Transcript 2. Critical Limb Ischemia

CRITICAL LIMB ISCHEMIA
Hugo Londero MD, FSCAI
Sanatorio Allende
Cordoba-Argentina
CRITICAL LIMB ISCHEMIA
Hugo Londero MD, FSCAI
Sanatorio Allende
Cordoba-Argentina
CRITICAL LIMB ISCHEMIA
ACUTE
CHRONIC
•Acute thrombosis of a chronic
atherosclerotic lesion
•Acute embolism
•Atheroembolism
•Aneurysm thrombosis
•Arterial trauma
•Flegamasia Alba Dolens
=/
•Progressive chronic lesions
(Atherosclerosis +Thrombosis)
•Lesions at multiple territories
•Diffuse disease of the arteries
bellow the knee
•Associated with diabetes
HIGH AMPUTATION RATE
Critical Limb Ischemia:
The natural history of CLI differs significantly from that of
claudication. CLI is associated with a high risk of limb loss in the
absence of revascularization, whereas claudication rarely
progresses to the point of requiring amputation
Critical Limb Ischemia (CLI)
• The prevalence of
diabetes in the general
population is around 8%
and rising rapidly
• Diabetes increases the
development of CLI
about 5 times
• Diabetes increase leg
amputations 5 to 10
times
CRITICAL LIMB ISCHEMIA
• Over 90% of amputations performed each
year in the USA are due to ischemia or
infected gangrene1
• 30% of amputees below the knee will never
walk again, like 70% of amputees above
the knee2
• After a major amputation: 60% have contra
lateral amputation within 5 years, 50% died
within 3 years3
1Krupski,
In: Vascular Surgery, Robert Rutherford 2000, WB Saunders
2Armstrong, In: Diabetic Foot Managemnet, HMS 2000
3Tentolouris N et al. Diabetes Care 2004; 27:1598-1694
Critical limb ischemia (CLI)
• Persistent rest pain
• More than 15 days evolution
• Analgesics required
• Trophic disorders
• Systolic ankle pressure <50mmhg
• Systolic ankle pressure <30mmhg
(diabetics)
• ABI less than 0,5
Eur J Vasc Surg 1992;6(Suppl A):1-32
Trophic Disorders:
• Hyperkeratotic nails
• Dermal Keratosis
•
Absence of hair
• Skin and subcutaneous tissue
atrophy
• Peripheral edema
• Ischemic Ulcer
• Ischemic Gangrene
Physical Examination:
Blush with hanging
position…
…pallor with leg
elevation
•
•
•
•
•
Ankle Brachial Index
The ABI for each limb is calculated by
dividing the higher of the pressure at
the ankle between the highest
brachial pressure
Easiest way to make the diagnosis
The ABI in occlusions of only one
arterial segment usually is between
0.5 and 0.8
ABI less than 0.5 are usually related
with multiple territories disease
Rest pain is usually associated with
an ABI less than 0.4
The diagnosis of CLI is
established with an ABI less
than 0.5
Pathophysiology of the Diabetic Foot
Normal Foot
Predisposing factors
Foot at risk of lesion
Triggers factors
Lesion or ulcer
Aggravating Factors
Critical lesion
AMPUTATION!!!
GLUCEMIA
TRAUMA
INFECTION
When to do an Angiography
ALWAYS
In diabetics patients with Critical Limb
Ischemia
OCCASIONALLY
in claudicants
Endovascular Treatement
•Multidisciplinary decision
• Patient clinical status
•To reestablish an straight line of flow to
the foot
LEG SALVAGGE –
NO PERMEABLITY or COSMETIC
60 years, male
Arterial Hypertension, type II diabetes, smoker, Chronic Renal
failure (Cr:1,67mg/dl) Ischemic cardiomyopathy, CABG at 1994.
300 m. Claudication in both legs.
Two month before, ischemic ulcer at the heel of the right foot.
Duplex Scan: Severe lesion at right superficial femoral artery,
Anterior and posterior tibial arteries occlusion, critical lesion at
tibio-peroneal trunk
Balón 3/100 mm
Kissing Balón con 3,5/38 mm
Distal By Pass
Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia
Marcello Romiti, MD,a Maximiano Albers, MD,a Francisco Cardoso Brochado-Neto, MD,a
Anai Espinelli S. Durazzo, MD,b Carlos Alberto Bragança Pereira, PhD,c and Nelson De Luccia, MD,b
Santos and São Paulo, Sao Paulo, Brazil
Results: The pooled estimate of success was 89.0% _ 2.2% for immediate technical result.
Results at 1 and 36 months were 77.4%_4.1% and 48.6%_8.0% for primary patency,
83.3%_1.4% and 62.9%_11.0% for secondary patency, 93.4%_2.3% and 82.4% _3.4% for
limb salvage, and 98.3% 0.7% and 68.4% _ 5.5% for patient survival, respectively. Studies with
>75% of the limbs with tissue loss fared worse than their respective comparative subgroup for
technical success and patency but not for limb salvage or survival. No publication bias was
detected.
Conclusion: The technical success and subsequent durability of crural angioplasty are
limited compared with bypass surgery, but the clinical benefit is acceptable because
limb salvage rates are equivalent to bypass surgery. Further studies are necessary to
determine the proper role of infrapopliteal angioplasty. (J Vasc Surg 2008;47:975-81.)
YUKON Trial (Bellow the knee long lesions)
161 pts .randomized to SES or BMS (12 months follow up)
.005
.004
DESTINY study (Drug Eluting Stents in the Critically Ischemic Lower Leg
(Bosiers et al 2011)
154 patients randomized to MultiLink Vision/Xience V
12 month patency rate
85.2%
P=.0001
54.4%
DESTINY study (Drug Eluting Stents in the Critically Ischemic Lower Leg
(Bosiers et al 2011)
154 patients randomized to MultiLink Vision/Xience V
12 month limb salvage
98.7%
97.1%
P=0.53
ANGIOSOMS
Wound blush
Final Comments
•Critical Limb Ischemia is a severe vascular
disease with high amputation incidence in the
short time.
•The objective of the treatment must be limb
salvage.
•The endovascular treatment successes is
high, but the artery patency is low. However
the healing of the trophic lesions and limb
salvage is high
Thank you very much !
Surgical Saw utilized in 1830
for leg amputation