4. WHY WE SHOULD REVASCULARIZE
THESE PATIENTS WITH CLI
5 -YEAR SURVIVAL
- After revascularisation 70 %
- After a major Amputation 26 %
Difference is highly significant: p = 0.014
6. TASC 2000
The original TransAtlantic InterSociety
Consensus (TASC) published in 2000 was the
first international consensus on the diagnosis
and treatment of PAD
7. TASC II primarily designed to provide
guidance for primary care physicians
Easy-to-read document (67 vs. 296 pages)
Not intended for vascular specialists !
TASC II - 2007
8. A number of aspects are not updated
It is not exhaustively referenced
Recommendations are deliberately simplified
Fails to recognize that more can be done with
endovascular and open techniques
2007 TASC LITE…
11. TASC A
TASC B
TASC C
TASC D
Definition for stenosis? > 50 %?
Heavy calcified lesion?
Absence of tibial vessels?
Total poplital artery occlusion?
Poplital artery stenosis?
?
?
?
?
14. Diabetics
Patients with CLI
Graziani L et al. EJVES 2007;33:453-60
BELOW THE KNEE LESIONS ?
36%36%
11%11% 27%27%
74%
Lesions located
in crural arteries
15. TASC II Classification for femoropopliteal lesions
allows wide individual interpretations and therefore,
the common use of this classification as a basis of
decision making and reporting outcome can be
questioned.
FEMOROPOPLITEAL LESIONS
17. TASC II B [2011]TASC II B [2011]
• Not endorsed by the SVS and by the ESVS
• Recommendations were not the product of rigorous
scientific scrutinity
• TASC II B advocates an endovascular first option even
in patients with claudication secondary to an isolated
tibial artery disease while there is no Grade A/B
supporting this conclusion
18. TASC II B [2011]TASC II B [2011]
TASC II B guidelines adopt a primarily
anatomical approach, which pays
insufficient attention to the clinical
symptoms and risk factors
19. EuropeanJournalofVascular&EndovascularSurgeryELSEVIER
Journal
European Journal of
Vascular & Endovascular Surgery
Celebrating our Silver Jubilee ...
www.ejves.com
pp.S1-S90Volume42Supplement2December2011
Volume 42 Supplement 2 December 2011 ISSN 1078-5884
Management of
Clinical Practice Guidelines
of the
European Society for Vascular Surgery
Critical Limb Ischaemia and Diabetic Foot
37. AK-FEMOROPOPLITEAL BYPASS
PROSTHESIS vs. GREAT SAPHENOUS VEIN
STUDIES Pereira
2006 Meta-analysis
Pereira
2006 Meta-analysis
Patients
Follow-up
1713 / 580
5 years
2431 / 703
5 years
Symptoms Claudication Critical Ischemia
Prim. Pat. PTFE 57.4% 48.3%
Prim. Pat. SV 77.2%
p<0.05
69.4%
p<0.05
Sec. Pat. PTFE 73.2% 54.0%
Sec. Pat. SV 80.1%
p<0.05
71.9%
p<0.05
A Saphenous vein
PERFORMS better than A prosthesis
EVEN ABOVE THE KNEE
38. AK-FEMOROPOPLITEAL BYPASS
PTFE vs. POLYESTER
STUDIES Jensen
2007 RCT (2 ans)
Takagi
2010 Meta-analysis (5
ans)
Patients PTFE/Polyester PTFE/Polyester
Symptoms 65% Cl / 35% CLI NA
Primary Pat. PTFE 57% 38.4%
Primary Pat. Polyester 70%
p=0.02
49.2%
Secondary Pat. PTFE 65% NA
Secondary Pat. Polyester 76%
p=0.04
NA
ABOVE THE KNEE
POLYESTER IS COMPARABLE TO PTFE
39. BK-FEMORO-POPLITEAL BYPASS
GREAT SAPHENOUS VEIN vs. PROSTHESIS
STUDIES Pereira
2006 (5 years)
Albers
2003 (5 years)
Patients 3779 43 studies
Symptoms Cl 35% / CLI 65% NA
Graft used SAPHENOUS VEIN PROSTHESIS
Primary Patency 64.8% Cl
68.9% CLI
30.5%
Secondary Patency 79.7% Cl
77.8% CLI
39.7%
Limb Salvage NA 55.7%
BELOW THE KNEE A Saphenous vein
IS better than A prosthesis
40. STUDIES Albers
2005 (5 years)
Albers
2003 (5 years)
Patients 2618 43 études
Symptoms Cl 3% /CLI 97% NA
Graft used ARM VEIN PROSTHESIS
Primary Patency 46.9% 30.5%
Secondary Patency 66.5% 39.7%
Limb Salvage 76.4% 55.7%
BELOW THE KNEE ANY vein
IS better than A prosthesis
BK-FEMORO-POPLITEAL BYPASS
PROSTHESIS vs. ALTERNATIVE VEIN
43. STUDIES Albers
2004 M
Albers
2004 M
Albers
2004 M
Albers
2004 M
Albers
2003 M
Patients
Follow-up
687
5 years
218
5 years
157
5 years
1254
5 years
43 studies
5 years
Symptômes CLI CLI CLI CLI CLI
MATERIAL Venous
Allograft
cryopreserved
Arterial
Allograft
cryopreserved
Venous
Allograft
Fresh
Ombilical
Vein
PROSTHESIS
Primary Patency NA NA NA NA 30.5%
Secondary
Patency
19% 21% 24% 30% 39.7%
Limb Salvage 60% 68% 39% 55% 55.7%
An ALLOGRAFT IS NOT BETTER THAN a PROSTHESIS
TIBIAL BYPASS - ALLOGRAFT
53. ENDOVASCULAR PROCEDURES
TASC ? N (%)
A 1 (0,6%)
B 61 (34,9%)
C 75 (42,9%)
D 38 (21,7%)
RUN-OFF [LEG] N (%)
0 23 (13,1%)
1 94 (53,7%)
2 52 (29,7%)
3 6 (3,4%)
M Desvergnes et al. University of Poitiers, non-published data, 2013
57. PRIMARY PATENCY FOR ENDOVASCULAR
SIMPLE ANGIOPLASTY IS BETTER THAN STENT
AND SUBINTIMAL ANGIOPLASTY IS BEHIND
58. BASIL: MAJOR ENDPOINTS
Amputation free survival (AFS) overall survival (OS, years)
For patients surviving > 2 years, a bypass first strategy was associated
with an increase in overall survival of 7.3 months (p=0.02) and an
increase in amputation-free-survival of 5.9 months (P=0.06) during a
follow-up of 3.1 years.
59. • 27% of all PTAs failed within 8 weeks
after randomisation vs. surgery 7%
(p<0.001)
• 75% of all failed PTAs were treated
surgically
• Surgery after failed PTA had a
significant worse AFS than initial bypass
surgery (p=0.006)
• Amputation free survival was
significantly better with vein grafts
(p=0.003)
BASIL: FURTHER RESULTS
69. ANGIOSOMES - RESULTS
0 1 2 3 4 5
YEARS
42%
vs. 39%
38%
vs. 39%
PRIMARYPATENCY
P=0,931
Angiosome Direct
Angiosome Indirect
0 1 2 3 4 5 YEARS
81%
vs. 80%
80%
vs. 79%
P=0,856
LIMBSALVAGE
Angiosome Direct
Angiosome Indirect
No difference in patency or limb salvage between
angiosome-direct or indirect endovascular procedures
CHU POITIERS
175 ENDOVASCULAR PROCEDURES
CHU POITIERS
175 ENDOVASCULAR PROCEDURES
70. ANGIOSOMES – DATA PUBLISHED
• Retrospective studies, heterogeneity of data
• No propensity analysis
Editor's Notes
Thank you Dr Veith, Dr Katzen. After TASC I published in 2000 which was a comprehensive and updated document
TASC II published in 2007 has disappointed a number of vascular specialists and did not meet their expectations of a major update. Apparently this was due to a common misconception about the intended purpose of TASC II which was to a significant degree aimed at referring physicians.
Read the slide
As the TASC consensus aims to recommend the preferable method of revascularization according to an anatomic classification.
AND is used in scientific reports to characterize patients population and treated lesions.
A major criticism of TASC II was the difficulty to use this anatomical classification particularly for infrainguinal arterial lesions
Many details are lacking in this classification,
Including the degree of stenosis, presence of heavily calcified lesions, doubt concerning the classification of total occlusion of the popliteal artery and 1-2/3 trifurcation vessels.
making the grading of the lesions cumbersome and allowing individual interpretations, which of course, diminishes the applicability of the classification and the value of these guidelines.
This a lesion with several potential classifications, TASC B or TASC D.
And this lesion is not fitting to any of the TASC II classes.
With ignorance of all isolated tibial arteries lesions so frequent in patients with CLI and in diabetic patients.
Read the slide
We were expecting some improvement when TASC Iib was send to the vascular surgical societies for approval, but despite some efforts this Iib version was misleading
Read the text
We hope that the TASC III committee will consider some of these issues, pending their decision, we are publishing next month the ESVS clinical guidelines on CLI and diabetic foot that covers some aspects of this problem. Thank you for your attention.
TASC should also not ignore extreme bypasses in these difficult situations
An endovascular first option is probably not the best option in these patients with CLI and only a distal artery open to the foot but a goos great saphenous vein available
And also the value of subintimal recanalization in tailored indications and not as an “endovascular first systematic option” particularly is the life expectancy of the patient is above 2 years
241 patients en ischémie critique des membres inférieurs
140 patients du groupe endovasculaire
Taux de perméabilité des 175 procédures endovasculaires : perméabilité primaire, primaire assistée et secondaire
Proportion élevée de lésions TASC C et D (mauvais pronostic en termes de perméabilité primaire) Forte proportion de lit d’aval précaire : Les données de la littérature suggèrent que la présence d’un lit d’aval précaire diminue les taux de perméabilité Nous avons donc analysé la perméabilité primaire des procédures endovasculaires en fonction du nombre d’axes jambiers perméables en les divisant en 2 groupes : Groupe 1 ( 0 ou 1 axe jambier perméable) Groupe 2 (2 ou 3 axes perméables) : pas de différence significative
Association lit d’aval précaire et lésions sévères peut expliquer les mauvais résultats.
Taux de perméabilité des 175 procédures endovasculaires : perméabilité primaire, primaire assistée et secondaire
Taux de perméabilité des 175 procédures endovasculaires : perméabilité primaire, primaire assistée et secondaire
Taux de perméabilité des 175 procédures endovasculaires : perméabilité primaire, primaire assistée et secondaire
Différence statistiquement significative en termes de perméabilité primaire, primaire assistée et secondaire
L’ensemble de ces données ne confirme donc pas l’amélioration attendue de la diffusion des stents nitinol et confirme les mauvais résultats de l’angioplastie sous-intimale en termes de perméabilité.
L’un des facteurs déterminant pour la réussite du pontage est la vascularisation du pied à l’angiographie, et donc la présence ou non d’une arche plantaire. Dans notre série, 24% des MI
Analyse des principaux résultats du groupe endovasculaire
A 1 et 2 ans