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Northside Cherokee 2 nd Annual CV Summit. Scott R. Beach, MD FACC. Peripheral Arterial Disease. Affects over 8 million Americans Affects 12% of the general population and 20% of those > 70 years old Prevalence continues to increase as baby boomer generation ages. Critical Limb Ischemia.

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Northside cherokee 2 nd annual cv summit

Northside Cherokee 2nd Annual CV Summit

Scott R. Beach, MD FACC


Peripheral arterial disease
Peripheral Arterial Disease

  • Affects over 8 million Americans

  • Affects 12% of the general population and 20% of those > 70 years old

  • Prevalence continues to increase as baby boomer generation ages


Critical limb ischemia
Critical Limb Ischemia

  • Subset of PVD patients

  • Prevelance is 1-2% of patients with PVD over the age of 50


Critical limb ischemia1
Critical Limb Ischemia

  • Blood flow is insufficient to meet tissue oxygen demands

  • Ischemic injury occurs in tissues with the least blood supply and results in necrosis

  • Local and systemic inflammatory response

  • Compensatory mechanisms:

    post stenotic arteriolar vasodilatation

    collateral circulation


Critical limb ischemia2
Critical Limb Ischemia

  • Acute ischemia – sudden decrease is blood flow that causes a potential threat to limb viability – rest pain, ischemic ulcers, and/or gangrene who present w/i 2 weeks of event

  • Chronic ischemia – similar manifestations as actue ischemia but > 2 weeks.


Critical limb ischemia3
Critical Limb Ischemia

  • Mortality approaches 25% at 1 year after diagnosis

  • Additional 25% require major amputation

  • Amputation increases morbidity and mortality – 50% mortality at 5 years

  • Only 65% BKA amputees ambulatory 1 yr

  • Only 29% AKA amputees ambulatory 1 yr


Rutherford classification
Rutherford Classification

  • Stage 0 – Asymptomatic

  • Stage 1 – Mild Claudication

  • Stage 2 – Moderate Claudication

  • Stage 3 – Severe Claudication

  • Stage 4 – Rest Pain

  • Stage 5 – Ischemic ulceration not exceeding the digits of the foot

  • Stage 6 – Severe Ischemic ulcers or gangrene


Pathophysiology
Pathophysiology

  • Usually seen when two or more levels of the distal arterial tree has a significant stenosis or occlusion.

  • Multi level disease promotes severe ischemia by reducing the effectiveness of collateral flow and lower distal systolic driving pressures


Cli treatment goals
CLI treatment goals

Pain Relief

Heal Wounds

Promote / Protect

Mobility

Save a LIMB Save a Life


Clinical presentation of cli
Clinical Presentation of CLI

  • Rest Pain - Pain in foot usually when limb is elevated and relieved with dependency

  • Ulceration – Distal areas of extremities such as tip of toes, severe pain, dry, poor vascularity

  • Gangrene – Devitalized tissue



  • Avoid at all cost
    Avoid at all Cost!

    BKA patient has 50% mortality at 5 years

    Estimated > 50% increase in energy expenditure in order to

    Ambulate after BKA



    Interventional options
    Interventional Options

    • Angiogram required to formulate “game plan”

    • Must evaluate inflow and outflow, usually multi-level disease

    • Treat inflow lesions first

    • Must optimize risk factors and anti platelet therapies


    Equipment basic needs
    Equipment : Basic Needs

    • Sheaths

    • Guidewires

    • Crossing catheters

    • PTA balloons

    • Stents

    • Re-entry devices

    • Athrectomy devices


    Tibial interventions
    Tibial Interventions

    • Retrograde

    • Antegrade

    • Crossing the lesion

    • Pedal access

    • Use of CTO devices

    • Subintimal vs intraluminal approach





    Anterior tibial lesion in cli
    Anterior Tibial lesion in CLI






    Tibial artery revascularization
    Tibial artery revascularization


    Economics of limb salvage
    Economics of Limb Salvage

    • Limb salvage revascularization is expensive, but better than the alternative of primary amputation.


    Critical limb ischemia4
    Critical Limb Ischemia

    • 1-year mortality for patients with CLI is 25% (mainly cardiac events)

    • The economic burden is high for patients with CLI

    • The median cost of medical care for a patient following an amputation is estimated to be twice that of a successful limb salvage


    Goals of endovascular treatment
    Goals of endovascular treatment

    • Increase tissue perfusion

    • Provide blood flow to affected area to faciliate healing

    • Achieve resolution of rest pain and gangrene

    • Improve patient function

    • Prevent limb loss


    Diagnostic testing
    Diagnostic Testing

    • ABI/ PVR

    • Ultrasound

    • CTA/ MRA – good for inflow but bad for outflow

    • Angiogram – provides most accurate road map for developing a plan for each individual


    Advantages of endovascular treatment
    Advantages of Endovascular Treatment

    • Minimally invasive

    • Avoidance of general anesthesia

    • Minimal risk of wound infection

    • Minimal recovery time

    • Minimal hospital stay, many going home the same day


    Good news
    Good News

    Goodney, JVS 2009; 50:54-60


    Revascularization trends
    Revascularization Trends

    Geraghty et al MVSS 2005


    Post revascularization plan
    Post revascularization plan

    • Check distal pulses

    • Evaluate for possible complications of revascularization both endovascular and surgical

    • Patient education


    Post operative period
    Post Operative Period

    • Graft occlusion – acute rest pain may be initial presentation, or sudden motor loss/ limb weakness

    • Surigcal incisions – must be kept clean and dry. Observe for signs of infection (cellulitis, elevated WBC, drainage)

    • Lymphatic injury – clear, pale yellow drainage, lymphocele


    Post operative
    Post operative

    • Hematoma

    • Pseudoaneurysm

    • Sphenous neuropathy – pain along the medial aspect of the lower part of the thigh and leg, usually resolves in 3-6 months


    Foot care
    Foot care

    • Alleviate heel pressure

    • No bare feet!

    • Apply lubricating cream to legs and feet

    • Gangrenous lesions must be kept clean and dry

    • Avoid heating pads, cold packs, and any adhesives


    Take home message
    Take home message

    • For patients who present with CLI, it is imperative to move quickly and consult an endovascular specalist

    • Positive outcomes require the cohesive team of endovascular specialists, podiatry, wound care, infectious disease specalists, and primary care physicians.


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