CRITICAL LIMB ISCHEMIA Hugo Londero MD, FSCAI Sanatorio Allende Cordoba-Argentina

CRITICAL LIMB ISCHEMIA Hugo Londero MD, FSCAI Sanatorio Allende Cordoba-Argentina

CRITICAL LIMB ISCHEMIA ACUTE Acute thrombosis of a chronic atherosclerotic lesion Acute embolism Atheroembolism Aneurysm thrombosis Arterial trauma Flegamasia Alba Dolens CHRONIC Progressive chronic lesions (Atherosclerosis +Thrombosis) Lesions at multiple territories Diffuse disease of the arteries bellow the knee Associated with diabetes = / HIGH AMPUTATION RATE

Critical Limb Ischemia: The natural history of CLI differs significantly from that of claudication. CLI is associated with a high risk of limb loss in the absence of revascularization, whereas claudication rarely progresses to the point of requiring amputation La claudicación puede producir una incapacidad tan importante como la IC severa o la EBPOC severa, afectando a un tercio de los pacientes con EAP Secundaria a compresión o irritación nerviosa, artritis o artrosis de cadera o rodilla; dolor neuropáticosecundario a neuropatía, desacondicionamiento físico

Critical Limb Ischemia (CLI) The prevalence of diabetes in the general population is around 8% and rising rapidly Diabetes increases the development of CLI about 5 times Diabetes increase leg amputations 5 to 10 times La EAP es igual a aterotrombosis de miembros inferiores, es el mismo proceso obstructivo que puede afectar a otros territorios, comparytiendo los mismos factores de riesgo

CRITICAL LIMB ISCHEMIA Over 90% of amputations performed each year in the USA are due to ischemia or infected gangrene1 30% of amputees below the knee will never walk again, like 70% of amputees above the knee2 After a major amputation: 60% have contra lateral amputation within 5 years, 50% died within 3 years3 1Krupski, In: Vascular Surgery, Robert Rutherford 2000, WB Saunders 2Armstrong, In: Diabetic Foot Managemnet, HMS 2000 3Tentolouris N et al. Diabetes Care 2004; 27:1598-1694

Critical limb ischemia (CLI) Persistent rest pain More than 15 days evolution Analgesics required Trophic disorders Systolic ankle pressure <50mmhg Systolic ankle pressure <30mmhg (diabetics) ABI less than 0,5 La EAP es igual a aterotrombosis de miembros inferiores, es el mismo proceso obstructivo que puede afectar a otros territorios, comparytiendo los mismos factores de riesgo Eur J Vasc Surg 1992;6(Suppl A):1-32

Trophic Disorders: Hyperkeratotic nails Dermal Keratosis Absence of hair Skin and subcutaneous tissue atrophy Peripheral edema Ischemic Ulcer Ischemic Gangrene

Physical Examination: Blush with hanging position… …pallor with leg elevation Angor inestable

The diagnosis of CLI is established with an ABI less than 0.5 Ankle Brachial Index The ABI for each limb is calculated by dividing the higher of the pressure at the ankle between the highest brachial pressure Easiest way to make the diagnosis The ABI in occlusions of only one arterial segment usually is between 0.5 and 0.8 ABI less than 0.5 are usually related with multiple territories disease Rest pain is usually associated with an ABI less than 0.4 The diagnosis of CLI is established with an ABI less than 0.5 Normalmente, la presión sistólica en el tobillo debe ser igual o mayor que en el brazo, es decir, la relación debe ser mayor o igual a 1 Falta añadir del NEJM la página 1611 La forma màs fácil y precoz de hacer el diagnóstico que debe realizarse en todo paciente mayor de 70 años, pacientes entre 50 y 69 con historia de DM y tabaquismo, cuando hay dolor de piernas al caminar, cuando hay un examen vascular anormal o cuando existe historia de enfermedad coronaria o renal

Pathophysiology of the Diabetic Foot Normal Foot Predisposing factors Foot at risk of lesion Triggers factors Lesion or ulcer Aggravating Factors Critical lesion AMPUTATION!!! GLUCEMIA TRAUMA INFECTION

When to do an Angiography ALWAYS In diabetics patients with Critical Limb Ischemia OCCASIONALLY in claudicants

Endovascular Treatement Multidisciplinary decision Patient clinical status To reestablish an straight line of flow to the foot LEG SALVAGGE – NO PERMEABLITY or COSMETIC

60 years, male Arterial Hypertension, type II diabetes, smoker, Chronic Renal failure (Cr:1,67mg/dl) Ischemic cardiomyopathy, CABG at 1994. 300 m. Claudication in both legs. Two month before, ischemic ulcer at the heel of the right foot. Duplex Scan: Severe lesion at right superficial femoral artery, Anterior and posterior tibial arteries occlusion, critical lesion at tibio-peroneal trunk

Cateter guia 6F

Tronco tibioperoneo y arteria peronea Balón 3/100 mm

Persistencia de lesion en la bifurcacion TTP y TA

Segunda guia a TTP y Kissing con balones de 3,5/28 Kissing Balón con 3,5/38 mm

Distal By Pass

Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia Marcello Romiti, MD,a Maximiano Albers, MD,a Francisco Cardoso Brochado-Neto, MD,a Anai Espinelli S. Durazzo, MD,b Carlos Alberto Bragança Pereira, PhD,c and Nelson De Luccia, MD,b Santos and São Paulo, Sao Paulo, Brazil Results: The pooled estimate of success was 89.0% _ 2.2% for immediate technical result. Results at 1 and 36 months were 77.4%_4.1% and 48.6%_8.0% for primary patency, 83.3%_1.4% and 62.9%_11.0% for secondary patency, 93.4%_2.3% and 82.4% _3.4% for limb salvage, and 98.3% 0.7% and 68.4% _ 5.5% for patient survival, respectively. Studies with >75% of the limbs with tissue loss fared worse than their respective comparative subgroup for technical success and patency but not for limb salvage or survival. No publication bias was detected. Conclusion: The technical success and subsequent durability of crural angioplasty are limited compared with bypass surgery, but the clinical benefit is acceptable because limb salvage rates are equivalent to bypass surgery. Further studies are necessary to determine the proper role of infrapopliteal angioplasty. (J Vasc Surg 2008;47:975-81.)

YUKON Trial (Bellow the knee long lesions) 161 pts YUKON Trial (Bellow the knee long lesions) 161 pts .randomized to SES or BMS (12 months follow up) .005 .004

DESTINY study (Drug Eluting Stents in the Critically Ischemic Lower Leg (Bosiers et al 2011) 154 patients randomized to MultiLink Vision/Xience V 12 month patency rate 85.2% 54.4% P=.0001

DESTINY study (Drug Eluting Stents in the Critically Ischemic Lower Leg (Bosiers et al 2011) 154 patients randomized to MultiLink Vision/Xience V 12 month limb salvage 98.7% 97.1% P=0.53

ANGIOSOMS

Wound blush

Final Comments Critical Limb Ischemia is a severe vascular disease with high amputation incidence in the short time. The objective of the treatment must be limb salvage. The endovascular treatment successes is high, but the artery patency is low. However the healing of the trophic lesions and limb salvage is high

Surgical Saw utilized in 1830 Thank you very much ! Surgical Saw utilized in 1830 for leg amputation