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Ankle level and pedal artery occlusive disease

Joseph L. Mills, Sr., MD

Professor and Chief, Division of Vascular Surgery & Endovascular Therapy Baylor College of Medicine Houston, Texas

Disclosure:

I have no conflicts of interest related to this presentation.

Portrait of Galileo drawn eight years before his trial by Octavio Leoni.

Galileo was born in 1564, in the same year as William Shakespeare. Celestial Revolutions

1608: Spectacle- makers from Flanders invented a primitive form of spyglass; Galileo was 45 years old when he heard of the invention. After

• ne night of thought, he

made one of his own with a magnification of three. He then stepped up the magnification to 8 or 10, and by 1609 had made his own

• telescope. His

demonstrations set in train the vogue for telescopic

• bservations .

“ “ “ “When you look at things differently, they look different.” ” ” ” Bob Hobson to Joe Mills, April 2004

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Are disease patterns changing?

• Traditional teaching:

– Smokers: AIOD and SFA disease – Diabetes: PFA, popliteal and tibial disease with relative pedal sparing

• Emerging pattern

– Renal failure +/- diabetes +/- other?

• Tibial and pedal disease
• Isolated pedal disease

Source: Andros and Lavery Rutherford’ ’ ’ ’s Vascular Surgery 2009.

Focal pedal disease: non-healing toe ulcer

flat toe waveform, AT pulse to just below ankle level

Initial Angiogram After 2.5 mm PTA

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Occlusions: Antegrade; support; heavy wire (V14 or V18)

February 2016: PTA and toe amp same admission February 2017: patent, foot remains healed “If there is no artery crossing the ankle, is the foot salvageable?”* Emerging disease pattern: isolated severe pedal disease 41 y/o woman with CKD - Wound 1, Ischemia 3, foot Infection 0 *Qualified yes – depends on WIfI stage

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Slide courtesy of Chris Attinger, M.D. (Georgetown University)

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When do angiosomes and when does pedal disease matter? When the foot circulation is compartmentalized: Example: The Orphan Heel Syndrome

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Alexandrescu, Hubermont, Vincent

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J Endovasc Ther 2008;15:580–593 Alexandrescu et al

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Attinger et al. PRS 2006. Volume 117, Number 7S Angiosomes of the Foot and Ankle

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Angiosomes

• Do angiosomes predict the site of a foot

wound, especially in patients with diabetes?

• Is angiosome-targeted revascularization

important, and if so, when does it matter?

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Angiosome correlation with wound site

• 200 consecutive diabetic patients with foot wounds

and detailed distal LE angiograms

• No correlation of index wound location with

angiographic lesions (analyzed by angiosome)

• Why? Most lesions are neuropathic and due to

repetitive pressure or shear

• Subgroup of non-neuropathic patients showed better

correlation (p=0.08)

Unpublished data courtesy of Dimitri Aerden, Brussels, Belgium

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When are angiosomes important?

• When the foot circulation is

COMPARTMENTALIZED

– Heel ulcers in patients with diabetes and end stage renal disease – We have termed this “Orphan Heel Syndrome” – Isolated tibial and pedal/arch disease

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58 year old diabetic man; Stage 5 CKD. Ambulatory with contralateral BKA Palpable DP pulse, remotely healed Right TMA. R Heel gangrene; no PT pulse

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Fluorescence Imaging to Assess Regional Perfusion Indocyanine green angiography before intervention

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Foot circulation can be compartmentalized

• Most commonly used standard noninvasive

tests more accurately reflect forefoot perfusion (eg. toe pressure)

• Patterns of ASO may result in regional

separation or compartmentalization of blood flow

• Classic example:

– Heel ulcer in patient with diabetes and ESRD

• n dialysis
• A palpable DP pulse doesn’

’ ’ ’t mean the heel is perfused

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Why do patients get heel ulcers?

• Pressure
• Shear
• Exacerbated by dependency, edema
• ISCHEMIA
• Major unmet need: how does one

recognize and quantify regional ischemia?

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Proposal

• A heel ulcer equals

malperfusion or ischemia until proven otherwise

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SALSA experience with complex heel ulcers

• 19/41 patients referred with deep heel ulcers required

major surgical debridement

• Mean age 64, range 48-91
• All had HgA1C > 8
• 31% had ESRD and were on dialysis
• All had detailed noninvasive testing - PT and DP

waveforms analyzed separately

• 53% underwent angiography (10 patients), of whom 7

underwent revascularization

• Major limb loss averted in 16/19 (major limb amp 15%

in this subgroup; highest risk group in our series)

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41 year-old woman with diabetes, on dialysis, with heel ulcer Post angioplasty

Heel view

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61 y/o diabetic s/p TMA. Palpable DP Pulse Non-healing heel ulcer x 15 months; Failed TCC

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Remote left BKA; Ambulatory in prosthesis

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PRE-PTA POST PTA

INDIRECT REVASCULARIZATION Wound completely healed in 6 weeks

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Heel ulcers are associated with:

• Poorly controlled diabetes mellitus
• Chronic kidney disease
• Heel ischemia

– Early angiography should be strongly considered – These patients have a high incidence of posterior tibial and peroneal ASO – Heel perfusion is often compartmentalized, or isolated from forefoot perfusion due to pedal, plantar and arch disease – A palpable DP pulse DOES NOT mean that the heel is perfused

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When are angiosomes important?

• When the foot circulation is

COMPARTMENTALIZED

–Heel ulcers in patients with diabetes and end stage renal disease –Isolated tibial and pedal/arch disease

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Concepts that might prevent or more rapidly heal heel ulcers

• Prevention

– Control of diabetes – Heel protection/off-loading in at risk patients (dialysis, nursing home) – Temperature monitoring/thermography

• Early treatment

– Regular evaluation of at risk patients – Offloading meticulous care as soon as recognized

• Heel Revascularization

– Consider early angiography – Revascularize the area of ischemia (heel - posterior tibial and/or peroneal whenever possible)

There are no “free shots”

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Pedal disease – summary observations

• Seems to be a relatively new phenomenon
• May exist with more proximal, usually tibial
• cclusive disease but also increasingly see

isolated pedal disease

• Seems to be associated with renal failure, not

necessarily diabetes

• Compartmentalization and regional

malperfusion zones seem to be more important than standard angiosome concept