wound and surgery-guided revascularization & flow-guided ... · wound and surgery-guided...
TRANSCRIPT
-
Wound and surgery-guided revascularization & flow-guided surgery: the multidisciplinary approach to limb salvage
Vincenzo Foppa, 1462“The miracle of the salvaged foot” Cappella Portinari, S. Eustorgio Church Milan, Italy
-
Disclosure
In the last 2 years I have the following potential conflicts of interest to report:
Consultant: Medtronic, Abbott, Boston Scientific, Contract Medical International, Cook, Asahi, Ivascular, Biotronic, Limflow, Spectranetics, Shire, Kardia, Astra Zeneca, Orbus, Bard
Virtual shareholder: Limflow
Roberto Ferraresi, MD
-
1. Tissue-guided revascularization
2. Flow-guided surgery:
― Complete revascularization
― Partial revascularization
― SAD pts: the “tension-free surgery” concept
-
dominant DPA 0.4%
Absence of the pedal-plantar loop 0.2%
balanced 79.1%
tarsal loop 7.2%dominant LPA 13.2%
Recognize the distribution pattern of the foot1°
-
Recognize the wound-related artery2°
-
2.
3.1.
4.
Conclusion
DR appears to result in improved wound healing and limb salvage
rates compared with IR, with no effect on mortality or re-intervention
rates…. When possible, these low quality data suggest DR should be
undertaken in preference to IR.
According to this concept, it seems reasonable to pursue below-
the-ankle arteries angioplasty in order to give direct flow to the
wound !
-
The value of an angiosome-oriented revascularization is inversely related to the function of collateral vessels
Recognize the role of collateral vessels3°
-
SAD with/without BADCollateral vessels are generally involved failure of the foot distribution system
Recognize the role of collateral vessels3°
-
Open BTK vessels
Limbsalvage
0 56%1 better than 0
1 73%
2 80%2-3 better than 1
3 83%
PTA of tibial arteries had a better outcome than PTA of the peroneal artery alone
Pursue a complete rev.4°
-
Results: The wound(s) interfered with one angiosome in only 24.0% cases.
Conclusions: In CLI, the tissue lesion affects several angiosomesin the majority of the cases.
Pursue a complete rev.4°
-
1. Recognize foot vessel anatomy & disease
2. Identify reasonable targets of revascularization
3. Try to give as much as possible blood flow to the wound! The foot surgeon will thank!
-
1. Tissue-guided Rev.: the angiosome concept
2. Flow-guided surgery:
― Complete revascularization
― Partial revascularization
― SAD pts: the “tension-free surgery” concept
-
When you have a complete blood supply everything is surgically possible
-
1. Tissue-guided Rev.: the angiosome concept
2. Flow-guided surgery:
― Complete revascularization
― Partial revascularization
― SAD pts: the “tension-free surgery” concept
-
Pure dorsal blood supply due to anatomical or technical reason
-
Pure plantar blood supply due to anatomical or technical reason
-
In pts with partial rev. foot surgery must be tailored on the vascular supply, respecting the main vessel!
-
1. Tissue-guided Rev.: the angiosome concept
2. Flow-guided surgery:
― Complete revascularization
― Partial revascularization
― SAD pts: the “tension-free surgery” concept
-
Normal pt1
-
SAD pt2
-
Advanced SAD pt3
-
1
2
3
-
1
2 3
-
1
2 3
-
1 2 3
-
SAD can jeopardize the outcome of foot surgery. Second intention, tension free surgery could be an option to improve outcome in SAD-CLI pts
-
Wound and surgery-guided revascularization & flow-guided surgery: the multidisciplinary approach to limb salvage
Vincenzo Foppa, 1462“The miracle of the salvaged foot” Cappella Portinari, S. Eustorgio Church Milan, Italy