Opciones para el salvamento de una extremidad no revascularizable

1. Non-revascularizable
ischemia
Instituto Nacional de Ciencias Medicas y Nutrición «Salvador Zubiran»
México
Ernesto Silerio R1CV

2. Introduction
• Chronic limb Threatening ischemia is a mayor public health problem.
Lack of public awareness and the
frequent failure to make an early
diagnosis
Broad variation in vascular aproach
Limited evidence base to guide
daily practice
Rapidly evolving
technologies in:
• Diagnostic
• Devices
• Drugs
• Techniques
• Biologics
Global vascular guidelines on the management of chronic limb-threatening ischemia

3. Non revascularizable ischemia
The majority of CLTI patients are anatomically suitable for
revascularization.
Dependent
on clinical
context.
Lack of a target artery
crossing the ankle and
absence of a suitable pedal
or plantar artery target.
WIfI stages 3 and 4.
Global vascular guidelines on the management of chronic limb-threatening ischemia

4. Options
Spinal cord stimulation
Lumbar sympathectomy
Intermittent pneumatic compression
Prostanoids
Hyperbaric oxygen therapy
Venous arterialization
Global vascular guidelines on the management of chronic limb-threatening ischemia

5. Spinal cord stimulation
• Five randomised and one controlled clinical trial
• 444 patients
• Primary end point: limb salvaje
• Limb salvage rates were found to be significantly higher in the SCS group (RR:
0.71; 95% CI, 0.56-0.90)
• The SCS grup required less analgesia
• No significant effect on ulcer healing
• Complication rate 17%
TASC II
ESVS
• insufficient evidence to
recommend its use in
the treatment of CLTI.
Global vascular guidelines on the management of chronic limb-threatening ischemia

6. lumbar sympathectomy
Randomised controlled trials have failed to identify any objective benefits for lumbar sympathectomy
Improvements in symptoms for patients with critical leg ischemia in approximately 60% of patients
symptomatic patients with critical leg ischaemia as an alternative to amputation in patients with
otherwise viable limbs
TASC II
ESVS
• Dont mention it as a
treatment to prevent
amputation but can be
considered to relieve
simptoms
Global vascular guidelines on the management of chronic limb-threatening ischemia

7. Intermitent compresion
• Systematic review (RCT, NRCT, CBA)
• 8 studies included
• Primary outcomes: All cause mortality, MACE, limb amputation, QoL, wound healing, adverse events and
complications rate.
• There is a lack of experimental studies examining the clinical effectiveness of IPC.
• Results from studies indicate that the treatment may be associated with improved limb salvage, wound
healing and pain management, but theres high risk of bias.
• Insufficient data to identify the optimal compression parameters to use.
No guidelines
Global vascular guidelines on the management of chronic limb-threatening ischemia

8. prostanoids
• Update of a review first published in 2010.
• RCTs describing the efficacy and safety of prostanoids compared with placebo or other
pharmacological control treatments for patients presenting with CLI without chance of
rescue or reconstructive intervention.
• 33 randomised controlled trials with 4477 participants
• There is no strong evidence on the efficacy and safety of prostanoids in patients with CLTI
on the basis of a high-quality meta-analysis of homogeneous, long-term RCTs
No clear difference in the incidence of cardiovascular mortality between
patients receiving prostanoids and those given placebo (RR 0.81, 95% CI 0.41
to 1.58).
No effect on the incidence of total amputations when compared with placebo
(RR 0.97, 95% CI 0.86 to 1.09).
Adverse events were more frequent with prostanoids than with placebo (RR
2.11, 95% CI 1.79 to 2.50).
Prostanoids reduced rest-pain (RR 1.30, 95% CI 1.06 to 1.59) and promoted
ulcer healing (RR 1.24, 95% CI 1.04 to 1.48) when compared with placebo
low-
quality
evidence
high-quality
evidence
moderate-
quality
evidence
moderate-
quality
evidence
TASC II
• Improved healing of
ischemic ulcers
• No benefit for
amputation
Global vascular guidelines on the management of chronic limb-threatening ischemia

9. Hiperbaric oxygen
12 trials and 577 patients
HBOT increased the rate of ulcer healing
in DFUs at 6 weeks but not at longer term
follow-up, with no significant difference in
the risk of major amputation.
• There may be a role for the use of HBOT to accelerate ulcer healing in
diabetic patients with nonhealing neuropathic ulcers and low-grade
ischemia who have failed to respond to conventional wound care.
• HBOT does not prevent major limb amputation and should not be
used as an alternative to revascularization in patients with CLTI.
TASC II
• Selected patients who have
not responded to
revascularization
Global vascular guidelines on the management of chronic limb-threatening ischemia

10. Venous arterialization
• 15 papers were included in this systematic review, 768 patients.
• The primary outcome measure was post-operative limb salvage at 12 months.
• Secondary outcome measures were 30 day or in-hospital mortality, survival,
patency, technical success, and wound healing.
• Venous arterialisation could be a valuable treatment option in patients facing
amputation of the affected limb; however, the current evidence is of low quality
Limb salvage rate at one year was 75% (0.75, 95% CI 0.70-
0.81).
Thirty day or in-hospital mortality ranged from 0 to 10%.
Overall survival ranged from 54% to 100% with a mean
follow-up ranging from 5 to 60 months.
Patency of the venous arterialisations was of 59-71% at 12
months.
Global vascular guidelines on the management of chronic limb-threatening ischemia

11. Thank you for your attention