Aggressive BTK Revascularization and Advanced Wound Care - Patient Specific Therapy Concepts

Aggressive BTK Revascularization and Advanced Wound Care - Patient Specific Therapy Concepts Dr Steven Kum MBBS MMed FRCS FAMS Vascular & Endovascular Surgeon Vascular Centre Department of Surgery Changi General Hospital Singapore

Disclosure Speaker name:... I have the following potential conflicts of interest to report: X Consulting/Honorarium Medtronic,Abbott, Boston, COOK, Staub, Biotronik, Bard, MdStart Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest

Goals of Limb Salvage Short and Mid Term Goals (6 months) Long Term Goals (1 year) Wound Healing before Restenosis/ Graft Failure Early Return to Walking Limb Salvage Focus Revascularisation Wound Care Rehabilitation Risk Factor Modification Focus Injury Prevention

Clear Infection Revascularization Clean Granulating Wound Skin Coverage/Reconstruction

Concept 1 Ischemia should be Aggressively treated

Multilevel + Multi vessel Occlusions SMOKER + DIABETICS

Ischemia is Relative! vs vs

Endovascular CLI Strategy R4 Rest pain Open SFA +/- BTK R5 Minor loss Open SFA + BTK R6 Major loss Open SFA + BTK Renal failure Incomplete plantar arch Large wound burden High surgical risk Open single Direct Angiosome Able to open Indirect Angiosome only Open multiple Angiosomes especially if high risk Early minor amputation and debridement to achieve skin closure before restenosis Close follow-up Consider early bypass if wound deteriorates or unable to open angiosome Modified from Peter Schneider

Direct Angiosome Direct and Indirect Angiosomes Indirect Angiosome

Direct and Indirect Angiosomes Direct Angiosome Direct Angiosome

Clock is Ticking the moment we complete the Angioplasty!

Concept 2 Asesement of the Wound and Infection

Question:: Which Angiosome is involved? How deep does it penetrate? Joints/Tendon involved?

Simultaneous Revascularization and Debridement under Popliteal Block Retrograde access

Factors to Consider Angiosome concept Getting blood directly to the wound No of vessels required to support wound healing Patency of the vessel will the vessel remain open long enough to support wound healing Treating un-essential vessels will we predispose the patient to future ischemia? Heart and Renal function

Some case Examples..

ATA/DP or PTA??? Multifocal PTA Stenosis DP Occlude d

ATA and DP POBA Rapid arrival of contrast via DP

Retrograde approaches - Retrograde PTA Previous Pop-PTA Bypass + Calcified vessels from renal failure Culottes Bifurcation Stenting with XIENCE DES

Plantar Loop Technique Very Selected Cases Only

4 months DISAPEAR Drug Study Impregnated bioabsorbable Stent in Asian Population Extremity Arterial Revascularization

Rutherford 6 Popliteal and Lateral Plantar DEB to P3 DEB to Lateral Plantar Artery

4 months for wound healing

Endovascular Salvage of Failed Bypass Occluded Pop-DP bypass Double Balloon ATA

BTK PIERCE Posterior Tibial Artery 0.014 PT2 MS wire 2 x 40 Amphiron 1.2 x 8mm Minitrek 16G Needle to Disrupt Plaque

BTK PIERCE

CO2 Angioplasty

Dedicated Stents SUPERA Stent

Aggressive Wound Care

Good old Sharp Debridement Advance Wound Dressings Maggot Therapy

Versajet Hydosurgery VAC Therapy + HBOT Split Skin Graft

13-11-2012 21-3-2013

Combination BTK Intervention and Aggressive Wound Care

What if there is nothing else u can do?

Percutaneous Deep Venous Arterialisation Limflow Procedure

LimFlow No. 4

Summary CLI Strategies Rutherford Status and extent of tissue loss determines which BTK vessels need to be treated Retrograde attempts have revolutionized BTK treatment Utilization of adjuncts can help reduce reintervention and are complementary Extravascular care is important to close the loop and ensures a good angiographic result translates to a good clinical result

Treating CLI It s a Long Road. So Get Comfortable!! steven_kum@cgh.com.s g