H&P Key Factors in Decision-Making 73F with DM, COPD, PAD - - PowerPoint PPT Presentation

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Damage Control Revascularization: Live to Walk another Day?

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CLI: Treatment Goals

Relief of pain Healing of wounds Preservation of a functional limb Minimize risk of other major CV events

EFFECTIVE REVASCULARIZATION

EFFECTIVE LIFESTYLE MODIFICATION AND MEDICAL THERAPIES

General health of the patient

• Age, comorbidities, ambulatory status

Foot: likelihood of functional salvage Severity of limb ischemia Anatomic distribution of disease Prior vascular interventions Availability of autogenous vein for LEB

• Ipsilateral GSV > contralateral GSV > alternative veins
• Prosthetics and other non-autogenous conduits inferior

Revascularization Strategies in CLI: Key Factors in Decision-Making

• PATIENT RISK
• SEVERITY OF LIMB THREAT
• VASCULAR ANATOMY

H&P

73F with DM, COPD, PAD directly admitted from the Limb Preservation Clinic with worsening ischemia to the L toes for three months 1PPD x 40 years, no meds, no allergies, no prior vascular interventions PE:

• Vasc: DP, PT non-palpable bilaterally. DP, PT monophasic bilaterally.
• Derm: Dry gangrene to digits 1-3. Ischemia extending onto the dorsum of the L

foot with boggy skin necrosis centrally.

• Neuro: There is no loss of protective sensation with light touch to the bilateral

plantar feet Non-Invasives: ABI .43 TP 0 WIfI: 332 Amputation Risk High STAGE 3

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Is this limb salvageable?

• A. YES
• B. NO

Angiogram

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NO AUTOGENOUS VEIN AVAILABLE

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How would you manage this patient?

• A. Primary BKA
• B. Endovascular revascularization via contralateral access
• C. Endovascular revascularization via antegrade and pedal

access (leave iliac alone)

• D. Endovascular common iliac stenting alone
• E. Open bypass with PTFE +/- vein cuff
• F. Open bypass with cryopreserved allograft

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Initial Debridement

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What would be the next level of amputation to consider?

• A. BKA
• B. TMA
• C. Chopart’s amputation
• D. Lis Franc amputation

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Hybrid Therapy

• Left common femoral endarterectomy with patch

angioplasty.

• Left common iliac artery angioplasty and stent with 7

mm x 38 mm iCAST.

• Left common femoral to anterior tibial artery bypass

with CryoVein.

• Chopart’s Amputation

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Post-Procedural Angiogram

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4 week Post-Op Visit

Wound healing nicely Palpable Graft Pulse and Biphasic AT signal at 1 month Patient ambulatory with prescription shoe provided by podiatry

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3 Month F/U

Wound still with complete healing Patient ambulating with FWW

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Keys to Success in Limb Salvage

Treat the patient and the limb, not the lesion. Goal is to maintain FUNCTION Multidisciplinary care – limb preservation team TIME IS TISSUE- “don’t fiddle and diddle” Infection control always the first priority Success of the FIRST vascular procedure matters Technical success, then vigilant surveillance Long-term relationship with the patient includes medical management, vascular and podiatric surveillance