Distal foot reconstruction: When and How Ramzan M. Zakir, MD, RPVI, - - PowerPoint PPT Presentation

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Distal foot reconstruction: When and How Ramzan M. Zakir, MD, RPVI, - - PowerPoint PPT Presentation

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Distal foot reconstruction: When and How Ramzan M. Zakir, MD, RPVI, FACC, FSCAI Clinical Associate Professor of Medicine Rutgers-Robert Wood Johnson Medical School Director of Complex Cardiovascular Interventions & Research Robert Wood

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Distal foot reconstruction: When and How

Ramzan M. Zakir, MD, RPVI, FACC, FSCAI

Clinical Associate Professor of Medicine Rutgers-Robert Wood Johnson Medical School Director of Complex Cardiovascular Interventions & Research Robert Wood Johnson Barnabas University Hospital Medical Director Vascular Management Associates

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Disclosures

  • Speakers Bureau
  • Boston Scientific
  • CSI
  • Philips Medical
  • Terumo Medical
  • Abbott
  • Scientific Advisory Board
  • Boston Scientific
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Indications

  • Clinical
  • CLI: Advanced Rutherford Class 5-

6, TUC B-D

  • Angiographic
  • Incomplete foot arch
  • Alternative retrograde access to

tibial vessel recanalization

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Rationale

  • Multiple studies have

demonstrated approximately 15% major amputation in presence of patent-fem distal bypass

  • Plantar Arch interruption was

found in almost all amputees

  • Elliot J Vasc Surgery 1993;18-881-888
  • Johnson J Vasc Surg 1995;22:280-286
  • Parsons J Vasc Surg 1998;28:1066-1071
  • Berceli J Vasc Surg 1999;30:499-508
  • Treiman J Vasc Surg 2000;31:1110-1118
  • Lofberg J Vasc Surg 2001;34:114-121
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Solution

  • Directly perfuse area of ischemia
  • Pedal Arch reconstruction
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Angiosomes Theory

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Plantar Arch Revascularization

  • Initially described in 2006
  • Extend the arterial recanalization even to more distal segments with

the intention to improved perfusion directly to wound

  • Alternative to tibial artery occlusions

*Graziani BSC Clinical Vision, Issue17, April 2006, Gosling, UK

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Conclusions

  • DAR is not a predictor of good outcomes in diabetic patients

undergoing endovascular procedures

  • Pedal arch patency seems to be a key factor to obtain good outcomes

in terms of wound healing and limb salvage

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To investigate the clinical implications of pedal artery angioplasty (PAA) for CLI patients presenting with Infrapopliteal and pedal artery diseases Nakama T et al, JACC Cardiovasc Interv, Jan 2017

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Study Synopsis

  • Study Type
  • Retrospective analysis from mult-center prospectively maintained database (5 clinical sites were included
  • Study Period
  • Jan. 2012-Jun. 2015
  • Patient enrollment: Jan 2012-Jun. 2014
  • Number of patients
  • 257 patients
  • Study Patients
  • CLI patients presenting with de novo infrapopliteal and pedal artery disease, which had ischemic tissue loss or gangrene

(Patients categorized into Rutherford 4 were excluded)

Nakama T et al, JACC Cardiovasc Interv, Jan 2017

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Cause of delayed wound healing

Nakama T et al, JACC Cardiovasc Interv, Jan 2017

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Primary Outcomes (WH)

211 days 365 days P=0.008 Nakama T et al, JACC Cardiovasc Interv, Jan 2017

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How

  • Anatomy
  • Plantar Loop, imaging views, anomalies
  • Wire/catheter/balloon and atherectomy techniques
  • Selective Angiography, Knuckle wire, reverse CART
  • Ultrasound guidance
  • Advance Access
  • Plantar, digital, occluded vessel access
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Angiography

  • Lateral Oblique View
  • 5th Meta-tarsal bone must be

separated

Manzi, M et al. Vascular Imaging of the Foot. RSNA 31(6), 2011

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Angiography

  • Anterior-Posterior View
  • 1st Metatarsal Space must be

visualized

Manzi, M et al. Vascular Imaging of the Foot. RSNA 31(6), 2011

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The clinical utility of below‐the‐ankle angioplasty using “transmetatarsal artery access” in complex cases of CLI

Catheterization and Cardiovascular Interventions, Volume: 83, Issue: 1, Pages: 123-129, First published: 20 May 2013, DOI: (10.1002/ccd.24992)

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Approach

  • Review prior angiograms
  • Antegrade access 5 or 6fr 45 cm sheath
  • 0.018 support catheter with 0.014 wire, change to 0.014 support catheter when traversing plantar

arch

  • Escalating strategy
  • True Lumen Crossing
  • Retrograde true lume crossing
  • Reverse CART/SAFARI
  • Digital Acess
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Wires

  • Regalia (Asahi Intecc)- 1g tip with superior steerabilty
  • Command (Abbott)- stainless steel body and a nitonol 2.8 gm tip
  • Gladius (Asahi Intecc) – 0.014 3g polymer jacket
  • Whisper (Abbott Vascular)- 0.8- 1.2 g hydrophilic tip
  • Fielder FC (Asahi Intecc) – 1.6g hydrophilic tip
  • Fielder XT (Asahi Intecc) – 0.009 hydrophilic tip; 0.8g
  • Halberd (Asahi Intecc)- 0.014 12g
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Wire Shaping

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Intervention

  • Primarily PTA
  • Atherectomy has been utilized
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Case

  • 67 year old female with Type 2 DM, non-smoker , cryptogenic

cirrhosis, with ischemic rest pain and non-healing toe ulcers, 2nd and 3rd digit

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Initial Angiography

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Initial Angiography

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Pedal Arch Wiring

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Pedal Arch Ballooning

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Final Angiography

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Conclusions

  • Pedal Loop reconstruction can be safely preformed in patients with

CLI allowing for improved wound healing

  • Further studies and registries are warranted to confirm long term

benefits and efficacy