Cli & Wound Healing 2009 04 12

CLI & Wound healing 大里仁愛醫院 心臟血管中心 副主任 楊文義

Limb Salvage

≠ Wound healing

Limb Salvage ≠ Patent Graft Occluded bypass grafts does not necessary mean amputation

Wound healing ≠ Revascularization Lower limbs with major arterial occlusion can have healing of wounds

• The overall cumulative limb salvage rate at 12 months was 81%. • The amputation-free survival rate at 12 months was 64%.

• Healing rate of the tissue lesions was 27% at 3 months, 40% at 6 months and 75% at 12 months. • The median time to complete healing of tissue lesions was 190 days (range11 days to > 365 days). • The tissue healing rates in patients with and without diabetes were respectively at 6 months 26% and 53% and at 12 months 63% and 87%

The overall cumulative limb salvage rate at 12 months was 81%. The amputation-free survival with completely healed wounds was 50% at 12 months.

Semin Vasc Surg 20:68-72, 2007

Semin Vasc Surg 20:68-72, 2007

Limb-threatening infection (A) treated with an emergent surgical proximal foot amputation (B).

• • • •

Stabilizing the Patient Performing Adequate Surgical Debridement Vascular Intervention Soft Tissue Reconstruction

• Most of the amputations in diabetic foot wounds are due to – POOR WOUND CARE, INFECTION – ISCHEMIA

Wound management, like medicine, is… COMMON SENSE

Stenting for Critical Limb Ischemia Results of stenting for long-segment SFA disease

Cleveland Clinic Gray et al., J Vasc Surg 1997;25:74-83

Stenting for Critical Limb Ischemia “stent fractures were detected in 45 of 121 treated legs (37.2%).”

None Fx

Fx

Dierk Scheinert et al., JACC 2005;45:312–5, Leipzig, Germany

SFA Stent Fracture

Dierk Scheinert et al., JACC 2005;45:312–5, Leipzig, Germany

CLI Management • Endovascular debulking – the larger, the better

• Patient preparation

– Very thorough evaluation renal, cardiac, infection – No emergency schedule

• Concepts of inflammation and acute coronary syndrome

– Antiplatelets,vasodilators & anticoagulation used routinely – Maintain the prior collateralization condition – Antibiotics use in most cases of acute ischemia

• Surgical bypass  the very last resort

– Artificial grafts & materials- Avoid if possible – All autogenous approach

• Ischemia evaluation

– Temperature measurement, doppler US, TcPO2 – Imaging– MRA, CTA

• The Key is not how well you see it, it’s about avoiding complications

• WOUND MANAGEMENT

Complete cut-off of ATA & PTA at ankle 47 y/M, no Af Acute right forefoot Cyanosis/gangrene

Male 47yrs Fore Foot Gangrene

2/13 2/27

3/7

3/21

Excimer Laser  Advantages  Smooth debulking of

thrombus/obtructing material with less complications during subsequent balloon application and no need for stenting.

Laser-Assisted Angioplasty for CLI  111 consecutive patients with 114 limbs,   



from 2000,Dec., to 2006, March. Male/Female - 70/41 Mean age - 68.7 Y/O All lesions are treated except patients with unstable condition or foot gangrene beyond salvage. 2.9 segments/limb

Classification of Results of LaserAssisted Angioplasty  PTA salvage (81) 71.0%  PTA assisted salvage (4) 3.5%  PTA failed with surgical salvage (1) 0.9%  PTA successful with amputation (4) 3.5%

Laser-Assisted Angioplasty for CLI Female 84 yrs Multi-level occlusion Multiple toes gangrene

AT

PT

Before procedure During procedure

AT

After procedure

Before Procedure

Laser-Assisted Angioplasty for CLI

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 Female, 72 yrs  Toe unhealed ulcer

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→

→

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AT

→

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PT

→ →

AT

Boston Flextome cutting balloon

Optical coherence tomography after cutting balloon angioplasty

Heart 2007;93:546

cryoballoon

Uremia, 69/F left forefoot necrosis Post bypass surgery at Taichung VGH Occluded graft, forefoot ischemic and gangrenous stump

Post laser angioplasty from leg to forefoot twice Complete wound healing Good rehabilitation and foot prosthesis care Able to walk 8 months later

Keys to successful wound healing of diabetic foot  Infection control, debridement  Ischemia evaluation and

management  General conditions handling  Foot deformity management  No need for HBO, Near-infrared therapy, angiogeneic therapy, flap coverage.