Roberto Ferraresi Peripheral Interventional Unit Bergamo – Italy [email protected] State-of-the-art lecture: below-the-knee interventions for critical limb ischemia
Aug 10, 2019
Roberto Ferraresi
Peripheral Interventional Unit
Bergamo – Italy
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)
www.robertoferraresi.it
Prox-BTK
vessels
Dist-BTK
vessels
BTA vessels
Arch
POP-TPT
SFA
Above-the-groin
vessels
Aggregated
segments
CLI
Risk Factor for CLI OR (p)
Above the ankle vessel disease 1,20 (<.05)
www.robertoferraresi.it
Prox-BTK
vessels
Dist-BTK
vessels
BTA vessels
Arch
POP-TPT
SFA
Above-the-groin
vessels
Aggregated
segments
www.robertoferraresi.it
Risk Factor for CLI OR (p)
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
www.robertoferraresi.it
Risk Factor for CLI OR (p)
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!)
www.robertoferraresi.it
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
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.
The angiosome concept in real practice
The angiosome concept in real practice
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!
www.robertoferraresi.it
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
www.robertoferraresi.it
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
www.robertoferraresi.it
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
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
• 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
Flow-guided surgery: what is the best forefoot amputation for this patient?
Consider 3 key points
Type Tissue FlowBiomechanical
needs
Distal TMA - +++ -
Flow-guided surgery: what is the best forefoot amputation for this patient?
Consider 3 key points
Type Tissue FlowBiomechanical
needs
Distal TMA - +++ -
Proximal TMA ++ ++/-- +++
Flow-guided surgery: what is the best forefoot amputation for this patient?
Consider 3 key points
Type Tissue FlowBiomechanical
needs
Distal TMA - +++ -
Proximal TMA ++ ++/-- +++
Trans-cuneiform +++ - ++
+ a
nkle
art
ho
de
sis
Flow-guided surgery: what is the best forefoot amputation for this patient?
Consider 3 key points
Type Tissue FlowBiomechanical
needs
Distal TMA - +++ -
Proximal TMA ++ ++/-- +++
Trans-cuneiform +++ - ++
Lisfranc +++ + +
+ a
nkle
art
ho
de
sis
Type Tissue FlowBiomechanical
needs
Distal TMA - +++ -
Proximal TMA ++ ++/-- +++
Trans-cuneiform +++ - ++
Lisfranc +++ + +
Chopart +++ ++ +
Flow-guided surgery: what is the best forefoot amputation for this patient?
Consider 3 key points
+ a
nkle
art
ho
de
sis
• Proximal open TMA with accurate sparing
of pedal-plantar loop vessel
• Bone coverage by Hyalomatrix
application
• Skin graft
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
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
State-of-the-art lecture: BTK interventions for critical limb ischemia
The strength of a chain
is the strength of the
weakest ring, not the
one of the strongest