Transcript Diapositiva 1

Case Review Session:
Limb Salvage
Interventions in Diabetic Patients:
The Diabetic Foot
L. Graziani M.D.
Servizio di Emodinamica
Istituto Clinico “Città di Brescia”
Brescia (Italy)
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Diabetic Arteriopathy
 In diabetic population the incidence of
arteriopathy is 14% after 2 years of diabetes,
15% after 10 years and 45% after 20 years.(#)
 In diabetic population the risk of developing
lower limb critical ischemia is 5 times greater
than in normal population.
In particular ischemic ulcers and gangrene
are present in about 10% of old diabetic
people: this condition is commonly defined
“Ischaemic Diabetic Foot”. (§)
# Melton LJ, Macken KM, et al. Diabetes Care 1980,3:650-654.
§ Krolewski AS, Warren JH, in: Joslin's Diabetes Mellitus (ed. 12). Philadelphia,
Pa, Lea & Febiger, pp 12-42.
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Characteristics of diabetic
arteriopathy
 “In addition to atherosclerotic changes, the
vessels of diabetic patients are characterized
by increased amounts of connective tissue,
such as fibronectin, collagen, and
glycoproteins, as well as increased amounts
of calcium in the medial layer of the arterial
wall, a constellation named diabetic
macroangiopathy. These changes lead to a
loss of elasticity of the arterial wall”.
International Textbook of Diabetes Mellitus. Chichester, England: John Wiley & Sons
Ltd; 1992:1435-1446.
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Massive medial calcifications
Case 1
Before PTA
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Result
ISCHAEMIC DIABETIC FOOT :
INDICATIONS FOR REVASCULARIZATION
1. RISK OF AMPUTATION - TO REDUCE THE LEVEL
2. CRITICAL LIMB ISCHAEMIA
3. PAIN AT REST (BUT PRESENT ONLY IN ABOUT 50% OF ISCHAEMIC
ULCERS !) (#)
4. ULCERATIONS (OFTEN AT THE ONSET !), EVEN HEALED
5. SYMPTOMATIC CLAUDICATION (OFTEN ABSENT→
NEUROPATHY !) (§)
6. DECREASED TRANSCUTANEOUS OXYGEN TENSION
(TcPO2 < 50mmHg) (‡)
# J Diabetes Complications. 1998;12:96-102, § Diabetes Care. 2001; 24:78-83,
‡ J Vasc Surg 31, 1, 2000
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Diabetic foot:
Revascularization Procedure




Antegrade approach
Low-profile (coronary type) wires and catheters
Long (8-10 cm) balloons, if needed
Prolonged inflations (3-8 min !!) using lowcompliant balloons at high pressure (13-18 Atm)
 Accurate choice of suitable balloon size
 Rotablator® for some short recurrences
 Avoid using Stents, particularly below the knee!
 Effective antiplatelet therapy (clopidogrel, ticlopidine)
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Case 2
STENTING
Male, 69 yrs, IDDM, previous fem-pop bypass graft, persistence of the right foot
ischaemic ulcer.
Procedure: Antegrade approach, ant. Tibial
occlusion crossed with an extra support,
hydrophilic coronary wire and 3.5mm balloon,
Magic Wallstent® deployment. Final balloon
dilatation.
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Diabetic foot: Treatment strategy
 Diabetic patients can develop ischaemic foot ulcer
(TcPo2 <50mmHg) even for occlusion of a single leg artery





due to lack of collaterals
In these subjects collaterals are usually and typically
poor, particularly from Peroneal to Tibials, therefore…
…optimal revascularization procedure aims to obtain
direct flow up to the foot preferably through the Pedal
(anterior Tibial) or Plantar (posterior Tibial) artery
In presence of ischaemic foot ulcer, Extensive
Angioplasty (to recanalize as many arteries as possible) is
always preferable (J Intern Med 2002;252:225-232)
Lesion site influences the choice of the tibial artery to
be recanalized (calcanear→ post. Tibial; forefoot→ ant. Tibial)
In some cases stenotic collaterals (i.e. from Peroneal to
Pedal/Plantar) can be successfully dilated
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Male, 70 yrs. NIDDM, TcPO2 = 32 mmHg !, previous 4th and 5th ray amputation due
to ischaemic necrosis. Recent onset of mid-foot ulcer due to foot malposition. Isolate
occlusion of Anterior Tibial. PTA → .014 hydrophilic coronary wire and 2.5mm balloon.
Before PTA
Case 3
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Result
SAME CASE
Mid-foot ulcer (Grade IV of
Wagner Classification), before
PTA. TcPO2 = 35mmHg
Same ulcer 2 months Post-PTA.
TcPO2 significantly improves:
65mmHg
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Diabetic foot: Treatment strategy
 Diabetic patients can develop ischaemic foot ulcer
(TcPo2 <50mmHg) even for occlusion of a single leg artery





due to lack of collaterals
In these subjects collaterals are usually and typically
poor, particularly from Peroneal to Tibials…
… therefore optimal revascularization procedure aims
to obtain direct flow up to the foot preferably through
the Pedal (anterior Tibial) or Plantar (posterior Tibial) artery
In presence of ischaemic foot ulcer, Extensive
Angioplasty (to recanalize as many arteries as possible) is
always preferable (J Intern Med 2002;252:225-232)
Lesion site influences the choice of the tibial artery to
be recanalized (calcanear→ post. Tibial; forefoot→ ant. Tibial)
In some cases stenotic collaterals (i.e. from Peroneal to
Pedal/Plantar) can be successfully dilated
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Before PTA
Case 4
Poor collaterals
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Result
Diabetic foot: Treatment strategy
 Diabetic patients can develop ischaemic foot ulcer
(TcPo2 <50mmHg) even for occlusion of a single leg artery





due to lack of collaterals
In these subjects collaterals are usually and typically
poor, particularly from Peroneal to Tibials…
… therefore optimal revascularization procedure aims
to obtain direct flow up to the foot preferably through
the Pedal (anterior Tibial) or Plantar (posterior Tibial) artery
In presence of ischaemic foot ulcer, Extensive
Angioplasty (to recanalize as many arteries as possible) is
always preferable (J Intern Med 2002;252:225-232)
Lesion site influences the choice of the tibial artery to
be recanalized (calcanear→ post. Tibial; forefoot→ ant. Tibial)
In some cases stenotic collaterals (i.e. from Peroneal to
Pedal/Plantar) can be successfully dilated
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Male, 63 yrs, NIDDM,
critical leg ischaemia,
pain at rest, foot ulcer.
Complete occlusion of
distal post. Tib. and
Plantar. Diffuse stenosis
and occlusion of the
Pedal, stenosed
Peroneal artery
Case 5
Procedure: Pedal artery
obstruction crossed with
an .014 coronary extrasupport hydrophilic wire,
followed by a 2.0 and
2.5Ø balloon catheter
dilatation.
Pedal
Rest pain ceased
immediately and major
amputation was avoided.
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Before PTA
Case 6
Result
Another
case…
Plantar
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Diabetic foot: Treatment strategy
 Diabetic patients can develop ischaemic foot ulcer
(TcPo2 <50mmHg) even for occlusion of a single leg artery





due to lack of collaterals
In these subjects collaterals are usually and typically
poor, particularly from Peroneal to Tibials…
… therefore optimal revascularization procedure aims
to obtain direct flow up to the foot preferably through
the Pedal (anterior Tibial) or Plantar (posterior Tibial) artery
In presence of ischaemic foot ulcer, Extensive
Angioplasty (to recanalize as many arteries as possible) is
always preferable (J Intern Med 2002;252:225-232)
Lesion site influences the choice of the tibial artery to
be recanalized (calcanear→ post. Tibial; forefoot→ ant. Tibial)
In some cases stenotic collaterals (i.e. from Peroneal to
Pedal/Plantar) can be successfully dilated
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Before PTA
Female, 70 yrs,
Case 7
IDDM, rest pain with
ischaemic left foot
ulcer.
Procedure:
occlusions were
crossed with a
regular 4 Fr/.035
catheter-wire
system and a .014
coronary wire.
Prolonged inflations
with 2.5, 3.5 and 5.0
Ø balloon catheters
were performed.
Rest pain ceased,
foot ulcer healed
and major
amputation was
avoided.
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Result
Considerations:
Revascularization
procedure must include
as many stenotic
segments as possible.
Luckily, long fem-pop and
tibial occlusions in
diabetic patients are
rarely associated with
evident thrombosis,
unless previous By-Pass
surgery was performed.
In fact, most below-theknee thrombolysis
procedures are related to
occlusive complications
after By-Pass surgery.
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Before PTA
Male, 65 yrs, NIDDM,
ischaemic left foot ulcer.
Severe stenosis of
Peroneal, ant. Tibial, Pedal
and Plantar arteries.
Case 8
Procedure: Antegrade
approach, .014 hydrophilic
“intermediate” coronary
wire was advanced along
the Pedal and the major
branch of the Plantar
artery. Stenoses dilatation
using 2.5 and 3.0Ø balloon
catheter was performed.
Balloons were inflated at16
Atm for 4 minutes each
time.
Foot ulcer healed in few
weeks.
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Result
Considerations:
Direct flow along the entire
length of ONE Tibial artery
is usually necessary to
promote ulcer healing.
Direct flow along TWO
Tibial arteries represents
the most favorable
condition for ulcer healing.
In the majority of cases,
obtaining direct flow along
a solitary Peroneal artery,
provides little improvement
of TcPO2 measurement,
due to lack of collaterals to
the foot.
www.extrem-es-angioplasty.it
Diabetic foot: Treatment strategy
 Diabetic patients can develop ischaemic foot ulcer
(TcPo2 <50mmHg) even for occlusion of a single leg artery





due to lack of collaterals
In these subjects collaterals are usually and typically
poor, particularly from Peroneal to Tibials…
… therefore optimal revascularization procedure aims
to obtain direct flow up to the foot preferably through
the Pedal (anterior Tibial) or Plantar (posterior Tibial) artery
In presence of ischaemic foot ulcer, Extensive
Angioplasty (to recanalize as many arteries as possible) is
always preferable (J Intern Med 2002;252:225-232)
Lesion site influences the choice of the tibial artery to
be recanalized (calcanear→ post. Tibial; forefoot→ ant. Tibial)
In some cases stenotic collaterals (i.e. from Peroneal to
Pedal/Plantar) can be successfully dilated
www.extrem-es-angioplasty.it
Diabetic foot: Treatment strategy
 Diabetic patients can develop ischaemic foot ulcer
(TcPo2 <50mmHg) even for occlusion of a single leg artery





due to lack of collaterals
In these subjects collaterals are usually and typically
poor, particularly from Peroneal to Tibials…
… therefore optimal revascularization procedure aims
to obtain direct flow up to the foot preferably through
the Pedal (anterior Tibial) or Plantar (posterior Tibial) artery
In presence of ischaemic foot ulcer, Extensive
Angioplasty (to recanalize as many arteries as possible) is
always preferable (J Intern Med 2002;252:225-232)
Lesion site influences the choice of the tibial artery to
be recanalized (calcanear→ post. Tibial; forefoot→ ant. Tibial)
In some cases stenotic collaterals (i.e. from Peroneal to
Pedal/Plantar) can be successfully dilated
www.extrem-es-angioplasty.it
Before PTA
Male, 63 yrs
IDDM with
Case 9
ischaemic foot
ulcer.
Diffuse
occlusion of all
leg arteries.
Procedure: a
.014 wire was
advanced along
the peroneal up
to the plantar,
through a
collateral.
A
2.0 and 2.5
mmØ, 10 cm
long balloon
was used.
4x3 min
inflations at 1214 Atm, using a
semi-compliant
balloon.
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Result
Considerations:
Mönckeberg’s medial
calcifications may act as rails to
guide the wire while maintaining
a correct centroluminal position.
This is particularly useful in case
of long occlusion recanalization.
Also collaterals between
peroneal and plantar or pedal
artery, present diffuse connective
thickening of the arterial wall.
In these branches it could
represent a protective factor
against arterial rupture during
balloon inflation.
Before PTA
Case 10
Another
case…
2x100mm
balloon
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Result
Conclusions 1
From: Rosenfield, Vale, Isner, in: Topol, Textbook of Cardiovascular
Medicine, 2nd Ed. Lippincott Williams & Wilkins, 2002
 “In patients with rest pain or ischemic
ulceration, restoration of uninterrupted patency
of at least one of the three major infrapopliteal
arteries is generally required .
In this group of patients, aggressive application
of percutaneous revascularization may achieve
extremely gratifying results, even in patients
with calcified and/or lengthy total occlusions”.
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Conclusions 2
From: Rosenfield, Vale, Isner, in: Topol, Textbook of Cardiovascular
Medicine, 2nd Ed. Lippincott Williams & Wilkins, 2002
 “…the incidence of restenosis—which remains
high—should not be a factor in the decision to
use a percutaneous approach for what is, in
many of these patients, a short-term problem.
If uninterrupted patency of even one vessel
can be achieved, the improvement in
antegrade nutrient flow is typically adequate to
facilitate limb salvage. Once healed, most
patients will do satisfactorily, even in the face
of documented reocclusion or restenosis”.
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