SlideShare a Scribd company logo

Challenges in the diabetic foot 2016

•Download as PPTX, PDF•
•
A
AMNCH Vascular Surgery

This document discusses the challenges in treating diabetic foot problems. It notes that neuropathy, deformity, trauma, ulceration, infection, ischemia and limb loss are common complications. A thorough assessment is needed to determine if the foot problem is neuropathic, ischemic, involves osteomyelitis, Charcot neuroarthropathy or a combination. Treatment depends on the underlying issues but may include offloading, antibiotics, debridement, revascularization procedures like angioplasty or bypass. Multidisciplinary care with specialists like vascular surgeons is important for managing the complex challenges of the diabetic foot.

Healthcare
1 of 59
Challenges in the Diabetic Foot Diabetic Foot Protection Service Tallaght Hospital, Dublin, Ireland Sean Tierney October 2016
Vascular surgery @ Tallaght Vascular disease Neuropathy Deformity Trauma UlcerHealing Limb loss
Vascular surgery @ Tallaght Vascular disease Neuropathy Deformity Trauma UlcerHealing Limb loss Ischaemia Infection/Osteomyelitis
Vascular surgery @ Tallaght The challenges • Is it neuropathic? • Is it ischaemic? or both • Is there osteomyelitis? • Is it Charcot? • What can we do about it?
Vascular surgery @ Tallaght Is there neuropathy? Sensory Motor Autonomic
Vascular surgery @ Tallaght Sensory neuropathy • -ve predictive value = 90%-98% • +ve predictive value = 18%-36% • 80% of foot ulcers and 100% of amputations occur in those with loss of sensation 32 mo followup J Fam Pract. 2000;49:S30 Diabetes Care. 1992;15:1386
Vascular surgery @ Tallaght Ipswich Touch test • If ≥2 (of 6) missed • Sensitivity 77% • Equivalent to SWMF Rayman G. Diabetes Care. Jul 2011; 34(7): 1517–1518.
Vascular surgery @ Tallaght Autonomic neuropathy
Vascular surgery @ Tallaght Autonomic neuropathy
Vascular surgery @ Tallaght Motor neuropathy Diabetes Care. 2001;24:1442 Diabetes Metab. 2003;29:261
Vascular surgery @ Tallaght Is it ischaemic?
Vascular surgery @ Tallaght Arterial supply Poitier et al, Eur J Vasc Endovasc 2011 • PAOD prevalence 9.5% - 13.6% • ~ 50% with ulcer • distal > proximal • Medial artery calcification more common
Vascular surgery @ Tallaght Is palpation of pulses reliable? DP only PT only Both Sensitivity 64 70 73 Specificity 81 83 92 NPV * 91 92 94 PPV 43 49 81 Accuracy 77 81 95 absent pulses • Negative predictive value of palpable pulses in excluding PAOD is 94% (vs ABI <0.9 as gold standard) Armstrong et al. Can J Cardiol 2010
Vascular surgery @ Tallaght ABI in Diabetes Poitier et al, Eur J Vasc Endovasc 2011
Vascular surgery @ Tallaght ABI in Diabetes Poitier et al, Eur J Vasc Endovasc 2011
Vascular surgery @ Tallaght <120s 60o <120s Beurger’s test -ve +ve
Vascular surgery @ Tallaght Toe pressure P>SBP
Vascular surgery @ Tallaght Toe pressure measurements • Less affected by medial calcification (neuropathy, CRF) • absolute toe pressure of <30 mmHg = critical ischemia • 1o healing of DFU – 85% TP >45 mmHg – 36% ≤45 mmHg (p < .001) * Brooks et al. Diabetic Medicine 2001, 18(12):528-532. * Apelqvist et al. Diabetes Care June 1989 12:6 373-378
Vascular surgery @ Tallaght Tissue oxygenation
Vascular surgery @ Tallaght Tissue oximetry & healing Londahl et al. Diabetolgia 2011
Vascular surgery @ Tallaght Tissue oximetry (summary) • tissue hypoxia is defined as “a TcPO2 <40 mm Hg” • associated with reduced likelihood of amputation healing • in critical limb ischemiaTcPO2 typically < 30 mm Hg Oxygen response • TcPO2 increases by > 40 mm Hg on 100% O2 usually associated with subsequent healing Fife et al. Undersea and Hyperbaric Medicine. 2009
Vascular surgery @ Tallaght • TcPO2 best in comparative analysis • Poor methodology • More research required
Vascular surgery @ Tallaght Is there osteomyelitis?
Vascular surgery @ Tallaght Clinical assessment • Debride – diagnostic and therapeutic • Probe wound - ?probes to bone • ?Bone biopsy • Imaging
Vascular surgery @ Tallaght Probes to bone Malhotra et al Diabet Foot Ankle. 2014
Vascular surgery @ Tallaght Plain XRay • osteopenia • periosteal thickening • cortical erosions • new bone formation • sequestrum • 30–50% bone loss required (2–3 weeks) • ? OM vs Charcot sensitivity 54% specificity 68% But NPV? Malhotra et al Diabet Foot Ankle. 2014
Vascular surgery @ Tallaght MRI Kapoor A et al. Arch Intern Med. 2007 • Early • Bone oedema (overdiagnosis) • vs Charcot ?? • “investigation of choice” sensitivity 90% specificity 80%
Vascular surgery @ Tallaght Scintigraphy • Tc-99m-Medronic Acid Bisphosphonate • sensitivity 80-90% specificity < 50% • inflammatory or trauma
Vascular surgery @ Tallaght Spect • CT • Isotope • Tc-99m + CT or MRI • ↑ specificity
Vascular surgery @ Tallaght Probes to bone Malhotra et al Diabet Foot Ankle. 2014
Vascular surgery @ Tallaght Is it Charcot?
Vascular surgery @ Tallaght Is it Charcot? • Swelling • Erythema • Neuropathy 100% • Pain 75% vs cellulitis vs osteomyelitis
Vascular surgery @ Tallaght Is it Charcot? • Xray – normal • MRI • Antibiotics ↓
Vascular surgery @ Tallaght What to do? Structural & neuropathy
Vascular surgery @ Tallaght Neuropathic ulcer Structural & neuropathy Offload Lewis J et al. Cochrane Database Syst Rev. 2013
Vascular surgery @ Tallaght Neuropathic ulcer
Vascular surgery @ Tallaght What to do? Structural & neuropathy Offload Ischaemia Osteomyelitis Acute Charcot
Vascular surgery @ Tallaght Osteomelitis – antibiotics tx • No sequestrum on Xray • No systemic sepsis +/- bone debridement/bx • 4 studies highly selected • 6/52 – 3/12 therapy + offloading • Healing in 60-80% • Urgent Sx in 1/3 • Recurrence in 1/3 Malhotra et al Diabet Foot Ankle. 2014
Vascular surgery @ Tallaght Osteomelitis - surgery • Antibiotics • Sliding scale • Surgical Debridement – all infected bone • Drainage
Vascular surgery @ Tallaght Infection • Multiple procedures • VAC closure • Offloading
Vascular surgery @ Tallaght What to do? Structural & neuropathy Offload Ischaemia Osteomyelitis Drain, debride, ABx Acute Charcot
Vascular surgery @ Tallaght Acute Charcot • Offload • Non-wt bearing • Assess stability clinical & Xray • Wait • 9-12 months
Vascular surgery @ Tallaght What to do? Structural & neuropathy Offload IschaemiaOsteomyelitis Drain, debride, ABx Acute Charcot Offload
Vascular surgery @ Tallaght Vascular Intervention Ischaemia Revascularisation
Vascular surgery @ Tallaght Imaging • Popliteal pulse – Angio • Femoral pulse – Duplex • ? Femoral pulse – CT Popposelli F. JVS 2010
Vascular surgery @ Tallaght Pedal Bypass surgery 0 20 40 60 80 100 0 6 12 18 24 30 36 42 48 54 60 Limbsurvivalasapercentage Time after surgery (months) Limb Salvage Good et al Ir J Med Sci 2010
Vascular surgery @ Tallaght Meta-analysis (pop pedal bypass) • N=1,2320 (79 studies) • @ 5 years • 1o patency 63% • 2o patency 71% • Limb salvage 78% • * 5 yr mortality ~50% Albers et al J Vasc Surg. 2006 43:498-503. *Hinchcliffe et al Diabetes Metab Res Review 2012
Vascular surgery @ Tallaght Patient Survival after Popliteo-pedal bypass 0 20 40 60 80 100 0 6 12 18 24 30 36 42 48 54 60 Time after surgery (months) Survivalasapercentage Pedal Bypass surgery Good et al Ir J Med Sci 2010
Vascular surgery @ Tallaght Options
Vascular surgery @ Tallaght Technical considerations • Consent • Ipsilateral (antegrade) • Local • ? 4/5Fr • ? ultrasound
Vascular surgery @ Tallaght Tibial angioplasty - results • 40 mo • 61 limbs in 53 patients (41 male, median age 73) • Rest pain /tissue loss) • TASC D O Connor et al ASGBI 2014
Vascular surgery @ Tallaght Tibial angioplasty – results 2 • Technical success 81.3% (49/61 limbs) • 2o procedure n=12 (4 distal bypass) • Survival (3 y) 72% • AFS (3 yr) 64% O Connor et al ASGBI 2014
Vascular surgery @ Tallaght Tibial angioplasty – meta-analysis • N = 2653 • Technical success = 90% @ 3 years • 1o patency 49% • 2o patency 63% • Limb salvage 80% • Survival 68% Romiti et al J Vas Surg 2008
Vascular surgery @ Tallaght Tibial angioplasty – meta-analysis • N = 2653 • Technical success = 90% • @ 3 years • 1o patency 49% • 2o patency 63% • Limb salvage 80% • Survival 68% Romiti et al J Vas Surg 2008 vs Bypass (@5 years) 63% 71% 78% 50% Albers et al J Vasc Surg. 2006 43:498-503.
Vascular surgery @ Tallaght Tibial artery disease • Sub-intimal vs luminal • Target vessels • 50% better healing rates • Re-assessment Lida O et al. J Vasc Surg. 2012; 55(2):363-370
Vascular surgery @ Tallaght The evidence?
Vascular surgery @ Tallaght Multidisciplinary care Nason et al. Ir J Med Sci 2013
Vascular surgery @ Tallaght
www.perfuse.net @theseant http://www.slideshare.net/stierney/diabetic-foot-2016

Recommended

Diabetic Foot 2016
Diabetic Foot 2016Diabetic Foot 2016
Diabetic Foot 2016
AMNCH Vascular Surgery
 
Establishing a Foot protection Clinic
Establishing a Foot protection ClinicEstablishing a Foot protection Clinic
Establishing a Foot protection Clinic
AMNCH Vascular Surgery
 
Dzavik V - AIMRADIAL 2014 - Rotablator and radial approach
Dzavik V - AIMRADIAL 2014 - Rotablator and radial approachDzavik V - AIMRADIAL 2014 - Rotablator and radial approach
Dzavik V - AIMRADIAL 2014 - Rotablator and radial approach
International Chair on Interventional Cardiology and Transradial Approach
 
Coppola J - AIMRADIAL 2014 - Left vs right radial access
Coppola J - AIMRADIAL 2014 - Left vs right radial accessCoppola J - AIMRADIAL 2014 - Left vs right radial access
Coppola J - AIMRADIAL 2014 - Left vs right radial access
International Chair on Interventional Cardiology and Transradial Approach
 
Bernat I - AIMRADIAL 2013 - STEMI-RADIAL trial
Bernat I - AIMRADIAL 2013 - STEMI-RADIAL trialBernat I - AIMRADIAL 2013 - STEMI-RADIAL trial
Bernat I - AIMRADIAL 2013 - STEMI-RADIAL trial
International Chair on Interventional Cardiology and Transradial Approach
 
Van Leeuwen M - AIMRADIAL 2015 - Upper limb function
Van Leeuwen M - AIMRADIAL 2015 - Upper limb functionVan Leeuwen M - AIMRADIAL 2015 - Upper limb function
Van Leeuwen M - AIMRADIAL 2015 - Upper limb function
International Chair on Interventional Cardiology and Transradial Approach
 
Montalescot G - AIMRADIAL 2013 - Prasugrel and radial
Montalescot G - AIMRADIAL 2013 - Prasugrel and radialMontalescot G - AIMRADIAL 2013 - Prasugrel and radial
Montalescot G - AIMRADIAL 2013 - Prasugrel and radial
International Chair on Interventional Cardiology and Transradial Approach
 
Bernat I - AIMRADIAL 2014 Technical - Radial artery occlusion
Bernat I - AIMRADIAL 2014 Technical - Radial artery occlusionBernat I - AIMRADIAL 2014 Technical - Radial artery occlusion
Bernat I - AIMRADIAL 2014 Technical - Radial artery occlusion
International Chair on Interventional Cardiology and Transradial Approach
 

Recommended

Diabetic Foot 2016
Diabetic Foot 2016Diabetic Foot 2016
Diabetic Foot 2016
AMNCH Vascular Surgery
 
Establishing a Foot protection Clinic
Establishing a Foot protection ClinicEstablishing a Foot protection Clinic
Establishing a Foot protection Clinic
AMNCH Vascular Surgery
 
Dzavik V - AIMRADIAL 2014 - Rotablator and radial approach
Dzavik V - AIMRADIAL 2014 - Rotablator and radial approachDzavik V - AIMRADIAL 2014 - Rotablator and radial approach
Dzavik V - AIMRADIAL 2014 - Rotablator and radial approach
International Chair on Interventional Cardiology and Transradial Approach
 
Coppola J - AIMRADIAL 2014 - Left vs right radial access
Coppola J - AIMRADIAL 2014 - Left vs right radial accessCoppola J - AIMRADIAL 2014 - Left vs right radial access
Coppola J - AIMRADIAL 2014 - Left vs right radial access
International Chair on Interventional Cardiology and Transradial Approach
 
Bernat I - AIMRADIAL 2013 - STEMI-RADIAL trial
Bernat I - AIMRADIAL 2013 - STEMI-RADIAL trialBernat I - AIMRADIAL 2013 - STEMI-RADIAL trial
Bernat I - AIMRADIAL 2013 - STEMI-RADIAL trial
International Chair on Interventional Cardiology and Transradial Approach
 
Van Leeuwen M - AIMRADIAL 2015 - Upper limb function
Van Leeuwen M - AIMRADIAL 2015 - Upper limb functionVan Leeuwen M - AIMRADIAL 2015 - Upper limb function
Van Leeuwen M - AIMRADIAL 2015 - Upper limb function
International Chair on Interventional Cardiology and Transradial Approach
 
Montalescot G - AIMRADIAL 2013 - Prasugrel and radial
Montalescot G - AIMRADIAL 2013 - Prasugrel and radialMontalescot G - AIMRADIAL 2013 - Prasugrel and radial
Montalescot G - AIMRADIAL 2013 - Prasugrel and radial
International Chair on Interventional Cardiology and Transradial Approach
 
Bernat I - AIMRADIAL 2014 Technical - Radial artery occlusion
Bernat I - AIMRADIAL 2014 Technical - Radial artery occlusionBernat I - AIMRADIAL 2014 Technical - Radial artery occlusion
Bernat I - AIMRADIAL 2014 Technical - Radial artery occlusion
International Chair on Interventional Cardiology and Transradial Approach
 
Koutouzis M - AIMRADIAL 2015 - Transradial and negative Allen test
Koutouzis M - AIMRADIAL 2015 - Transradial and negative Allen testKoutouzis M - AIMRADIAL 2015 - Transradial and negative Allen test
Koutouzis M - AIMRADIAL 2015 - Transradial and negative Allen test
International Chair on Interventional Cardiology and Transradial Approach
 
Gilchrist IC 201305
Gilchrist IC 201305Gilchrist IC 201305
Gilchrist IC 201305
International Chair on Interventional Cardiology and Transradial Approach
 
Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approach
Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approachSciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approach
Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approach
International Chair on Interventional Cardiology and Transradial Approach
 
Benamer H
Benamer HBenamer H
Benamer H
International Chair on Interventional Cardiology and Transradial Approach
 
Porto I - AIMRADIAL 2014 - Bleeding and events
Porto I - AIMRADIAL 2014 - Bleeding and eventsPorto I - AIMRADIAL 2014 - Bleeding and events
Porto I - AIMRADIAL 2014 - Bleeding and events
International Chair on Interventional Cardiology and Transradial Approach
 
Cohen MG - Transradial access - 201507
Cohen MG - Transradial access - 201507Cohen MG - Transradial access - 201507
Cohen MG - Transradial access - 201507
International Chair on Interventional Cardiology and Transradial Approach
 
Kanovsky J - AIMRADIAL 2014 - Radial artery remodeling
Kanovsky J - AIMRADIAL 2014 - Radial artery remodelingKanovsky J - AIMRADIAL 2014 - Radial artery remodeling
Kanovsky J - AIMRADIAL 2014 - Radial artery remodeling
International Chair on Interventional Cardiology and Transradial Approach
 
Applegate RJ - AIMRADIAL 2014 - Learning curve
Applegate RJ - AIMRADIAL 2014 - Learning curveApplegate RJ - AIMRADIAL 2014 - Learning curve
Applegate RJ - AIMRADIAL 2014 - Learning curve
International Chair on Interventional Cardiology and Transradial Approach
 
Pejkov H - AIMRADIAL 2014 - Anatomical variations
Pejkov H - AIMRADIAL 2014 - Anatomical variationsPejkov H - AIMRADIAL 2014 - Anatomical variations
Pejkov H - AIMRADIAL 2014 - Anatomical variations
International Chair on Interventional Cardiology and Transradial Approach
 
Kwok CS - AIMRADIAL 2014 - Gender, syndrome, clinical outcomes
Kwok CS - AIMRADIAL 2014 - Gender, syndrome, clinical outcomesKwok CS - AIMRADIAL 2014 - Gender, syndrome, clinical outcomes
Kwok CS - AIMRADIAL 2014 - Gender, syndrome, clinical outcomes
International Chair on Interventional Cardiology and Transradial Approach
 
Yeh RW - Femoral vs radial: evidence - 201507
Yeh RW - Femoral vs radial: evidence - 201507Yeh RW - Femoral vs radial: evidence - 201507
Yeh RW - Femoral vs radial: evidence - 201507
International Chair on Interventional Cardiology and Transradial Approach
 
Dzavik V - AIMRADIAL 2014 - Radial artery size
Dzavik V - AIMRADIAL 2014 - Radial artery sizeDzavik V - AIMRADIAL 2014 - Radial artery size
Dzavik V - AIMRADIAL 2014 - Radial artery size
International Chair on Interventional Cardiology and Transradial Approach
 
Patel TM 201111
Patel TM 201111Patel TM 201111
Patel TM 201111
International Chair on Interventional Cardiology and Transradial Approach
 
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunctionBiederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction
International Chair on Interventional Cardiology and Transradial Approach
 
Bienert I - AIMRADIAL 2015 - Exposure
Bienert I - AIMRADIAL 2015 - ExposureBienert I - AIMRADIAL 2015 - Exposure
Bienert I - AIMRADIAL 2015 - Exposure
International Chair on Interventional Cardiology and Transradial Approach
 
Gabric ID - AIMRADIAL 2014 - Primary PCI and left radial approach
Gabric ID - AIMRADIAL 2014 - Primary PCI and left radial approachGabric ID - AIMRADIAL 2014 - Primary PCI and left radial approach
Gabric ID - AIMRADIAL 2014 - Primary PCI and left radial approach
International Chair on Interventional Cardiology and Transradial Approach
 
Kirtane AJ - AIMRADIAL 2014 - Bivalirudin anticoagulation
Kirtane AJ - AIMRADIAL 2014 - Bivalirudin anticoagulationKirtane AJ - AIMRADIAL 2014 - Bivalirudin anticoagulation
Kirtane AJ - AIMRADIAL 2014 - Bivalirudin anticoagulation
International Chair on Interventional Cardiology and Transradial Approach
 
Rao SV 2014
Rao SV 2014Rao SV 2014
Rao SV 2014
International Chair on Interventional Cardiology and Transradial Approach
 
Cortese B - AIMRADIAL 2014 Endovascular - Iliac intervention
Cortese B - AIMRADIAL 2014 Endovascular - Iliac interventionCortese B - AIMRADIAL 2014 Endovascular - Iliac intervention
Cortese B - AIMRADIAL 2014 Endovascular - Iliac intervention
International Chair on Interventional Cardiology and Transradial Approach
 
Bertrand OF - AIMRADIAL 2013 - Radial in 100%?
Bertrand OF - AIMRADIAL 2013 - Radial in 100%?Bertrand OF - AIMRADIAL 2013 - Radial in 100%?
Bertrand OF - AIMRADIAL 2013 - Radial in 100%?
International Chair on Interventional Cardiology and Transradial Approach
 
Providing a lymphoedema service
Providing a lymphoedema serviceProviding a lymphoedema service
Providing a lymphoedema service
AMNCH Vascular Surgery
 
Beyond consent
Beyond consentBeyond consent
Beyond consent
AMNCH Vascular Surgery
 

More Related Content

What's hot

Koutouzis M - AIMRADIAL 2015 - Transradial and negative Allen test
Koutouzis M - AIMRADIAL 2015 - Transradial and negative Allen testKoutouzis M - AIMRADIAL 2015 - Transradial and negative Allen test
Koutouzis M - AIMRADIAL 2015 - Transradial and negative Allen test
International Chair on Interventional Cardiology and Transradial Approach
 
Gilchrist IC 201305
Gilchrist IC 201305Gilchrist IC 201305
Gilchrist IC 201305
International Chair on Interventional Cardiology and Transradial Approach
 
Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approach
Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approachSciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approach
Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approach
International Chair on Interventional Cardiology and Transradial Approach
 
Benamer H
Benamer HBenamer H
Benamer H
International Chair on Interventional Cardiology and Transradial Approach
 
Porto I - AIMRADIAL 2014 - Bleeding and events
Porto I - AIMRADIAL 2014 - Bleeding and eventsPorto I - AIMRADIAL 2014 - Bleeding and events
Porto I - AIMRADIAL 2014 - Bleeding and events
International Chair on Interventional Cardiology and Transradial Approach
 
Cohen MG - Transradial access - 201507
Cohen MG - Transradial access - 201507Cohen MG - Transradial access - 201507
Cohen MG - Transradial access - 201507
International Chair on Interventional Cardiology and Transradial Approach
 
Kanovsky J - AIMRADIAL 2014 - Radial artery remodeling
Kanovsky J - AIMRADIAL 2014 - Radial artery remodelingKanovsky J - AIMRADIAL 2014 - Radial artery remodeling
Kanovsky J - AIMRADIAL 2014 - Radial artery remodeling
International Chair on Interventional Cardiology and Transradial Approach
 
Applegate RJ - AIMRADIAL 2014 - Learning curve
Applegate RJ - AIMRADIAL 2014 - Learning curveApplegate RJ - AIMRADIAL 2014 - Learning curve
Applegate RJ - AIMRADIAL 2014 - Learning curve
International Chair on Interventional Cardiology and Transradial Approach
 
Pejkov H - AIMRADIAL 2014 - Anatomical variations
Pejkov H - AIMRADIAL 2014 - Anatomical variationsPejkov H - AIMRADIAL 2014 - Anatomical variations
Pejkov H - AIMRADIAL 2014 - Anatomical variations
International Chair on Interventional Cardiology and Transradial Approach
 
Kwok CS - AIMRADIAL 2014 - Gender, syndrome, clinical outcomes
Kwok CS - AIMRADIAL 2014 - Gender, syndrome, clinical outcomesKwok CS - AIMRADIAL 2014 - Gender, syndrome, clinical outcomes
Kwok CS - AIMRADIAL 2014 - Gender, syndrome, clinical outcomes
International Chair on Interventional Cardiology and Transradial Approach
 
Yeh RW - Femoral vs radial: evidence - 201507
Yeh RW - Femoral vs radial: evidence - 201507Yeh RW - Femoral vs radial: evidence - 201507
Yeh RW - Femoral vs radial: evidence - 201507
International Chair on Interventional Cardiology and Transradial Approach
 
Dzavik V - AIMRADIAL 2014 - Radial artery size
Dzavik V - AIMRADIAL 2014 - Radial artery sizeDzavik V - AIMRADIAL 2014 - Radial artery size
Dzavik V - AIMRADIAL 2014 - Radial artery size
International Chair on Interventional Cardiology and Transradial Approach
 
Patel TM 201111
Patel TM 201111Patel TM 201111
Patel TM 201111
International Chair on Interventional Cardiology and Transradial Approach
 
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunctionBiederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction
International Chair on Interventional Cardiology and Transradial Approach
 
Bienert I - AIMRADIAL 2015 - Exposure
Bienert I - AIMRADIAL 2015 - ExposureBienert I - AIMRADIAL 2015 - Exposure
Bienert I - AIMRADIAL 2015 - Exposure
International Chair on Interventional Cardiology and Transradial Approach
 
Gabric ID - AIMRADIAL 2014 - Primary PCI and left radial approach
Gabric ID - AIMRADIAL 2014 - Primary PCI and left radial approachGabric ID - AIMRADIAL 2014 - Primary PCI and left radial approach
Gabric ID - AIMRADIAL 2014 - Primary PCI and left radial approach
International Chair on Interventional Cardiology and Transradial Approach
 
Kirtane AJ - AIMRADIAL 2014 - Bivalirudin anticoagulation
Kirtane AJ - AIMRADIAL 2014 - Bivalirudin anticoagulationKirtane AJ - AIMRADIAL 2014 - Bivalirudin anticoagulation
Kirtane AJ - AIMRADIAL 2014 - Bivalirudin anticoagulation
International Chair on Interventional Cardiology and Transradial Approach
 
Rao SV 2014
Rao SV 2014Rao SV 2014
Rao SV 2014
International Chair on Interventional Cardiology and Transradial Approach
 
Cortese B - AIMRADIAL 2014 Endovascular - Iliac intervention
Cortese B - AIMRADIAL 2014 Endovascular - Iliac interventionCortese B - AIMRADIAL 2014 Endovascular - Iliac intervention
Cortese B - AIMRADIAL 2014 Endovascular - Iliac intervention
International Chair on Interventional Cardiology and Transradial Approach
 
Bertrand OF - AIMRADIAL 2013 - Radial in 100%?
Bertrand OF - AIMRADIAL 2013 - Radial in 100%?Bertrand OF - AIMRADIAL 2013 - Radial in 100%?
Bertrand OF - AIMRADIAL 2013 - Radial in 100%?
International Chair on Interventional Cardiology and Transradial Approach
 

What's hot (20)

Koutouzis M - AIMRADIAL 2015 - Transradial and negative Allen test
Koutouzis M - AIMRADIAL 2015 - Transradial and negative Allen testKoutouzis M - AIMRADIAL 2015 - Transradial and negative Allen test
Koutouzis M - AIMRADIAL 2015 - Transradial and negative Allen test
 
Gilchrist IC 201305
Gilchrist IC 201305Gilchrist IC 201305
Gilchrist IC 201305
 
Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approach
Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approachSciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approach
Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approach
 
Benamer H
Benamer HBenamer H
Benamer H
 
Porto I - AIMRADIAL 2014 - Bleeding and events
Porto I - AIMRADIAL 2014 - Bleeding and eventsPorto I - AIMRADIAL 2014 - Bleeding and events
Porto I - AIMRADIAL 2014 - Bleeding and events
 
Cohen MG - Transradial access - 201507
Cohen MG - Transradial access - 201507Cohen MG - Transradial access - 201507
Cohen MG - Transradial access - 201507
 
Kanovsky J - AIMRADIAL 2014 - Radial artery remodeling
Kanovsky J - AIMRADIAL 2014 - Radial artery remodelingKanovsky J - AIMRADIAL 2014 - Radial artery remodeling
Kanovsky J - AIMRADIAL 2014 - Radial artery remodeling
 
Applegate RJ - AIMRADIAL 2014 - Learning curve
Applegate RJ - AIMRADIAL 2014 - Learning curveApplegate RJ - AIMRADIAL 2014 - Learning curve
Applegate RJ - AIMRADIAL 2014 - Learning curve
 
Pejkov H - AIMRADIAL 2014 - Anatomical variations
Pejkov H - AIMRADIAL 2014 - Anatomical variationsPejkov H - AIMRADIAL 2014 - Anatomical variations
Pejkov H - AIMRADIAL 2014 - Anatomical variations
 
Kwok CS - AIMRADIAL 2014 - Gender, syndrome, clinical outcomes
Kwok CS - AIMRADIAL 2014 - Gender, syndrome, clinical outcomesKwok CS - AIMRADIAL 2014 - Gender, syndrome, clinical outcomes
Kwok CS - AIMRADIAL 2014 - Gender, syndrome, clinical outcomes
 
Yeh RW - Femoral vs radial: evidence - 201507
Yeh RW - Femoral vs radial: evidence - 201507Yeh RW - Femoral vs radial: evidence - 201507
Yeh RW - Femoral vs radial: evidence - 201507
 
Dzavik V - AIMRADIAL 2014 - Radial artery size
Dzavik V - AIMRADIAL 2014 - Radial artery sizeDzavik V - AIMRADIAL 2014 - Radial artery size
Dzavik V - AIMRADIAL 2014 - Radial artery size
 
Patel TM 201111
Patel TM 201111Patel TM 201111
Patel TM 201111
 
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunctionBiederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction
 
Bienert I - AIMRADIAL 2015 - Exposure
Bienert I - AIMRADIAL 2015 - ExposureBienert I - AIMRADIAL 2015 - Exposure
Bienert I - AIMRADIAL 2015 - Exposure
 
Gabric ID - AIMRADIAL 2014 - Primary PCI and left radial approach
Gabric ID - AIMRADIAL 2014 - Primary PCI and left radial approachGabric ID - AIMRADIAL 2014 - Primary PCI and left radial approach
Gabric ID - AIMRADIAL 2014 - Primary PCI and left radial approach
 
Kirtane AJ - AIMRADIAL 2014 - Bivalirudin anticoagulation
Kirtane AJ - AIMRADIAL 2014 - Bivalirudin anticoagulationKirtane AJ - AIMRADIAL 2014 - Bivalirudin anticoagulation
Kirtane AJ - AIMRADIAL 2014 - Bivalirudin anticoagulation
 
Rao SV 2014
Rao SV 2014Rao SV 2014
Rao SV 2014
 
Cortese B - AIMRADIAL 2014 Endovascular - Iliac intervention
Cortese B - AIMRADIAL 2014 Endovascular - Iliac interventionCortese B - AIMRADIAL 2014 Endovascular - Iliac intervention
Cortese B - AIMRADIAL 2014 Endovascular - Iliac intervention
 
Bertrand OF - AIMRADIAL 2013 - Radial in 100%?
Bertrand OF - AIMRADIAL 2013 - Radial in 100%?Bertrand OF - AIMRADIAL 2013 - Radial in 100%?
Bertrand OF - AIMRADIAL 2013 - Radial in 100%?
 

Viewers also liked

Providing a lymphoedema service
Providing a lymphoedema serviceProviding a lymphoedema service
Providing a lymphoedema service
AMNCH Vascular Surgery
 
Beyond consent
Beyond consentBeyond consent
Beyond consent
AMNCH Vascular Surgery
 
Introduction to vascular surgery
Introduction to vascular surgeryIntroduction to vascular surgery
Introduction to vascular surgery
AMNCH Vascular Surgery
 
Wound management Association Ireland 2011
Wound management Association Ireland 2011Wound management Association Ireland 2011
Wound management Association Ireland 2011
AMNCH Vascular Surgery
 
Vascular emergencies tcd sjh 2017
Vascular emergencies tcd sjh 2017Vascular emergencies tcd sjh 2017
Vascular emergencies tcd sjh 2017
AMNCH Vascular Surgery
 
Faculty of radiologists 2015
Faculty of radiologists 2015Faculty of radiologists 2015
Faculty of radiologists 2015
AMNCH Vascular Surgery
 
Rcsi global surgery (final)
Rcsi global surgery (final)Rcsi global surgery (final)
Rcsi global surgery (final)
AMNCH Vascular Surgery
 
Tierney communication 2011
Tierney communication 2011Tierney communication 2011
Tierney communication 2011
AMNCH Vascular Surgery
 
Professor Tim O'Brien, Director of REMEDI (Regenerative Medicine Institute
Professor Tim O'Brien, Director of REMEDI (Regenerative Medicine InstituteProfessor Tim O'Brien, Director of REMEDI (Regenerative Medicine Institute
Professor Tim O'Brien, Director of REMEDI (Regenerative Medicine Institute
Investnet
 
Approach to leg ulcers
Approach to leg ulcersApproach to leg ulcers
Approach to leg ulcers
AMNCH Vascular Surgery
 
Unimed Presentation - Dr. Donald Pelto
Unimed Presentation - Dr. Donald PeltoUnimed Presentation - Dr. Donald Pelto
Unimed Presentation - Dr. Donald Pelto
Donald Pelto
 
Diabetic Foot Evidence 2010
Diabetic Foot Evidence 2010Diabetic Foot Evidence 2010
Diabetic Foot Evidence 2010
ISCHEMIC CARDIOPATHY
 
Diabetic Foot
Diabetic FootDiabetic Foot
Diabetic Foot
Ahmed Moamen
 
Vascular trauma
Vascular traumaVascular trauma
Vascular trauma
Joel Arudchelvam MBBS, MD, MRCS, FCSSL
 
Vascular techniques
Vascular techniquesVascular techniques
Vascular techniques
AMNCH Vascular Surgery
 
Peripheral Vascular Injuries
Peripheral Vascular InjuriesPeripheral Vascular Injuries
Peripheral Vascular Injuries
Lateef Khan
 
Arterial trauma
Arterial traumaArterial trauma
Arterial trauma
Joel Arudchelvam MBBS, MD, MRCS, FCSSL
 
The diabetic foot - Derek Park
The diabetic foot - Derek ParkThe diabetic foot - Derek Park
The diabetic foot - Derek Park
Derek Park
 
Abdominal vascular injuries
Abdominal vascular injuriesAbdominal vascular injuries
Abdominal vascular injuries
Abdulsalam Taha
 
extremity Vascular trauma / injury
extremity Vascular trauma / injuryextremity Vascular trauma / injury
extremity Vascular trauma / injury
Joel Arudchelvam MBBS, MD, MRCS, FCSSL
 

Viewers also liked (20)

Providing a lymphoedema service
Providing a lymphoedema serviceProviding a lymphoedema service
Providing a lymphoedema service
 
Beyond consent
Beyond consentBeyond consent
Beyond consent
 
Introduction to vascular surgery
Introduction to vascular surgeryIntroduction to vascular surgery
Introduction to vascular surgery
 
Wound management Association Ireland 2011
Wound management Association Ireland 2011Wound management Association Ireland 2011
Wound management Association Ireland 2011
 
Vascular emergencies tcd sjh 2017
Vascular emergencies tcd sjh 2017Vascular emergencies tcd sjh 2017
Vascular emergencies tcd sjh 2017
 
Faculty of radiologists 2015
Faculty of radiologists 2015Faculty of radiologists 2015
Faculty of radiologists 2015
 
Rcsi global surgery (final)
Rcsi global surgery (final)Rcsi global surgery (final)
Rcsi global surgery (final)
 
Tierney communication 2011
Tierney communication 2011Tierney communication 2011
Tierney communication 2011
 
Professor Tim O'Brien, Director of REMEDI (Regenerative Medicine Institute
Professor Tim O'Brien, Director of REMEDI (Regenerative Medicine InstituteProfessor Tim O'Brien, Director of REMEDI (Regenerative Medicine Institute
Professor Tim O'Brien, Director of REMEDI (Regenerative Medicine Institute
 
Approach to leg ulcers
Approach to leg ulcersApproach to leg ulcers
Approach to leg ulcers
 
Unimed Presentation - Dr. Donald Pelto
Unimed Presentation - Dr. Donald PeltoUnimed Presentation - Dr. Donald Pelto
Unimed Presentation - Dr. Donald Pelto
 
Diabetic Foot Evidence 2010
Diabetic Foot Evidence 2010Diabetic Foot Evidence 2010
Diabetic Foot Evidence 2010
 
Diabetic Foot
Diabetic FootDiabetic Foot
Diabetic Foot
 
Vascular trauma
Vascular traumaVascular trauma
Vascular trauma
 
Vascular techniques
Vascular techniquesVascular techniques
Vascular techniques
 
Peripheral Vascular Injuries
Peripheral Vascular InjuriesPeripheral Vascular Injuries
Peripheral Vascular Injuries
 
Arterial trauma
Arterial traumaArterial trauma
Arterial trauma
 
The diabetic foot - Derek Park
The diabetic foot - Derek ParkThe diabetic foot - Derek Park
The diabetic foot - Derek Park
 
Abdominal vascular injuries
Abdominal vascular injuriesAbdominal vascular injuries
Abdominal vascular injuries
 
extremity Vascular trauma / injury
extremity Vascular trauma / injuryextremity Vascular trauma / injury
extremity Vascular trauma / injury
 

Similar to Challenges in the diabetic foot 2016

Diabetic foot 2015
Diabetic foot 2015Diabetic foot 2015
Diabetic foot 2015
AMNCH Vascular Surgery
 
Contemporary management of iliofemoral venous thrombosis
Contemporary management of iliofemoral venous thrombosisContemporary management of iliofemoral venous thrombosis
Contemporary management of iliofemoral venous thrombosis
uvcd
 
RAPTOR
RAPTORRAPTOR
RAPTOR
CICM 2019 Annual Scientific Meeting
 
La rivascolarizzazione degli arti inferiori nel paziente anziano: rischi e va...
La rivascolarizzazione degli arti inferiori nel paziente anziano: rischi e va...La rivascolarizzazione degli arti inferiori nel paziente anziano: rischi e va...
La rivascolarizzazione degli arti inferiori nel paziente anziano: rischi e va...
ASMaD
 
Complex Aortic Arch Surgery
Complex Aortic Arch SurgeryComplex Aortic Arch Surgery
Complex Aortic Arch Surgery
Dicky A Wartono
 
Quels impact de l'hépatopathie sous jacente? - Dr Andrea Laurenzi
Quels impact de l'hépatopathie sous jacente? - Dr Andrea LaurenziQuels impact de l'hépatopathie sous jacente? - Dr Andrea Laurenzi
Quels impact de l'hépatopathie sous jacente? - Dr Andrea Laurenzi
Centre Hepato-Biliaire / AP-HP Hopital Paul Brousse
 
Proximal femoral fractures
Proximal femoral fracturesProximal femoral fractures
Proximal femoral fractures
Mohamed Abulsoud
 
Descending aortic aneurysm
Descending aortic aneurysmDescending aortic aneurysm
Descending aortic aneurysm
AhmedElBorae1
 
proximalfemoralfractures-180330205050.pptx
proximalfemoralfractures-180330205050.pptxproximalfemoralfractures-180330205050.pptx
proximalfemoralfractures-180330205050.pptx
gufp
 
Carotid surgery 2014
Carotid surgery 2014Carotid surgery 2014
Carotid surgery 2014
AMNCH Vascular Surgery
 
Avascular necrosis of hip
Avascular necrosis of hipAvascular necrosis of hip
Avascular necrosis of hip
vinod naneria
 
Evar in ruptured aaa + fast track 9.7.61
Evar in ruptured aaa + fast track 9.7.61Evar in ruptured aaa + fast track 9.7.61
Evar in ruptured aaa + fast track 9.7.61
Mai Parachy
 
Cohen MG 201305
Cohen MG 201305Cohen MG 201305
Cohen MG 201305
International Chair on Interventional Cardiology and Transradial Approach
 
Dvt prophylaxis in orthopaedic surgery
Dvt prophylaxis in orthopaedic surgeryDvt prophylaxis in orthopaedic surgery
Dvt prophylaxis in orthopaedic surgery
NamithRangaswamy
 
1-Spine Pasternak Mayo.pptx
1-Spine Pasternak Mayo.pptx1-Spine Pasternak Mayo.pptx
1-Spine Pasternak Mayo.pptx
KhuMinhLi
 
Small bladder capacity on kidney transplantation
Small bladder capacity on kidney transplantationSmall bladder capacity on kidney transplantation
Small bladder capacity on kidney transplantation
VNINH46
 
Challenges of Radial Access-Anatomy, Tools and Success
Challenges of Radial Access-Anatomy, Tools and SuccessChallenges of Radial Access-Anatomy, Tools and Success
Challenges of Radial Access-Anatomy, Tools and Success
Mir Ahmed
 
03 aimradial2016 thu2 J Roberts
03 aimradial2016 thu2 J Roberts03 aimradial2016 thu2 J Roberts
03 aimradial2016 thu2 J Roberts
International Chair on Interventional Cardiology and Transradial Approach
 
06 Olivecrona aimradial20170922 Radial CTO
06 Olivecrona aimradial20170922 Radial CTO06 Olivecrona aimradial20170922 Radial CTO
06 Olivecrona aimradial20170922 Radial CTO
International Chair on Interventional Cardiology and Transradial Approach
 
Postoperative AKI
Postoperative AKIPostoperative AKI
Postoperative AKI
scanFOAM
 

Similar to Challenges in the diabetic foot 2016 (20)

Diabetic foot 2015
Diabetic foot 2015Diabetic foot 2015
Diabetic foot 2015
 
Contemporary management of iliofemoral venous thrombosis
Contemporary management of iliofemoral venous thrombosisContemporary management of iliofemoral venous thrombosis
Contemporary management of iliofemoral venous thrombosis
 
RAPTOR
RAPTORRAPTOR
RAPTOR
 
La rivascolarizzazione degli arti inferiori nel paziente anziano: rischi e va...
La rivascolarizzazione degli arti inferiori nel paziente anziano: rischi e va...La rivascolarizzazione degli arti inferiori nel paziente anziano: rischi e va...
La rivascolarizzazione degli arti inferiori nel paziente anziano: rischi e va...
 
Complex Aortic Arch Surgery
Complex Aortic Arch SurgeryComplex Aortic Arch Surgery
Complex Aortic Arch Surgery
 
Quels impact de l'hépatopathie sous jacente? - Dr Andrea Laurenzi
Quels impact de l'hépatopathie sous jacente? - Dr Andrea LaurenziQuels impact de l'hépatopathie sous jacente? - Dr Andrea Laurenzi
Quels impact de l'hépatopathie sous jacente? - Dr Andrea Laurenzi
 
Proximal femoral fractures
Proximal femoral fracturesProximal femoral fractures
Proximal femoral fractures
 
Descending aortic aneurysm
Descending aortic aneurysmDescending aortic aneurysm
Descending aortic aneurysm
 
proximalfemoralfractures-180330205050.pptx
proximalfemoralfractures-180330205050.pptxproximalfemoralfractures-180330205050.pptx
proximalfemoralfractures-180330205050.pptx
 
Carotid surgery 2014
Carotid surgery 2014Carotid surgery 2014
Carotid surgery 2014
 
Avascular necrosis of hip
Avascular necrosis of hipAvascular necrosis of hip
Avascular necrosis of hip
 
Evar in ruptured aaa + fast track 9.7.61
Evar in ruptured aaa + fast track 9.7.61Evar in ruptured aaa + fast track 9.7.61
Evar in ruptured aaa + fast track 9.7.61
 
Cohen MG 201305
Cohen MG 201305Cohen MG 201305
Cohen MG 201305
 
Dvt prophylaxis in orthopaedic surgery
Dvt prophylaxis in orthopaedic surgeryDvt prophylaxis in orthopaedic surgery
Dvt prophylaxis in orthopaedic surgery
 
1-Spine Pasternak Mayo.pptx
1-Spine Pasternak Mayo.pptx1-Spine Pasternak Mayo.pptx
1-Spine Pasternak Mayo.pptx
 
Small bladder capacity on kidney transplantation
Small bladder capacity on kidney transplantationSmall bladder capacity on kidney transplantation
Small bladder capacity on kidney transplantation
 
Challenges of Radial Access-Anatomy, Tools and Success
Challenges of Radial Access-Anatomy, Tools and SuccessChallenges of Radial Access-Anatomy, Tools and Success
Challenges of Radial Access-Anatomy, Tools and Success
 
03 aimradial2016 thu2 J Roberts
03 aimradial2016 thu2 J Roberts03 aimradial2016 thu2 J Roberts
03 aimradial2016 thu2 J Roberts
 
06 Olivecrona aimradial20170922 Radial CTO
06 Olivecrona aimradial20170922 Radial CTO06 Olivecrona aimradial20170922 Radial CTO
06 Olivecrona aimradial20170922 Radial CTO
 
Postoperative AKI
Postoperative AKIPostoperative AKI
Postoperative AKI
 

More from AMNCH Vascular Surgery

Peripheral vascular disease 2015
Peripheral vascular disease 2015Peripheral vascular disease 2015
Peripheral vascular disease 2015
AMNCH Vascular Surgery
 
Acute limb ischaemia
Acute limb ischaemiaAcute limb ischaemia
Acute limb ischaemia
AMNCH Vascular Surgery
 
Abdominal Aortic Aneurysm 2015
Abdominal Aortic Aneurysm 2015Abdominal Aortic Aneurysm 2015
Abdominal Aortic Aneurysm 2015
AMNCH Vascular Surgery
 
Venous issues 2014
Venous issues 2014Venous issues 2014
Venous issues 2014
AMNCH Vascular Surgery
 
Pcs sligo 2013
Pcs sligo 2013Pcs sligo 2013
Pcs sligo 2013
AMNCH Vascular Surgery
 
Vascular trauma
Vascular traumaVascular trauma
Vascular trauma
AMNCH Vascular Surgery
 
Introduction
IntroductionIntroduction
Introduction
AMNCH Vascular Surgery
 

More from AMNCH Vascular Surgery (7)

Peripheral vascular disease 2015
Peripheral vascular disease 2015Peripheral vascular disease 2015
Peripheral vascular disease 2015
 
Acute limb ischaemia
Acute limb ischaemiaAcute limb ischaemia
Acute limb ischaemia
 
Abdominal Aortic Aneurysm 2015
Abdominal Aortic Aneurysm 2015Abdominal Aortic Aneurysm 2015
Abdominal Aortic Aneurysm 2015
 
Venous issues 2014
Venous issues 2014Venous issues 2014
Venous issues 2014
 
Pcs sligo 2013
Pcs sligo 2013Pcs sligo 2013
Pcs sligo 2013
 
Vascular trauma
Vascular traumaVascular trauma
Vascular trauma
 
Introduction
IntroductionIntroduction
Introduction
 

Recently uploaded

Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)
Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)
Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)
bkling
 
Psychedelic Retreat Portugal - Escape to Lighthouse Retreats for an unforgett...
Psychedelic Retreat Portugal - Escape to Lighthouse Retreats for an unforgett...Psychedelic Retreat Portugal - Escape to Lighthouse Retreats for an unforgett...
Psychedelic Retreat Portugal - Escape to Lighthouse Retreats for an unforgett...
Lighthouse Retreat
 
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardso...
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardso...TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardso...
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardso...
rightmanforbloodline
 
Innovative Minds France's Most Impactful Healthcare Leaders.pdf
Innovative Minds France's Most Impactful Healthcare Leaders.pdfInnovative Minds France's Most Impactful Healthcare Leaders.pdf
Innovative Minds France's Most Impactful Healthcare Leaders.pdf
eurohealthleaders
 
HUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COM
HUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COMHUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COM
HUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COM
priyabhojwani1200
 
Common Challenges in Dermatology Billing and How to Overcome.pptx
Common Challenges in Dermatology Billing and How to Overcome.pptxCommon Challenges in Dermatology Billing and How to Overcome.pptx
Common Challenges in Dermatology Billing and How to Overcome.pptx
patriciaava1998
 
Pediatric Emergency Care for Children | Apollo Hospital
Pediatric Emergency Care for Children | Apollo HospitalPediatric Emergency Care for Children | Apollo Hospital
Pediatric Emergency Care for Children | Apollo Hospital
Apollo 24/7 Adult & Paediatric Emergency Services
 
DRAFT Ventilator Rapid Reference version 2.4.pdf
DRAFT Ventilator Rapid Reference version 2.4.pdfDRAFT Ventilator Rapid Reference version 2.4.pdf
DRAFT Ventilator Rapid Reference version 2.4.pdf
Robert Cole
 
CCSN_June_06 2024_jones. Cancer Rehabpptx
CCSN_June_06 2024_jones. Cancer RehabpptxCCSN_June_06 2024_jones. Cancer Rehabpptx
CCSN_June_06 2024_jones. Cancer Rehabpptx
Canadian Cancer Survivor Network
 
LEAD Innovation Launch_WHO Innovation Initiative.pptx
LEAD Innovation Launch_WHO Innovation Initiative.pptxLEAD Innovation Launch_WHO Innovation Initiative.pptx
LEAD Innovation Launch_WHO Innovation Initiative.pptx
ChetanSharma78255
 
Exploring the Benefits of Binaural Hearing: Why Two Hearing Aids Are Better T...
Exploring the Benefits of Binaural Hearing: Why Two Hearing Aids Are Better T...Exploring the Benefits of Binaural Hearing: Why Two Hearing Aids Are Better T...
Exploring the Benefits of Binaural Hearing: Why Two Hearing Aids Are Better T...
Ear Solutions (ESPL)
 
Tips for Pet Care in winters How to take care of pets.
Tips for Pet Care in winters How to take care of pets.Tips for Pet Care in winters How to take care of pets.
Tips for Pet Care in winters How to take care of pets.
Dinesh Chauhan
 
chatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdf
chatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdfchatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdf
chatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdf
marynayjun112024
 
Bath patient Fundamental of Nursing.pptx
Bath patient Fundamental of Nursing.pptxBath patient Fundamental of Nursing.pptx
Bath patient Fundamental of Nursing.pptx
MianProductions
 
PET CT beginners Guide covers some of the underrepresented topics in PET CT
PET CT beginners Guide covers some of the underrepresented topics in PET CTPET CT beginners Guide covers some of the underrepresented topics in PET CT
PET CT beginners Guide covers some of the underrepresented topics in PET CT
MiadAlsulami
 
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
DR Jag Mohan Prajapati
 
NKTI Annual Report - Annual Report FY 2022
NKTI Annual Report - Annual Report FY 2022NKTI Annual Report - Annual Report FY 2022
NKTI Annual Report - Annual Report FY 2022
nktiacc3
 
Top massage center in ajman chandrima Spa
Top massage center in ajman chandrima SpaTop massage center in ajman chandrima Spa
Top massage center in ajman chandrima Spa
Chandrima Spa Ajman
 
CANSA support - Caring for Cancer Patients' Caregivers
CANSA support - Caring for Cancer Patients' CaregiversCANSA support - Caring for Cancer Patients' Caregivers
CANSA support - Caring for Cancer Patients' Caregivers
CANSA The Cancer Association of South Africa
 
Bringing AI into a Mid-Sized Company: A structured Approach
Bringing AI into a Mid-Sized Company: A structured ApproachBringing AI into a Mid-Sized Company: A structured Approach
Bringing AI into a Mid-Sized Company: A structured Approach
Brian Frerichs
 

Recently uploaded (20)

Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)
Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)
Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)
 
Psychedelic Retreat Portugal - Escape to Lighthouse Retreats for an unforgett...
Psychedelic Retreat Portugal - Escape to Lighthouse Retreats for an unforgett...Psychedelic Retreat Portugal - Escape to Lighthouse Retreats for an unforgett...
Psychedelic Retreat Portugal - Escape to Lighthouse Retreats for an unforgett...
 
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardso...
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardso...TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardso...
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardso...
 
Innovative Minds France's Most Impactful Healthcare Leaders.pdf
Innovative Minds France's Most Impactful Healthcare Leaders.pdfInnovative Minds France's Most Impactful Healthcare Leaders.pdf
Innovative Minds France's Most Impactful Healthcare Leaders.pdf
 
HUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COM
HUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COMHUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COM
HUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COM
 
Common Challenges in Dermatology Billing and How to Overcome.pptx
Common Challenges in Dermatology Billing and How to Overcome.pptxCommon Challenges in Dermatology Billing and How to Overcome.pptx
Common Challenges in Dermatology Billing and How to Overcome.pptx
 
Pediatric Emergency Care for Children | Apollo Hospital
Pediatric Emergency Care for Children | Apollo HospitalPediatric Emergency Care for Children | Apollo Hospital
Pediatric Emergency Care for Children | Apollo Hospital
 
DRAFT Ventilator Rapid Reference version 2.4.pdf
DRAFT Ventilator Rapid Reference version 2.4.pdfDRAFT Ventilator Rapid Reference version 2.4.pdf
DRAFT Ventilator Rapid Reference version 2.4.pdf
 
CCSN_June_06 2024_jones. Cancer Rehabpptx
CCSN_June_06 2024_jones. Cancer RehabpptxCCSN_June_06 2024_jones. Cancer Rehabpptx
CCSN_June_06 2024_jones. Cancer Rehabpptx
 
LEAD Innovation Launch_WHO Innovation Initiative.pptx
LEAD Innovation Launch_WHO Innovation Initiative.pptxLEAD Innovation Launch_WHO Innovation Initiative.pptx
LEAD Innovation Launch_WHO Innovation Initiative.pptx
 
Exploring the Benefits of Binaural Hearing: Why Two Hearing Aids Are Better T...
Exploring the Benefits of Binaural Hearing: Why Two Hearing Aids Are Better T...Exploring the Benefits of Binaural Hearing: Why Two Hearing Aids Are Better T...
Exploring the Benefits of Binaural Hearing: Why Two Hearing Aids Are Better T...
 
Tips for Pet Care in winters How to take care of pets.
Tips for Pet Care in winters How to take care of pets.Tips for Pet Care in winters How to take care of pets.
Tips for Pet Care in winters How to take care of pets.
 
chatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdf
chatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdfchatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdf
chatgptfornlp-230314021506-2f03f614.pdf. 21506-2f03f614.pdf
 
Bath patient Fundamental of Nursing.pptx
Bath patient Fundamental of Nursing.pptxBath patient Fundamental of Nursing.pptx
Bath patient Fundamental of Nursing.pptx
 
PET CT beginners Guide covers some of the underrepresented topics in PET CT
PET CT beginners Guide covers some of the underrepresented topics in PET CTPET CT beginners Guide covers some of the underrepresented topics in PET CT
PET CT beginners Guide covers some of the underrepresented topics in PET CT
 
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
 
NKTI Annual Report - Annual Report FY 2022
NKTI Annual Report - Annual Report FY 2022NKTI Annual Report - Annual Report FY 2022
NKTI Annual Report - Annual Report FY 2022
 
Top massage center in ajman chandrima Spa
Top massage center in ajman chandrima SpaTop massage center in ajman chandrima Spa
Top massage center in ajman chandrima Spa
 
CANSA support - Caring for Cancer Patients' Caregivers
CANSA support - Caring for Cancer Patients' CaregiversCANSA support - Caring for Cancer Patients' Caregivers
CANSA support - Caring for Cancer Patients' Caregivers
 
Bringing AI into a Mid-Sized Company: A structured Approach
Bringing AI into a Mid-Sized Company: A structured ApproachBringing AI into a Mid-Sized Company: A structured Approach
Bringing AI into a Mid-Sized Company: A structured Approach
 

Challenges in the diabetic foot 2016

  • 1. Challenges in the Diabetic Foot Diabetic Foot Protection Service Tallaght Hospital, Dublin, Ireland Sean Tierney October 2016
  • 2. Vascular surgery @ Tallaght Vascular disease Neuropathy Deformity Trauma UlcerHealing Limb loss
  • 3. Vascular surgery @ Tallaght Vascular disease Neuropathy Deformity Trauma UlcerHealing Limb loss Ischaemia Infection/Osteomyelitis
  • 4. Vascular surgery @ Tallaght The challenges • Is it neuropathic? • Is it ischaemic? or both • Is there osteomyelitis? • Is it Charcot? • What can we do about it?
  • 5. Vascular surgery @ Tallaght Is there neuropathy? Sensory Motor Autonomic
  • 6. Vascular surgery @ Tallaght Sensory neuropathy • -ve predictive value = 90%-98% • +ve predictive value = 18%-36% • 80% of foot ulcers and 100% of amputations occur in those with loss of sensation 32 mo followup J Fam Pract. 2000;49:S30 Diabetes Care. 1992;15:1386
  • 7. Vascular surgery @ Tallaght Ipswich Touch test • If ≥2 (of 6) missed • Sensitivity 77% • Equivalent to SWMF Rayman G. Diabetes Care. Jul 2011; 34(7): 1517–1518.
  • 8. Vascular surgery @ Tallaght Autonomic neuropathy
  • 9. Vascular surgery @ Tallaght Autonomic neuropathy
  • 10. Vascular surgery @ Tallaght Motor neuropathy Diabetes Care. 2001;24:1442 Diabetes Metab. 2003;29:261
  • 11. Vascular surgery @ Tallaght Is it ischaemic?
  • 12. Vascular surgery @ Tallaght Arterial supply Poitier et al, Eur J Vasc Endovasc 2011 • PAOD prevalence 9.5% - 13.6% • ~ 50% with ulcer • distal > proximal • Medial artery calcification more common
  • 13. Vascular surgery @ Tallaght Is palpation of pulses reliable? DP only PT only Both Sensitivity 64 70 73 Specificity 81 83 92 NPV * 91 92 94 PPV 43 49 81 Accuracy 77 81 95 absent pulses • Negative predictive value of palpable pulses in excluding PAOD is 94% (vs ABI <0.9 as gold standard) Armstrong et al. Can J Cardiol 2010
  • 14. Vascular surgery @ Tallaght ABI in Diabetes Poitier et al, Eur J Vasc Endovasc 2011
  • 15. Vascular surgery @ Tallaght ABI in Diabetes Poitier et al, Eur J Vasc Endovasc 2011
  • 16. Vascular surgery @ Tallaght <120s 60o <120s Beurger’s test -ve +ve
  • 17. Vascular surgery @ Tallaght Toe pressure P>SBP
  • 18. Vascular surgery @ Tallaght Toe pressure measurements • Less affected by medial calcification (neuropathy, CRF) • absolute toe pressure of <30 mmHg = critical ischemia • 1o healing of DFU – 85% TP >45 mmHg – 36% ≤45 mmHg (p < .001) * Brooks et al. Diabetic Medicine 2001, 18(12):528-532. * Apelqvist et al. Diabetes Care June 1989 12:6 373-378
  • 19. Vascular surgery @ Tallaght Tissue oxygenation
  • 20. Vascular surgery @ Tallaght Tissue oximetry & healing Londahl et al. Diabetolgia 2011
  • 21. Vascular surgery @ Tallaght Tissue oximetry (summary) • tissue hypoxia is defined as “a TcPO2 <40 mm Hg” • associated with reduced likelihood of amputation healing • in critical limb ischemiaTcPO2 typically < 30 mm Hg Oxygen response • TcPO2 increases by > 40 mm Hg on 100% O2 usually associated with subsequent healing Fife et al. Undersea and Hyperbaric Medicine. 2009
  • 22. Vascular surgery @ Tallaght • TcPO2 best in comparative analysis • Poor methodology • More research required
  • 23. Vascular surgery @ Tallaght Is there osteomyelitis?
  • 24. Vascular surgery @ Tallaght Clinical assessment • Debride – diagnostic and therapeutic • Probe wound - ?probes to bone • ?Bone biopsy • Imaging
  • 25. Vascular surgery @ Tallaght Probes to bone Malhotra et al Diabet Foot Ankle. 2014
  • 26. Vascular surgery @ Tallaght Plain XRay • osteopenia • periosteal thickening • cortical erosions • new bone formation • sequestrum • 30–50% bone loss required (2–3 weeks) • ? OM vs Charcot sensitivity 54% specificity 68% But NPV? Malhotra et al Diabet Foot Ankle. 2014
  • 27. Vascular surgery @ Tallaght MRI Kapoor A et al. Arch Intern Med. 2007 • Early • Bone oedema (overdiagnosis) • vs Charcot ?? • “investigation of choice” sensitivity 90% specificity 80%
  • 28. Vascular surgery @ Tallaght Scintigraphy • Tc-99m-Medronic Acid Bisphosphonate • sensitivity 80-90% specificity < 50% • inflammatory or trauma
  • 29. Vascular surgery @ Tallaght Spect • CT • Isotope • Tc-99m + CT or MRI • ↑ specificity
  • 30. Vascular surgery @ Tallaght Probes to bone Malhotra et al Diabet Foot Ankle. 2014
  • 31. Vascular surgery @ Tallaght Is it Charcot?
  • 32. Vascular surgery @ Tallaght Is it Charcot? • Swelling • Erythema • Neuropathy 100% • Pain 75% vs cellulitis vs osteomyelitis
  • 33. Vascular surgery @ Tallaght Is it Charcot? • Xray – normal • MRI • Antibiotics ↓
  • 34. Vascular surgery @ Tallaght What to do? Structural & neuropathy
  • 35. Vascular surgery @ Tallaght Neuropathic ulcer Structural & neuropathy Offload Lewis J et al. Cochrane Database Syst Rev. 2013
  • 36. Vascular surgery @ Tallaght Neuropathic ulcer
  • 37. Vascular surgery @ Tallaght What to do? Structural & neuropathy Offload Ischaemia Osteomyelitis Acute Charcot
  • 38. Vascular surgery @ Tallaght Osteomelitis – antibiotics tx • No sequestrum on Xray • No systemic sepsis +/- bone debridement/bx • 4 studies highly selected • 6/52 – 3/12 therapy + offloading • Healing in 60-80% • Urgent Sx in 1/3 • Recurrence in 1/3 Malhotra et al Diabet Foot Ankle. 2014
  • 39. Vascular surgery @ Tallaght Osteomelitis - surgery • Antibiotics • Sliding scale • Surgical Debridement – all infected bone • Drainage
  • 40. Vascular surgery @ Tallaght Infection • Multiple procedures • VAC closure • Offloading
  • 41. Vascular surgery @ Tallaght What to do? Structural & neuropathy Offload Ischaemia Osteomyelitis Drain, debride, ABx Acute Charcot
  • 42. Vascular surgery @ Tallaght Acute Charcot • Offload • Non-wt bearing • Assess stability clinical & Xray • Wait • 9-12 months
  • 43. Vascular surgery @ Tallaght What to do? Structural & neuropathy Offload IschaemiaOsteomyelitis Drain, debride, ABx Acute Charcot Offload
  • 44. Vascular surgery @ Tallaght Vascular Intervention Ischaemia Revascularisation
  • 45. Vascular surgery @ Tallaght Imaging • Popliteal pulse – Angio • Femoral pulse – Duplex • ? Femoral pulse – CT Popposelli F. JVS 2010
  • 46. Vascular surgery @ Tallaght Pedal Bypass surgery 0 20 40 60 80 100 0 6 12 18 24 30 36 42 48 54 60 Limbsurvivalasapercentage Time after surgery (months) Limb Salvage Good et al Ir J Med Sci 2010
  • 47. Vascular surgery @ Tallaght Meta-analysis (pop pedal bypass) • N=1,2320 (79 studies) • @ 5 years • 1o patency 63% • 2o patency 71% • Limb salvage 78% • * 5 yr mortality ~50% Albers et al J Vasc Surg. 2006 43:498-503. *Hinchcliffe et al Diabetes Metab Res Review 2012
  • 48. Vascular surgery @ Tallaght Patient Survival after Popliteo-pedal bypass 0 20 40 60 80 100 0 6 12 18 24 30 36 42 48 54 60 Time after surgery (months) Survivalasapercentage Pedal Bypass surgery Good et al Ir J Med Sci 2010
  • 49. Vascular surgery @ Tallaght Options
  • 50. Vascular surgery @ Tallaght Technical considerations • Consent • Ipsilateral (antegrade) • Local • ? 4/5Fr • ? ultrasound
  • 51. Vascular surgery @ Tallaght Tibial angioplasty - results • 40 mo • 61 limbs in 53 patients (41 male, median age 73) • Rest pain /tissue loss) • TASC D O Connor et al ASGBI 2014
  • 52. Vascular surgery @ Tallaght Tibial angioplasty – results 2 • Technical success 81.3% (49/61 limbs) • 2o procedure n=12 (4 distal bypass) • Survival (3 y) 72% • AFS (3 yr) 64% O Connor et al ASGBI 2014
  • 53. Vascular surgery @ Tallaght Tibial angioplasty – meta-analysis • N = 2653 • Technical success = 90% @ 3 years • 1o patency 49% • 2o patency 63% • Limb salvage 80% • Survival 68% Romiti et al J Vas Surg 2008
  • 54. Vascular surgery @ Tallaght Tibial angioplasty – meta-analysis • N = 2653 • Technical success = 90% • @ 3 years • 1o patency 49% • 2o patency 63% • Limb salvage 80% • Survival 68% Romiti et al J Vas Surg 2008 vs Bypass (@5 years) 63% 71% 78% 50% Albers et al J Vasc Surg. 2006 43:498-503.
  • 55. Vascular surgery @ Tallaght Tibial artery disease • Sub-intimal vs luminal • Target vessels • 50% better healing rates • Re-assessment Lida O et al. J Vasc Surg. 2012; 55(2):363-370
  • 56. Vascular surgery @ Tallaght The evidence?
  • 57. Vascular surgery @ Tallaght Multidisciplinary care Nason et al. Ir J Med Sci 2013
  • 58. Vascular surgery @ Tallaght