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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

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  • 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