Critical limb ischemia, Angiosomes and BTK/BTA interventions Michael Cumming, MD, FRCPC, MBA Medical Director CDI Vascular
Problems with revascularization Healing
Amputation •
• mean time 15-20 weeks •
• 10-18% of ischemic wounds
•
Slow
Failed
“No Option” CLI
• Most common reason for amputation •
BPG Patients
• > 50% have patent BPG
Simons JP, Goodney PP, Nolan BW, et al. Failure to achieve clinical improvement despite graft patency in patients undergoing infrainguinal lower extremity bypass for critical limb ischemia. J Vasc Surg 2010;51(6):1419–1424 Khan MU, lall P, Harris lM, et al. Predictors of limb loss despite a patent endovascular-treated arterial segment. J Vasc Surg 2009;49(6):1445–1446 Söderström M, Arvela E, Albäck A, et al. Healing of ischaemic tissue lesions after infrainguinal bypass surgery for critical leg ischaemia. Eur J Vasc Endovasc Surg 2008;36:90–95 Johnson BL, Glickman MH, Bandyk DF, Esses GE. Failure of foot salvage in patients with end-stage renal disease after surgical revascularization. J Vasc Surg. 1995 Sep;22(3):280-5 Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). European Journal of Vascular and Endovascular Surgery 2007; 33:S1-S75 Faglia E, Clerici G, Clerissi J, et al. Long-term prognosis of diabetic patients with critical limb ischemia: a population-based cohort study. Diabetes Care. 2009 May;32(5):822-7
Potential to do better Quality of Revascularization
• Angiosomes • Pedal arch • Wound perfusion
Endovascular Advances •
Retrograde access •
•
Crossing CTO’s Skills development
14 12 10 8 6
4
2
350 300 250 200 150 100 50
publications
Interest in angiosomes PubMed
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
0 2013
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Angiosome Concept • ATA •
Dorsum of foot
• PA •
Lateral forefoot
•
Heel
• PTA •
Medial Plantar
•
Lateral Plantar
•
Heel
Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental studies and clinical applications. Br J Plast Surg 1987;40:113–141
Angiosome connections Arterial - Arterial
Collateral
Angiosome & Wound location
82% Concordance Rate between wound location and vessel occlusion
Osawa S, Terashi H, Tsuji Y, Kitano I, Sugimoto K. Importance of the six angiosomes concept
angiosome and non-angiosome targeted revascularization • Comparison of the wound healing rates at 1, 3, and 6 months for both the direct revascularization and indirect revascularization groups
Kabra A, Suresh KR, Vivekanand V, et al. Outcomes of angiosome and non-angiosome targeted revascularization in critical lower limb ischemia. J Vasc Surg. 2013 Jan;57(1):44-9.
Direct vs Indirect • Estimated freedom from major amputation • Higher limb salvage rate in the direct group at all times Osamu L, Soga Y, Hirano K, et al. Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia
Ulcer healing in 250 DFU’s Ulcer healing rates in patients with direct and those with indirect perfusion to the foot ulcer after endovascular revascularization
Value of arterial-arterial connections
Osawa S, Terashi H, Tsuji Y, Kitano I, Sugimoto K. Importance of the six angiosomes concept through arterial-arterial connections in CLI. Int Angiol. 2013 Aug;32(4):375-85.
Role of Collateral Vessels
Pedal Arch
Alson MD, Lang EV, Kaufman JA. Pedal arterial imaging. J Vasc Interv Radiol 1997;8:9–18
Quality of the pedal arch
387 Limbs with CLI
.
• Intact or partially intact PA • Better overall wound healing • Better wound healing rate
• No affect on AFS Rashid H, Slim H, Zayed H, Huang DY, et al. The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome. J Vasc Surg. 2013 May;57(5):1219-26
Hiong TK, LINC, 2012 Feb
Wound Blush vs Angiosome
â&#x20AC;˘ The limb salvage rate was significantly higher in the wound blush-positive group than in the wound blush-negative group and remained so for at least 3 years after the EVT (96.4% vs 56.8%, P < .001). Utsunomiya M, Nakamura M, Nakanishi M, et al. Impact of wound blush as an angiographic end point of endovascular therapy for patients with critical limb
Quality of revascularization • Angiosome • Direct • Indirect • Indirect via • Collateral • Connection
•
•
–
Pedal Arch
Wound blush
Fluorescent angiography?
Olive Registry: 314 Tibial Angioplasties
Shinke T, Oba Y, Ohura N, et al. Endovascular Treatment for Infrainguinal Vessels in Patients With Critical Limb Ischemia : OLIVE Registry, a Prospective, Multicenter
Endovascular advances Access and crossing
Retrograde access • Tibial • Pedal • Metatarsal • Trans collateral
Zander T, Gonzalez G, De Alba L, et al. Transcollateral approach for percutaneous revascularization of complex superficial femoral artery and tibioperoneal trunk occlusions. J Vasc Interv Radiol. 2012;23(5):691-695
Tibial/Petal
92% technical success Low complication rate El-Sayed HF. Retrograde Pedal/Tibial Artery Access for Treatment of Infragenicular Arterial Occlusive Disease. Methodist Debakey Cardiovasc J. 2013 Apr-Jun; 9(2): 73â&#x20AC;&#x201C;78.
Transmetatarsal • Used in 31 of 811 consecutive CLI cases • 87% technical success • AFS 82% at 12 months in technical successes Palena LM, Brocco E, Manzi M. The clinical utility of below-the-ankle angioplasty using “transmetatarsal artery access” in complex cases of CLI. Catheterization and Cardiovascular Interventions. Article first published online: 10 JUN 2013
Retrograde access • Safe • High technical success rates • Bail out for antegrade failures OR • Primary
Crossing BTK CTO’s • Dedicated crossing • Catheters • Wires
• Crossing devices • Technical skills
Guidewires • Navigational • Crossing • Support Walker C. Guidewire Selection for Peripheral Vascular Interventions. Endovascular Today:2013;May:80-83
Technique Stay luminal
Skills • •
Straight guidewires Progressive weighting • •
Follow calcium Reentry difficult
Mustapha J. A New Approach to Diagnosing and Treating CLI. Endovascular Today. 2010, Sept (9):41-50.
•
Tactile Feedback •
Visual cues
Revascularization strategy Quality Anatomical Imaging
Plan of Attack •
MRA
•
CTA
• Prefer to image Ca++ •
•
Primary & secondary access •
Target vessel and backup
• Easiest versus angiosome
US if renal insufficiency
Jens S, Koelemay MJ, Reekers JA, Bipat S. Diagnostic performance of computed tomography angiography and contrast-enhanced magnetic resonance angiography in patients with critical limb ischaemia and intermittent claudication: systematic
•
Sheath, catheters, wires
Intra procedure Decision making • Persist versus different tools • Change target artery • Change access
Patience and Persistence • always prep primary and secondary)
• Slow learning curve
Application to clinical practice Series of case examples for BTK/BTA endovascular intervention
86 yo female, nhw lateral malleolus • Present for 3 weeks • Long smoking history • Quit > 10 years ago
• Type 2 DM • Lives independently
Diabetic Foot Ulceration
Management Physiologic Testing
Conservative
•
•
Right ABI 0.71
•
Right TBI 0.40
TcPO2 not done
•
2 Months
• Optimized medical care • Optimal wound care with podiatry •
No Improvement
3 week follow up
79 yo female, ESRD, DM Right foot recurring wounds last 4 months Prior partial amputation 2nd toe ABI/TBI non compressible
1. Calf 2. Distal foot
3. Chest (Ref) 4. Proximal foot
45 yo male, nhw Left 1-2th toes • Present for > 4 weeks • Type 1 DM • Hemodialysis 10 years
Pre, 1 month, 2 month FU
Click icon to add picture
73 yo male, Type I DM, ESRD Dry gangrene left 1st and 2nd digits Lives independently Prior RLE BKA Ambulatory with prosthesis Offered LLE BKA -> Refused
US Guided Anterior communicating
At 2 months doing well
Refused transmetatarsal amputation Remains ambulatory
65 year old female, CRF, DM I
3 hours later
AT 6 months Wound healed Palpable DP
83 yo male, ESRD, DM Prior failed Pop â&#x20AC;&#x201C; ATA BPG Prior failed endovascular attempt Refused BKA Lives independently
Healed TMA 3 months
Remains ambulatory Living independently Girl friend moved back in
Click icon to add picture
67 YO MALE, Type I dm Non healing wound left 2nd digit 4 months Pain Did not want toe amputation
1 Month follow up
Summary Quality of Revascularization •
•
Angiosome
•
Pedal loop
Wound perfusion
Endovascular •
Targeted revascularization •
Multiple vessels •
Pedal vessels