State-of-the-art lecture: below-the-knee interventions for ... · Roberto Ferraresi Peripheral...

Roberto Ferraresi

Peripheral Interventional Unit

Bergamo – Italy

[email protected]

State-of-the-art lecture:

below-the-knee interventions for critical limb ischemia

Potential conflicts of interest

Speaker's name: Roberto Ferraresi

I have the following potential conflicts of interest to report:

Consultant: Medtronic, Abbott, Cook, Biotronik

Stockholder of a healthcare company: LimFlow

State-of-the-art lecture: BTK interventions for critical limb ischemia

1. BTK & below-the-ankle disease in CLI

2. The angiosome-guided revascularization

3. Flow-guided surgery

4. Protocols and multidisciplinary team

Disease distribution in a series of 1915 with PAD and a complete angiographic study of BTK vessels

“Below-the-ankle vessel disease in CLI patients: innocent bystander or leading actor?” Ferraresi R et Al, submitted for publication 2015

PAD symptoms N° %

Claudication 183 9.6

Ischemic Rest Pain 90 4.7

Ulceration or Gangrene 1642 85.7

Total 1915 100

9.8

45.5

46.5

0 artery 14.3

1 artery 24.3

2 arteries 37.6

3 arteries 23.7

0 artery 13.2

1 artery 25.5

2 arteries 44.9

3 arteries 16.4

0 artery 27.9

1 artery 20.2

2 arteries 31.5

3 arteries 20.4

25,2

Prevalence of disease

(%)

Prox-BTK

vessels

Dist-BTK

vessels

BTA vessels

Arch

POP-TPT

SFA

Above-the-

groin vessels

Aggregated

segments

Lateral Plantar

Medial Plantar

Dorsalis Pedis

Plantar Arch

9.8

45.5

46.5

0 artery 14.3

1 artery 24.3

2 arteries 37.6

3 arteries 23.7

0 artery 13.2

1 artery 25.5

2 arteries 44.9

3 arteries 16.4

0 artery 27.9

1 artery 20.2

2 arteries 31.5

3 arteries 20.4

25,2

Prevalence of disease

(%)

Prox-BTK

vessels

Dist-BTK

vessels

BTA vessels

Arch

POP-TPT

SFA

Above-the-

groin vessels

Aggregated

segments

1. Foot vessel disease is

present in >70% of patients

with CLI

2. Foot vessel disease is

particularly represented in

DM-ESRD pts

www.robertoferraresi.it

Risk Factor for CLI OR (p)

Above the ankle vessel disease 1,20 (<.05)

Foot vessel disease (arch excluded) 1,58 (<.05)

Arch = small vessel disease 7,83 (<.01)


Prox-BTK

vessels

Dist-BTK

vessels

BTA vessels

Arch

POP-TPT

SFA

Above-the-groin

vessels

Aggregated

segments

CLI


Above the ankle vessel disease 1,20 (<.05)


Prox-BTK

vessels

Dist-BTK

vessels

BTA vessels

Arch

POP-TPT

SFA

Above-the-groin

vessels

Aggregated

segments



Foot vessel disease 1,58 (<.05)

CLI

Prox-BTK

vessels

Dist-BTK

vessels

BTA vessels

Arch

POP-TPT

SFA

Above-the-groin

vessels

Aggregated

segments



Arch = small vessel disease 7,83 (<.01)

CLI

1. The disease of every above-the-

ankle vessel segment has a weak

association with CLI: we need

many of them to get CLI

2. BTA vessel disease has the

strongest association with CLI,

particularly the small vessel

disease of the arch (the tiger of

CLI!)


The angiosome concept in real practice

• 9 studies 1290 limbs (CLI RTF 5-6)

• ENDO + OPEN revascularization

• Systematic review comparing DR versus IR

Conclusion

When feasible, direct revascularization of the foot angiosome affected by

ischemic tissue lesions may improve wound healing and limb salvage rates

compared with indirect revascularization.

• 15 studies 1,868 limbs (CLI RTF 5-6)

• ENDO + OPEN revascularization

• Systematic review comparing DR versus IR

Conclusion

DR of the tibial vessels appears to result in improved wound healing and

limb salvage rates compared with IR… However, the quality of evidence on

which these conclusions are based on is low.



Direct revascularization according to the

angiosome concept seems to be better

than indirect revascularization in terms

of wound healing and limb salvage

All of the studies

comparing direct and

indirect revascularization

are retrospective

1. We can assume that the operators focused on traditional optimal technical targets rather than the WRA

2. We don’t know if the same patients would have been technically revascularizable following an angiosome-oriented approach.

3. It is possible that in the “indirect revascularization” groups there was a propensity to collect patients with the most technically challenging disease and the differences in the outcomes may simply reveal basal differences in the extension and type of obstructive disease

Try to do what is possible and don’t

lose time on unrealistic targets!


Direct revascularization could have a different

value depending on the presence or not of a good

distal distribution network

Inadequate distal distribution systemGood distal distribution system

Varela et al. demonstrated that

the restoration of blood flow to

the ulcer through collateral

vessels (pedal and distal

peroneal branches) provided

similar results to those obtained

through its specific source

artery in terms of healing and

limb salvage.

Good distal distribution system


Kawarada et Al demonstrated that

a single tibial artery

revascularization, whether of the

ATA or PTA, yielded comparable

improvements in microcirculation

of the dorsal and plantar foot.

Approximately half of the feet

revascularized had a change in

microcirculation that was not

consistent with the 2D angiosome

theory

Good distal distribution system


In diabetic and ESRD pts

collateral vessels formation is

reduced or absent foot

circulation becomes functionally

terminal because of lack of

collaterals. This is the reason

why we need to improve the

most direct blood flow to the

wounded area

Circulation, 1999;99:2239-2242;

Cardiovasc Res. 2001 Feb 16;49(3):554-60;

Circulation, 2004;2343-2348;

Azuma N et Al. Factors influencing wound healing of

critical ischaemic foot after bypass surgery: Is the

angiosome important in selecting bypass target artery? Eur

J Vasc Endovasc Surg 2012;43:322-28

Inadequate distal distribution system

Azuma et Al. demonstrated that in

bypass surgery the angiosome

concept seems unimportant, at

least in non-ESRD cases.

«We believe that a good artery

with good runoff to the foot,

regardless of the angiosome,

should be selected in non-ESRD

pts… On the other hand,

angiosome-oriented target

selection might improve the poorer

outcomes in ESRD pts.»

Inadequate distal distribution system

The value of an angiosome-oriented

revascularization is inversely

related to the function of collateral

vessels

Not every wound, especially in case of deep infection, is confined

into a single angiosome space; patients with extensive tissue

damage cannot be classified on the basis of an angiosome-

oriented revascularization.

Open BTK vessels

Limbsalvage

0 56%1 better than 0

1 73%

2 80%2-3 better than 1

3 83%

PTA of tibial arteries had a better outcome than PTA of the peroneal artery alone

Extensive tissue damage cannot be

classified on the basis of an

angiosome-oriented scheme. In

these patients complete rev. better

than partial rev

Consider the rule of collateral

vessel disease/function

Try to do what is possible and don’t

lose time on unrealistic targets!

Complete rev. better than partial rev.

in Rutherford 6 pts

• Male, 75 yy

• Type 2 DM

• Forefoot gangrene

Impossible to open PTA

neither antegradely nor

retrogradely

Flow-guided surgery: what is the best forefoot amputation for this patient?

Consider 3 key points

Type Tissue FlowBiomechanical

needs




needs

Distal TMA - +++ -




needs

Distal TMA - +++ -

Proximal TMA ++ ++/-- +++




needs

Distal TMA - +++ -


Trans-cuneiform +++ - ++

+ a

nkle

art

ho

de

sis




needs

Distal TMA - +++ -



Lisfranc +++ + +

+ a

nkle

art

ho

de

sis


needs

Distal TMA - +++ -



Lisfranc +++ + +

Chopart +++ ++ +



+ a

nkle

art

ho

de

sis

• Proximal open TMA with accurate sparing

of pedal-plantar loop vessel

• Bone coverage by Hyalomatrix

application

• Skin graft

Treatment protocol in TUC C-D wounds

Treatment protocols

in ischemic wounds

We give to every patient

(without contraindication)

double anti-PLTs therapy

and renal protection (saline,

bicarbonate, acetilcystein)

Treatment protocols

in ischemic wounds

Revascularization

• Angioplasty

• Bypass

Final treatment

• Surgical

• Orthopedic

• Rehabilitation

Revascularization is the first

line therapy in TUC C lesion

Treatment protocols

in ischemic wounds

Revascularization

• Angioplasty

• Bypass

Final treatment

• Surgical

• Orthopedic

• Rehabilitation

Infection Treatment

• Ulcer debridement

• Urgent surgery for gangrene, abscess, phlegmon

• Identification of bacterial strains appropriate antimicrobial therapy

Infection treatment is the first line

therapy in TUC D lesion

Treatment protocols

in ischemic wounds

Revascularization

• Angioplasty

• Bypass

Final treatment

• Surgical

• Orthopedic

• Rehabilitation

Infection Treatment

• Ulcer debridement

• Urgent surgery for gangrene, abscess, phlegmon

• Identification of bacterial strains appropriate antimicrobial therapy

Medical team “Toe” team

“Flow” team

Foot surgeon

Orthopedic

Plastic surgeon

Multidisciplinary team

Vascular surgeonInterventional

cardiologist or

radiologist

CLI

Diabetologist

Nephrologist

Cardiologist

Infectivologist

Neurologist

Vascular surgeon

Podiatrist

?

Can a cardiologist

become a master

in CLI treatment?

Yes, if he/she is

able to work in a

multidisciplinary

team


The strength of a chain

is the strength of the

weakest ring, not the

one of the strongest

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