest, LSV with Superficial Chronic Phlebitis SHOULDER Harvest Right Cephalic Vein
Posterior Tibial Popliteal Peroneal Occluded TP Trunk
Reversed Right Cephalic Vein Pop to TP Trunk Bypass
Reversed Right Cephalic Vein Pop to TP Trunk Bypass
POST OP BYPASS DAY 7 WOUND STARTING TO HEAL
"How do we as a medical community get ahead of and manage this disease for patients."
"How do we as a medical community get ahead of and manage this disease for patients."
Community Network for CLI
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