CARDIOALEX 2011Critical limb ischemia

Critical limb ischemia from endovascular to surgical point of view:

Critical limb ischemia from endovascular to surgical point of view Mr. Mohamed Omar El- Farok M.Sc , FRCSENG,FRCSED,

Topics to be discussed :

Topics to be discussed CLI important facts Basil trail CLI strategy Foot angioplasty Conclusion

CLI important facts :

CLI important facts CLI 100 % require amputation in 12 months without revascularization They have 4-30% 30 day perioperative mortality They have 8-37 % 30 day perioperative morbidity 50 % of CLI patients die within 2 years from presentation 25% of diabetics will face CLI Shockingly primary amputation is still the most common CLI treatment in USA Ref : Strategic health Resources

CLI important facts :

CLI important facts 67 % of USA CLI patients had primary amputation as initial treatment More shockingly 50 % of primary amputation is done without angiography or simple ABI Despite 85-90% 12 month limb salvage rate reported with revascularizaiton Ref : Strategic health Resources

Slide 5:

What are the options?

What is the evidence ?:

What is the evidence ?

BASIL trial:

BASIL trial BASIL controlled randomized trial Bypass first vs PTA first strategy in CLI - Fontain III or IV - Infrainguinal lesions Fem-pop – tibial - Patient eligible for both Endpoints - Amputation free servival - All cause mortality 47 UK centers 5.5 years duration Basil investigators. Lancet 2005;366:1925-1934

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BASIL trial PTA vs. bypass surgery • BASIL = controlled randomized trial  452 patients (228 bypass & 224 PTA) Bypass PTA days % % % % £ 4614 57 5 68 41 23322 3635 41 3 71 59 17419 FMRP 2011 – Total days in hospital all patients 30-day morbidity 30-day mortality 12-month amputation free survival 12-month reintervention rate 12-month hospital costs Basil investigators. Lancet 2005;366:1925-1934.

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FMRP 2011 – 5 BASIL trial PTA vs. bypass surgery Bradbury et al. (2010) . Journal of Vascular Surgery, 51, 5S-17S. Amputation-free survival Overall survival The same

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1Y 3Y Surgery 68% 57% PTA 71% 52% FMRP 2011 – 6 BASIL trial Primary endpoint • Amputation-free survival – Hazard ratio 0.85 in favor of surgery (95%; CI: 0.5-1.07 – p=0.107) • 2-year all-cause mortality – Hazard ratio 0.61 in favor of surgery (95% CI: 0.5-0.75 – p=0.009)

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BASIL trial recommendations • CLI patients with >2y life expectancy are probably better served with surgery (vein bypass) • CLI patients with <2y life expectancy are probably better served with endovascular strategies  more likely to suffer surgical morbidity and mortality  angioplasty is significantly less expensive than surgery in the short-term. Vascular surgical aim is for straight vessel to the foot , any vessel

Basil Trial comments :

Basil Trial comments It is valid for its time Now situation is different It was right for year 2000 not for 2011 Cost issues have completely changed

Advances in the arterial field ::

Advances in the arterial field :

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9 Endovascular treatment 2011 Long stents Flexible stents Drug-coated balloons Drug-eluting stents Long low-pressure balloons Dedicated BTK stents BTK DES FMRP 2011 –

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FMRP 2011 – 10 Endovascular treatment 2011 • CTO devices for intraluminal recanalisation Crosser (Bard) • Re-entry devices Frontrunner (Cordis) Rotablator (BSCI) Outback (Cordis)

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FMRP 2011 – 24 Surgery in many cases not possible • CLI patients: important comorbidities – Severe coronary disease – – – – Previous strokes Renovascular failure Diabetes mellitus COPD • Lack of target vessel • Infected distal anastomosis area • Inadequate venous conduit in 40–50% Surgery mortality rate 3.3% Ducaju MG et al. J Cardiovasc Surg 2001; 42:651-656.

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FMRP 2011 – What would you choose ? 26 obvious

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FMRP 2011 – 27 The advise In the new real world , in a center with experience in endovascular treatment and vascular treatment in 90% of the CLI population endovascular-first is to be recomended

Slide 19:

Foot vessels angioplasty

Better views : :

Better views :

Foot arteries anatomy & angiosomes: :

Foot arteries anatomy & angiosomes : Foot lesion Related angiosome Related artery ( Wound Related Artery )

Slide 22:

Angiosomes of the foot

Conclusion :

Conclusion CLI is a Global Epidemic New technology is available to achieve >85-90% 6-12 month limb salvage rates There is strategic changes in CLI managements From endovascular or surgery as initial management to endovascular first in all cases From patent flow to the foot to wound related vessel revascularizaiton Novel Endopharmacotherapy appear safe and may improve further outcome in CLI

Take home message :

Take home message Treat the critically ischemic toe Like the critically schaemic LAD !

Thank you:

Thank you