This document summarizes the evolution of limb salvage techniques from amputation to bypass surgery to endovascular treatments. It describes how in the 1960s-1970s, amputation was usually the standard treatment for critical limb ischemia. However, in the late 1960s, some surgeons began challenging this by performing bypass surgeries to save limbs. Since the late 2000s, endovascular procedures have become the primary treatment for infrainguinal arterial disease, though open bypass surgery is still occasionally needed. The future of treatment is expected to involve more catheter-based techniques utilizing new technologies, though open surgery will still be necessary in some cases. Repeated endovascular or open interventions can still be worthwhile for limb salvage when all

1. EVOLUTION OF LIMB SALVAGE
TECHNICS & WHERE THEY ARE
GOING : FROM AMPUTATION
TO BYPASS TO ENDOVASC Rx
FRANK J. VEITH
SITE - 2013
BARCELONA – MAY 9, 2013

2. THE PAST

3. OLD HISTORY
IN THE 1960s &1970s
SURGEONS CARED FOR CLI
DEFINED AS
REST PAIN, GANGRENE, ULCERATION
STANDARD Rx AMPUTATION

4. MORE HISTORY
IN THE LATE 1960s
WE BEGAN
TO CHALLENGE
THAT STANDARD
(AMPUTATION)

5. UNUSUALLY
EXCELLENT
ARTERIOGRAPHY
1971
83 YO DIABETIC
GANGRENOUS TOE
BYPASS
10 YEARS OFLIMB
SALVAGE
POSTERIOR
TIBIAL

6. FIRST TO PUSH
LIMB SALVAGE
SURGERY &
VERY AGGRESSIVE
APPROACH TO LS
(WITH BYP & PTA)

7. MY BACKGROUND
STANDARD VASC SURGEON &
ENDOVASCULAR ADVOCATE
• 1978 – LIMB SALVAGE & ILIAC PTA
• 1988 – TIBIAL PTA; LATER SIPTA
• 1992 – 1ST US EVAR WITH PARODI
MARIN, SCHONHOLZ

8. & FIRST TO PUSH
REDO BYP OR PTA
ST BYP OR
WHEN 1
PTA FAILED
OR WAS FAILING
- UNUSUAL APPROACHES
TO HELP

9. MOST OF OUR PATIENTS
WERE DIABETIC ( > 70%)
HENCE RELEVANCE
TO DIABETIC FOOT
CARE – CURRENT FAD

10. ONE EXAMPLE

11. 1978
78 YO DIABETIC
AMP RECOM AT 3
NYC HOSPITALS
NO SAPHENOUS V

12. ASV PT BYPASS

16. ANGIO AFTER 4 YRS
LIMB SALVAGE 6 YRS

17. EXTENSIVE
FOOT & HEEL
GANGRENE

19. AFTER ANT TIB
BYPASS &
DEBRIDEMENT
& EXCISION OF
ACHILLES
TENDON

21. WALKING
6 YEARS
LATER

22. FIRST TO DO
VEIN BYPASSES
TO VERY DISTAL
PEDAL ARTERY
BRANCHES

24. ANGIO AFTER 4 YRS

26. BYPASS TO
LAT TARSAL
PATENT >12 YRS

27. MORE THAN 98% OF
PTS WITH CLI HAVE
PATTERN OF DISEASE
SUITABLE FOR
REVASCULARIZATION
BY OPEN OR ENDO RxS
- VEITH, ANN SURG 1991

28. IS ALL THIS
WORTHWHILE ?

29. CONCLUSIONS REGARDING PATIENTS
WITH LIMBS THREATENED BY
INFRAINGUINAL ARTERIOSCLEROSIS
ANN SURG 1981, 1991
AGGRESSIVE USE OF ALL THESE &
OTHER LIMB SALVAGE TECHNIQUES
INCLUDING REOPS AND RE-PTAs
WERE WORTHWHILE WHEN EMPLOYED
IN 3700 CONSECUTIVE PATIENTS

30. REPETETIVE BYP
OR PTA ARE THEY
WORTHWHILE ?
YES (5-14 PROCED)
LIPSITZ, VEITH
VASCULAR - APRIL 2013

31. 1 OUTSTANDING Pt – 17 Yrs
•
Surgery #1
2/13/92
– EIA to CFA goretex
– Fem-pop reversed GSV
•
Surgery #2
1/31/94
– LàR fem-fem goretex
– Thrombectomy of fem-pop
•
Surgery #3
•
Surgery #8
8/22/96
•
Surgery #9
1/3/02
13 – R CIA to PFA goretex
– PFA to AT goretex
– Thrombolysis 1/97
BYPASSES
– Thrombolysis 8/97
12/28/94
– Thrombectomy of CIA to PFA
– AT to AT LSV
– CIA graft to AT graft goretex
– Redo fem-fem goretex
– Thrombectomy of fem-pop
•
Surgery #4
11/10/95
– L EIA to R AKPop goretex
– AKPop to BKPop vein
•
Surgery #5
11/15/95
– Redo vein AKPop to BKPop
•
Surgery #6
5/8/96
– L EIA to R vein graft goretex
– Extension to TPT with vein
•
Surgery #7
5/9/96
– Thrombectomy of goretex
•
Surgery #10
1/4/02
– Thrombectomy of CIAàPFAàATàAT
•
# 13 •
2003
Surgery #11
2/20/02
– Thrombectomy of CIAàPFAàATàAT
– Extension to distal AT goretex
Surgery #12
6/17/02
– Thrombectomy of CIAàATàAT
– Patch angioplasty of distal anastomosis
- New CIA-to-Perineal PTFE

32. AT FIRST OTHERS INCL
OTHER SURGEONS & VS
DOUBTED US &
THOUGHT OUR
AGGRESSIVE LIMB SALV
APPROACH CRAZY
NOW ACCEPTED

33. THE PRESENT
IS
A CHANGING WORLD

34. IN LAST 5-10 YEARS
SEA CHANGE IN
TREATMENT OF
INFRANGUINAL ASO

35. THE CHANGE
UP TO 10 YRS AGO
Rx INFRAINGUINAL ASO
PRIMARILY OPEN SURG
SUPPLEMENTED BY CB RxS
NOW RxS PRIMARILY ENDOV
I.E. ENDOV IS FIRST OPTION
- PTA, STENTS, SGs, ETC

36. INDEED
THERE ARE NOW SOME
WHO SAY NO ROLE FOR
OPEN BYPASS SURGERY
- “IF CAN’T Rx ENDO
Rx WITH AMPUTATION”
IS THIS RIGHT ???

37. COULD NOT BE MORE WRONG
STILL A SUBSTANTIAL NUMBER
OF PTS WITH INFRAING ASO
WHO NEED OPEN SURG (BYP/TX)
AT SOME TIME IN
THEIR DISEASE COURSE
PROPORTION VARIES ?
20-40%?

38. THE FUTURE
AS TECHNOLOGY IMPROVES
• MORE THAN 85% OF
PROCEDURES FOR CLI
WILL BE CATHETER BASED
• MANY PROCEDURES WILL BE
VERY DISTAL AND DIFFICULT
• REDO PROCEDURES OFTEN
WILL BE REQUIRED (CB/OP)

39. EVOLVING ENDOVASC OPTIONS
WILL INCLUDE NEW TECHNOLOGIES
• TO IMPROVE BALLOON PTA &
STENTING AT ALL LEVELS
• TO IMPROVE OTHER CB RxS
(LASER, ATHERO, CRYO, ETC)
• ??? CELL OR GENE THERAPY
- EFFICACY MUST BE PROVEN
BY GOOD RCTs
- COST IS AN ISSUE

40. MY CONCLUSIONS
THE POSITIVES
• INTERVENTIONAL Rx OF LE
ASO IS HOTTEST NEW AREA
IN VASCULAR DIS Rx
• STATIN Rx WON’T DO IT HERE
• GREAT NEED IN THIS AREA
• MANY ADVANCES WILL BE
MADE OVER NEXT DECADE

41. MY CONCLUSIONS
NEGATIVES OR DIFFICULT
• MANY VARIABLES
• HARD TO PROVE Rx VALUE
• NEED FOR HI LEVEL
EVIDENCE & ENDOV SKILLS
• ALWAYS NEED FOR OPEN Rx
• COST IS BIG ISSUE
• MUST BE SURE IS NEED TO Rx

42. FINAL CONCLUSION
• WHEN A PATIENT IS FACING
AN AMPUTATION
• WHETHER YOU ARE AN
INTERVENTIONALIST OR
SURGEON
• NEVER, NEVER GIVE UP!
- UNLESS YOUR PROCEDURE
WILL TAKE THE PT’S LIFE

43. THANK YOU