Chronic critical limb ischemia
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Transcript of Chronic critical limb ischemia
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Jean-Baptiste RiccoVascular service
Hospital Jean BernardUniversity of Poitiers, France
CHRONIC CRITICAL LIMB ISCHEMIA
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DIFFICULT PATIENTS TO TAKE CARE
82 y.o. man s/p aortic tube graft 12 years ago
Rest pain, gangrene of the right toe
Chronic heart failure
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THIS MAN IS LIKE AN OLD BRIDGE
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WHY WE SHOULD REVASCULARIZE THESE PATIENTS WITH CLI
5 -YEAR SURVIVAL - After revascularisation 70 %- After a major Amputation 26 %
Difference is highly significant: p = 0.014
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TASC 2000
NEED FOR GUIDELINES
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TASC 2000
The original TransAtlantic InterSociety
Consensus (TASC) published in 2000 was the
first international consensus on the diagnosis
and treatment of PAD
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TASC II primarily designed to provide
guidance for primary care physicians
Easy-to-read document (67 vs. 296 pages)
Not intended for vascular specialists !
TASC II - 2007
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A number of aspects are not updated
It is not exhaustively referenced
Recommendations are deliberately simplified
Fails to recognize that more can be done with
endovascular and open techniques
2007 TASC LITE…
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TASC II CLASSIFICATION
INTEROBSERVER DISAGREEMENT
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TASC A
TASC B
TASC C
TASC D
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TASC A
TASC B
TASC C
TASC D
Definition for stenosis? > 50 %?
Heavy calcified lesion?Absence of tibial vessels?
Total poplital artery occlusion?
Poplital artery stenosis?
?
?
?
?
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HOW DO YOU CLASSIFY THIS LESION?
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HOW DO YOU CLASSIFY THIS LESION?
?
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Diabetics
Patients with CLI
Graziani L et al. EJVES 2007;33:453-60
BELOW THE KNEE LESIONS ?
36%36%
11%11% 27%27%
74%Lesions located
in crural arteries
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TASC II Classification for femoropopliteal lesions
allows wide individual interpretations and therefore,
the common use of this classification as a basis of
decision making and reporting outcome can be
questioned.
FEMOROPOPLITEAL LESIONS
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TASC II B
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TASC II B [2011]TASC II B [2011]
• Not endorsed by the SVS and by the ESVS
• Recommendations were not the product of rigorous
scientific scrutinity
• TASC II B advocates an endovascular first option even
in patients with claudication secondary to an isolated
tibial artery disease while there is no Grade A/B
supporting this conclusion
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TASC II B [2011]TASC II B [2011]
TASC II B guidelines adopt a primarily
anatomical approach, which pays
insufficient attention to the clinical
symptoms and risk factors
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European Journal of Vascular & Endovascular Surgery
EL
SE
VIE
R
JournalEuropean Journal ofVascular & Endovascular Surgery
Celebrating our Silver Jubilee ...
ww
w.ejves.compp. S1 - S90 Volum
e 42 Supplement 2 Decem
ber 2011
Volume 42 Supplement 2 December 2011 ISSN 1078-5884
YEJVS_v42_i5_COVER.indd 1 10/1/2011 12:40:04 PM
Management of
Clinical Practice Guidelinesof the
European Society for Vascular Surgery
Critical Limb Ischaemia and Diabetic Foot
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OPEN SURGICAL TECHNIQUES
FOR CLI PATIENTS
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BYPASS WITH THE SAPHENOUS VEIN
The best that can happen to a patient with CLI !
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PROXIMAL ANASTOMOSIS
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DISTAL ANASTOMOSIS
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BYPASS WITH FREE VASCULAR FLAP
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• Short autogenous bypass• Perigeniculate collateral arteries
PERIGENICULATE ARTERY BYPASS
Barral et al. Eur J Vasc Endovasc Surg
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PROSTHETIC BYPASS FOR CLI
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PROSTHETIC BYPASS + DVP
Devine et al.
Devine et al.
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EXTREME BYPASS&
ADJUNCT WOUND THERAPY
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73 years old male, diabetic, and living at home
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TCPO2 = 32ABI = 0.7
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PEDAL BYPASS
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NEGATIVE PRESSURE WOUND THERAPY
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NEGATIVE PRESSURE WOUND THERAPY
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promotes healing after revascularization
NEGATIVE PRESSURE WOUND THERAPY
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DEAD FOOT ?
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AK-FEMOROPOPLITEAL BYPASSPROSTHESIS vs. GREAT SAPHENOUS VEIN
STUDIES Pereira2006 Meta-analysis
Pereira2006 Meta-analysis
PatientsFollow-up
1713 / 580 5 years
2431 / 7035 years
Symptoms Claudication Critical Ischemia
Prim. Pat. PTFE 57.4% 48.3%
Prim. Pat. SV 77.2%p<0.05
69.4%p<0.05
Sec. Pat. PTFE 73.2% 54.0%
Sec. Pat. SV 80.1%p<0.05
71.9%p<0.05
A Saphenous vein
PERFORMS better than A prosthesis
EVEN ABOVE THE KNEE
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AK-FEMOROPOPLITEAL BYPASSPTFE vs. POLYESTER
STUDIES Jensen2007 RCT (2 ans)
Takagi2010 Meta-analysis (5
ans)
Patients PTFE/Polyester PTFE/Polyester
Symptoms 65% Cl / 35% CLI NA
Primary Pat. PTFE 57% 38.4%
Primary Pat. Polyester 70%p=0.02
49.2%
Secondary Pat. PTFE 65% NA
Secondary Pat. Polyester 76%p=0.04
NA
ABOVE THE KNEE
POLYESTER IS COMPARABLE TO PTFE
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BK-FEMORO-POPLITEAL BYPASSGREAT SAPHENOUS VEIN vs. PROSTHESIS
STUDIES Pereira2006 (5 years)
Albers2003 (5 years)
Patients 3779 43 studies
Symptoms Cl 35% / CLI 65% NA
Graft used SAPHENOUS VEIN PROSTHESIS
Primary Patency 64.8% Cl68.9% CLI
30.5%
Secondary Patency 79.7% Cl77.8% CLI
39.7%
Limb Salvage NA 55.7%
BELOW THE KNEE A Saphenous vein
IS better than A prosthesis
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STUDIES Albers 2005 (5 years)
Albers2003 (5 years)
Patients 2618 43 études
Symptoms Cl 3% /CLI 97% NA
Graft used ARM VEIN PROSTHESIS
Primary Patency 46.9% 30.5%
Secondary Patency 66.5% 39.7%
Limb Salvage 76.4% 55.7%
BELOW THE KNEE ANY vein
IS better than A prosthesis
BK-FEMORO-POPLITEAL BYPASSPROSTHESIS vs. ALTERNATIVE VEIN
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STUDIES Griffiths 2004 RCT (3years)
Laurila2004 RCT (2 years)
Procedures 46 cuff/ 44 31 AV Fistula / 28
Symptoms Cl 10% / CLI 90% CLI 100%
Adjunct VENOUS CUFF A.V. FISTULA
Sec. Pat. with Adjunct 45% 40%
Sec. Pat. PTFE Alone 19%p= 0.02 40%
Limb Salv. + Adjunct 78% 65%
Limb Salv + PTFE Alone 61%p= 0.08 68%
DISTAL VENOUS cuff CAN HELP
BK-FEMORO-POPLITEAL BYPASSPROSTHESIS ± ADJUNCT
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INFRA-POPLITEAL BYPASSREVERSED VEIN OR IN-SITU ?
STUDIES Albers 2006 (5 years)
Albers 2006 (5 years)
Albers2006 (5 years)
Patients 1024 908 2320
Symptoms 100% CLI 100% CLI 100% CLI
Technique IN SITU REVERSED GLOBAL
Primary Patency 58.5% 65.9% 63%
Secondary Patency 66.5% 73.2% 70.7%
Limb Salvage 75.3% 79.7% 77.7%
BOTH TECHNIQUES GIVE COMPARABLE RESULTS
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STUDIES Albers2004 M
Albers2004 M
Albers2004 M
Albers2004 M
Albers2003 M
PatientsFollow-up
6875 years
2185 years
1575 years
12545 years
43 studies5 years
Symptômes CLI CLI CLI CLI CLI
MATERIAL Venous Allograft
cryopreserved
Arterial Allograft
cryopreserved
VenousAllograft
Fresh
Ombilical Vein
PROSTHESIS
Primary Patency NA NA NA NA 30.5%
Secondary Patency
19% 21% 24% 30% 39.7%
Limb Salvage 60% 68% 39% 55% 55.7%
An ALLOGRAFT IS NOT BETTER THAN a PROSTHESIS
TIBIAL BYPASS - ALLOGRAFT
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ENDOVASCULAR TECHNIQUES
FOR CLI PATIENTS
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TIBIAL ANGIOPLASTY
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TIBIAL ANGIOPLASTY - RESULT
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PRE PER POST
SUBINTIMAL RECANALIZATION
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SUBINTIMAL RECANALIZATION
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CUTTING BALLOON
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CRITICAL LIMB ISCHEMIA
M Desvergnes et al. University of Poitiers, non-published data, 2013
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RISK FACTORS ENDOVASCULARN=140
OPEN BYPASSN=105
P
Age (mean) 78 70 P<0.05
Sex ratio M/W 79 / 61 79 / 22 NS
Diabetes 91 (65%) 42 (41,6%) P<0.05
HTA 136 (97,1%) 96 (95%) NS
Dyslipidemia 103 (73,6%) 81 (80,2%) NS
Smoking 79 (56,4%) 86 (85,1%) NS
Coronary disease 69 (49,3%) 50 (49,5%) NS
Cardiac insufficiency 43 (30,7%) 19 (18,8%) NS
Renal insufficiency 74 (52,9%) 35 (34,6%) P<0.05
Pulmonary disease 30 (21,4%) 39 (38,6%) NS
CRITICAL LIMB ISCHEMIA
M Desvergnes et al. University of Poitiers, non-published data, 2013
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PRIMARY PATENCY
ENDO OPEN
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ENDOVASCULAR PROCEDURES
TASC ? N (%)
A 1 (0,6%)
B 61 (34,9%)
C 75 (42,9%)
D 38 (21,7%)
RUN-OFF [LEG] N (%)
0 23 (13,1%)
1 94 (53,7%)
2 52 (29,7%)
3 6 (3,4%)
M Desvergnes et al. University of Poitiers, non-published data, 2013
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SECONDARY PATENCY
ENDO OPEN
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LIMB SALVAGE
ENDO OPEN
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PATIENT ALIVE WITHOUT AN AMPUTATION
ENDO OPEN
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PRIMARY PATENCY FOR ENDOVASCULAR
SIMPLE ANGIOPLASTY IS BETTER THAN STENT
AND SUBINTIMAL ANGIOPLASTY IS BEHIND
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BASIL: MAJOR ENDPOINTS
Amputation free survival (AFS) overall survival (OS, years)
For patients surviving > 2 years, a bypass first strategy was associated with an increase in overall survival of 7.3 months (p=0.02) and an increase in amputation-free-survival of 5.9 months (P=0.06) during a follow-up of 3.1 years.
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• 27% of all PTAs failed within 8 weeks after randomisation vs. surgery 7%(p<0.001)
• 75% of all failed PTAs were treated surgically
• Surgery after failed PTA had a significant worse AFS than initial bypass surgery (p=0.006)
• Amputation free survival was significantly better with vein grafts (p=0.003)
BASIL: FURTHER RESULTS
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ANGIOSOMES
A NEW CONCEPT FOR CLI ?
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PLANTAR ARCH AND ANGIOSOMEPLANTAR ARCH AND ANGIOSOME
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ANGIOSOME
CONNECTED
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ANGIOSOME
NO ARCH BUT CONNECTED
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ANGIOSOME
NOT CONNECTED
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NOT CONNECTED
ANGIOSOME
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ANGIOSOME
NO ARCH AND NOT CONNECTED
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ANGIOSOMES – CLI PATIENTS
CHU POITIERS175 ENDOVASCULAR
PROCEDURES
ANGIOSOME DIRECT (N=134)
ANGIOSOME INDIRECT
(N=41)p
MEAN AGE 77 [42-97] 77,4 [43-89] 0,98
SEX RATIO (M/F) 49,2% 68,9% 0,01
DIABETES 61,9% 78,04% 0,05
RENAL FAILURE 56,7% 48,7% 0,37
HTA 97,7% 97,5% 0,94
CORONARY DISEASE 46,2% 82,9% 0,01
SMOKING 55,9% 58,5% 0,77
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CHU POITIERS175 ENDOVASCULAR
PROCEDURES
ANGIOSOME DIRECT (N=134)
ANGIOSOME INDIRECT
(N=41)p
LOCALISATIONSFA-POPSFA-POP-TIBIALTIBIAL
70%16%14%
057%43%
<0,001
RUN OFF01>2
11%51%38%
20%63%17%
0,012
TECHNIQUEANGIOPLASTYSTENTINGSUBINTIMAL
53%21%26%
76%7%17%
0,012
ANGIOSOMES - TECHNIQUES
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ANGIOSOMES - RESULTS
0 1 2 3 4 5 YEARS
42% vs. 39%
38% vs. 39%
PR
IMA
RY
PA
TE
NC
Y
P=0,931
Angiosome DirectAngiosome Indirect
0 1 2 3 4 5 YEARS
81% vs. 80%
80% vs. 79%
P=0,856
LIM
B S
AL
VA
GE
Angiosome DirectAngiosome Indirect
No difference in patency or limb salvage between angiosome-direct or indirect endovascular procedures
CHU POITIERS175 ENDOVASCULAR PROCEDURES
CHU POITIERS175 ENDOVASCULAR PROCEDURES
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ANGIOSOMES – DATA PUBLISHED
• Retrospective studies, heterogeneity of data• No propensity analysis
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