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Chronic critical limb ischemia
- 1. Jean-Baptiste Ricco Vascular service Hospital Jean Bernard University of Poitiers, France CHRONIC CRITICAL LIMB ISCHEMIA
- 2. DIFFICULT PATIENTS TO TAKE CARE 82 y.o. man s/p aortic tube graft 12 years ago Rest pain, gangrene of the right toe Chronic heart failure
- 3. THIS MAN IS LIKE AN OLD BRIDGE
- 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
- 5. TASC 2000 NEED FOR GUIDELINES
- 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…
- 10. TASC A TASC B TASC C TASC D
- 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? ? ? ? ?
- 12. HOW DO YOU CLASSIFY THIS LESION?
- 13. HOW DO YOU CLASSIFY THIS LESION? ?
- 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
- 16. TASC II B
- 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
- 20. OPEN SURGICAL TECHNIQUES FOR CLI PATIENTS
- 21. BYPASS WITH THE SAPHENOUS VEIN The best that can happen to a patient with CLI !
- 24. BYPASS WITH FREE VASCULAR FLAP
- 25. • Short autogenous bypass • Perigeniculate collateral arteries PERIGENICULATE ARTERY BYPASS Barral et al. Eur J Vasc Endovasc Surg
- 26. PROSTHETIC BYPASS FOR CLI
- 27. PROSTHETIC BYPASS + DVP Devine et al. Devine et al.
- 28. EXTREME BYPASS & ADJUNCT WOUND THERAPY
- 29. 73 years old male, diabetic, and living at
- 31. TCPO2 = 32 ABI = 0.7
- 32. PEDAL BYPASS
- 33. NEGATIVE PRESSURE WOUND THERAPY
- 34. NEGATIVE PRESSURE WOUND THERAPY
- 35. promotes healing after revascularization NEGATIVE PRESSURE WOUND THERAPY
- 36. DEAD 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
- 41. STUDIES Griffiths 2004 RCT (3years) Laurila 2004 RCT (2 years) Procedures 46 cuff/ 44 31 AV Fistula / 28 Symptoms Cl 10% / CLI 90% CLI 100% Adjunct VENOUS CUFF A.V. FISTULA Sec. Pat. with Adjunct 45% 40% Sec. Pat. PTFE Alone 19% p= 0.02 40% Limb Salv. + Adjunct 78% 65% Limb Salv + PTFE Alone 61% p= 0.08 68% DISTAL VENOUS cuff CAN HELP BK-FEMORO-POPLITEAL BYPASS PROSTHESIS ± ADJUNCT
- 42. INFRA-POPLITEAL BYPASS REVERSED VEIN OR IN-SITU ? STUDIES Albers 2006 (5 years) Albers 2006 (5 years) Albers 2006 (5 years) Patients 1024 908 2320 Symptoms 100% CLI 100% CLI 100% CLI Technique IN SITU REVERSED GLOBAL Primary Patency 58.5% 65.9% 63% Secondary Patency 66.5% 73.2% 70.7% Limb Salvage 75.3% 79.7% 77.7% BOTH TECHNIQUES GIVE COMPARABLE RESULTS
- 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
- 46. TIBIAL ANGIOPLASTY - RESULT
- 47. PRE PER POST SUBINTIMAL RECANALIZATION
- 49. CUTTING BALLOON
- 50. CRITICAL LIMB ISCHEMIA M Desvergnes et al. University of Poitiers, non-published data, 2013
- 51. RISK FACTORS ENDOVASCULAR N=140 OPEN BYPASS N=105 P Age (mean) 78 70 P<0.05 Sex ratio M/W 79 / 61 79 / 22 NS Diabetes 91 (65%) 42 (41,6%) P<0.05 HTA 136 (97,1%) 96 (95%) NS Dyslipidemia 103 (73,6%) 81 (80,2%) NS Smoking 79 (56,4%) 86 (85,1%) NS Coronary disease 69 (49,3%) 50 (49,5%) NS Cardiac insufficiency 43 (30,7%) 19 (18,8%) NS Renal insufficiency 74 (52,9%) 35 (34,6%) P<0.05 Pulmonary disease 30 (21,4%) 39 (38,6%) NS CRITICAL LIMB ISCHEMIA M Desvergnes et al. University of Poitiers, non-published data, 2013
- 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
- 56. PATIENT ALIVE WITHOUT AN AMPUTATION ENDO OPEN
- 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
- 60. ANGIOSOMES A NEW CONCEPT FOR CLI ?
- 61. PLANTAR ARCH AND ANGIOSOMEPLANTAR ARCH AND ANGIOSOME
- 66. ANGIOSOME NO ARCH AND NOT CONNECTED
- 67. ANGIOSOMES – CLI PATIENTS CHU POITIERS 175 ENDOVASCULAR PROCEDURES ANGIOSOME DIRECT (N=134) ANGIOSOME INDIRECT (N=41) p MEAN AGE 77 [42-97] 77,4 [43-89] 0,98 SEX RATIO (M/F) 49,2% 68,9% 0,01 DIABETES 61,9% 78,04% 0,05 RENAL FAILURE 56,7% 48,7% 0,37 HTA 97,7% 97,5% 0,94 CORONARY DISEASE 46,2% 82,9% 0,01 SMOKING 55,9% 58,5% 0,77
- 68. CHU POITIERS 175 ENDOVASCULAR PROCEDURES ANGIOSOME DIRECT (N=134) ANGIOSOME INDIRECT (N=41) p LOCALISATION SFA-POP SFA-POP-TIBIAL TIBIAL 70% 16% 14% 0 57% 43% <0,001 RUN OFF 0 1 >2 11% 51% 38% 20% 63% 17% 0,012 TECHNIQUE ANGIOPLASTY STENTING SUBINTIMAL 53% 21% 26% 76% 7% 17% 0,012 ANGIOSOMES - TECHNIQUES
- 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