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

CLI: Treatment Goals � Relief of pain � Healing of wounds � Preservation of a functional limb Damage Control Revascularization: Live to EFFECTIVE REVASCULARIZATION Walk another Day? � Minimize risk of other major CV events EFFECTIVE LIFESTYLE MODIFICATION AND MEDICAL THERAPIES 4/16/2016 Revascularization Strategies in CLI: H&P Key Factors in Decision-Making � 73F with DM, COPD, PAD directly admitted from the Limb Preservation Clinic with worsening ischemia to the L toes for three months � General health of the patient • PATIENT RISK � 1PPD x 40 years, no meds, no allergies, no prior vascular interventions • Age, comorbidities, ambulatory status � Foot: likelihood of functional salvage � PE: � Severity of limb ischemia • Vasc: DP, PT non-palpable bilaterally. DP, PT monophasic bilaterally. � Anatomic distribution of disease • SEVERITY OF LIMB THREAT • Derm: Dry gangrene to digits 1-3. Ischemia extending onto the dorsum of the L � Prior vascular interventions foot with boggy skin necrosis centrally. � Availability of autogenous vein for LEB • Neuro: There is no loss of protective sensation with light touch to the bilateral • Ipsilateral GSV > contralateral GSV > alternative veins plantar feet • Prosthetics and other non-autogenous conduits inferior • VASCULAR ANATOMY � Non-Invasives: ABI .43 TP 0 � WIfI: 332 Amputation Risk High STAGE 3 4 4/16/2016 1 4/16/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Is this limb salvageable? A. YES B. NO 5 4/16/2016 Angiogram NO AUTOGENOUS VEIN AVAILABLE 7 4/16/2016 4/16/2016 2 4/16/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Initial Debridement 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 9 4/16/2016 10 4/16/2016 What would be the next Hybrid Therapy level of amputation to consider? • Left common femoral endarterectomy with patch A. BKA angioplasty. B. TMA • Left common iliac artery angioplasty and stent with 7 mm x 38 mm iCAST. C. Chopart’s amputation • Left common femoral to anterior tibial artery bypass D. Lis Franc amputation with CryoVein. • Chopart’s Amputation 11 4/16/2016 12 4/16/2016 3 4/16/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Post-Procedural Angiogram 13 4/16/2016 3 Month F/U 4 week Post-Op Visit � Wound still with complete healing � Wound healing nicely � Patient ambulating with � Palpable Graft Pulse and Biphasic AT signal at 1 month FWW � Patient ambulatory with prescription shoe provided by podiatry 15 4/16/2016 16 4/16/2016 4 4/16/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

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 5 4/16/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]