Click to edit title style Vascular Surgery & Endovascular - PowerPoint PPT Presentation

4/8/2017 Ankle level and pedal artery occlusive Disclosure: disease Joseph L. Mills, Sr., MD I have no conflicts of interest Professor and Chief, Division of Click to edit title style Vascular Surgery & Endovascular Therapy related Baylor College of Medicine Houston, Texas to this presentation. Click to edit subtitle style Celestial 1608: Spectacle- makers from Revolutions Flanders invented a primitive form of spyglass; Galileo was 45 years old when he heard of the invention. After one night of thought, he made one of his own with a Portrait of Galileo magnification of three. He drawn eight years then stepped up the before his trial by magnification to 8 or 10, and Octavio Leoni. by 1609 had made his own telescope. His demonstrations set in train the vogue for telescopic observations . “ “ When you look at things “ “ differently, they look different. ” ” ” ” Galileo was born in 1564, in the same year as William Shakespeare. Bob Hobson to Joe Mills, April 2004 1

4/8/2017 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 Focal pedal disease: non-healing toe ulcer flat toe waveform, AT pulse to just below ankle level Rutherford ’ ’ ’ ’ s Vascular Surgery Source: Andros and Lavery 2009. Initial Angiogram After 2.5 mm PTA 2

4/8/2017 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 3

4/8/2017 14 Slide courtesy of Chris Attinger, M.D. (Georgetown University) 4

4/8/2017 When do angiosomes and when does pedal disease matter? When the foot circulation is compartmentalized: Example: The Orphan Heel Syndrome Alexandrescu et al J Endovasc Ther 2008;15:580–593 19 Alexandrescu, Hubermont, Vincent 20 5

4/8/2017 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? Attinger et al. PRS 2006. Volume 117, Number 7S Angiosomes of the Foot and Ankle 22 21 When are angiosomes important? Angiosome correlation with wound site • 200 consecutive diabetic patients with foot wounds and detailed distal LE angiograms • When the foot circulation is COMPARTMENTALIZED • No correlation of index wound location with angiographic lesions (analyzed by angiosome) – Heel ulcers in patients with diabetes and end • Why? Most lesions are neuropathic and due to stage renal disease repetitive pressure or shear – We have termed this “Orphan Heel Syndrome” • Subgroup of non-neuropathic patients showed better – Isolated tibial and pedal/arch disease correlation (p=0.08) Unpublished data courtesy of Dimitri Aerden, Brussels, Belgium 23 24 6

4/8/2017 Fluorescence Imaging to Assess Regional Perfusion Indocyanine green angiography before intervention 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 25 26 Foot circulation can be Why do patients get heel ulcers? compartmentalized • Pressure • Shear • Most commonly used standard noninvasive • Exacerbated by dependency, edema tests more accurately reflect forefoot perfusion (eg. toe pressure) • Patterns of ASO may result in regional separation or compartmentalization of blood • ISCHEMIA flow • Major unmet need: how does one • Classic example: • A palpable DP pulse doesn ’ ’ t mean the recognize and quantify regional ’ ’ – Heel ulcer in patient with diabetes and ESRD on dialysis ischemia? heel is perfused 27 28 7

4/8/2017 SALSA experience with complex Proposal heel ulcers • A heel ulcer equals • 19/41 patients referred with deep heel ulcers required major surgical debridement • Mean age 64, range 48-91 malperfusion or • All had HgA1C > 8 • 31% had ESRD and were on dialysis ischemia until • All had detailed noninvasive testing - PT and DP waveforms analyzed separately proven otherwise • 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) 29 30 8

4/8/2017 41 year-old woman with diabetes, on dialysis, with heel ulcer Post angioplasty Heel view 61 y/o diabetic s/p TMA. Palpable DP Pulse Non-healing heel ulcer x 15 months; Failed TCC 36 9

4/8/2017 Remote left BKA; Ambulatory in prosthesis 37 38 INDIRECT REVASCULARIZATION PRE-PTA POST PTA Wound completely healed in 6 weeks 39 40 10

4/8/2017 Heel ulcers are associated with: When are angiosomes important? • Poorly controlled diabetes mellitus • Chronic kidney disease • Heel ischemia • When the foot circulation is COMPARTMENTALIZED – Early angiography should be strongly considered – These patients have a high incidence of posterior –Heel ulcers in patients with diabetes and tibial and peroneal ASO end stage renal disease – Heel perfusion is often compartmentalized, or –Isolated tibial and pedal/arch disease isolated from forefoot perfusion due to pedal, plantar and arch disease – A palpable DP pulse DOES NOT mean that the heel is perfused 41 42 There are no “free shots” 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) 43 11

4/8/2017 Pedal disease – summary observations • Seems to be a relatively new phenomenon • May exist with more proximal, usually tibial occlusive 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 12