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7/27/2019 1362577943_PVD & DM RevascularizaR
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Peripheral Vascular Disease,
Angiography - Angioplasty andSurgical Techniques
Dr. Rajdeep Agrawal,MD, DM
Interventional Cardiologist &Vascular Interventionist,
Sir H N Hospital,MumbaiBreach Candy HospitalCumballa Hill Hospital
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Dr. Rajdeep Agrawal
Indications of Angiography in
PVD Life style limiting claudication
Critical ischemia / limb threateningischemia (rest pain, nocturnal pain,non healing ulcer, gangrene
Graft stenosis
High surgical riskAcute ischemia of lower limb
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Dr. Rajdeep Agrawal
Arteriogram
Remains the Gold standard for vascularevaluation.
Should be done only in patients who have
clinical indications for vascularinterventions (surgery or angioplasty)
Complications are less than 5% and
mortality about 0.025%.
Patients should be well hydraded before
and after angiograms, especially
diabetics.
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Dr. Rajdeep Agrawal
Angioplasty -- History
Charles Dotter (1964)
First angioplasty using co-axial
catheter
Andreas Gruentzig (1977)
First PTCA using double lumencatheter
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Dr. Rajdeep Agrawal
Percutaneous TransluminalAngioplasty (PTA) in Peripheral
Vascular Disease
An over view of the arterialpathologies of the lower limbs
and their percutaneoustreatment
modalities
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Dr. Rajdeep Agrawal
Percutaneous TransluminalAngioplasty
A non-surgical technique designed toincrease the lumen of the vessel & thus
prevent ischemia & its complications
Mechanism
Inflated balloon exerts circumferential
pressure on the plaque
1. Plaque splitting & disruption
2.
Stretching of the vessel wall
3. Compression of the atheroma
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Rutherford Becker classification of PVD
Grade
Category
Symptoms
O O None
I 1 Mild claudications
I 2 Moderate claudications
I 3 Severe (life style limiting)claudications
II 4 Rest pain
III 5 Nonhealing ulcers focalgangrene
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Rutherford Becker classification of PVD
Ankle Brachial Index -
> 0.90 No significant obstructive
disease
0.50 to 0.90 Claudications (Grade I)
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Ideal settings for PTA
LesionsCharacteristics
PatientCharacteristics
Short Non diabeticConcentric Claudication
Non calcified
SolitaryNon occlusive
Large vessel
Continuous run off
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Dr. Rajdeep Agrawal
Percutaneous TransluminalAngioplasty (PTA) in Peripheral
Vascular Disease
Modalities will include
Angioplasty,
Stents,
Lasers,
Rotablaters,
And Thrombolysis
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Percutaneous TransluminalAngioplasty (PTA) in Peripheral
Vascular Disease
Modalities will be treated together or separately
in the territories commonly affected byvascular disease
Acute arterial obstruction will be treated as a
separate issue, where multimodal treatmentsmay come together
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Dr. Rajdeep Agrawal
Lower Limb Ischemia -Vascular involvement in Diabetic
Aorto illiac relatively spared.
Most of the diseases involves
infrainguinal arteries (femoral - popliteal -tibial)
About 60% have involvement of plantar
arch and digital arteries.
About 80% have microangiopathy
Does not adversely affect the outcome of
vascular reconstruction.
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Angiography -- Technique
Approach Femoral / Brachial
Vascular accessusing Seldingerstechnique
Material / Hardware 0.035 guide wire
Renal catheter, Simmons cath
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Seldinger needle & guide wire forintroducing an arterial catheter
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Arterial Occlusionjust above theknee causing
claudication ofthe calf; goodcollateralcirculation
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Balloon Catheter for PTA
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Contraindications topercutaneous revascularization
PTA C/I - Medically unstable
(Absolute) - Stenosis adjacent to aneurysm
or near an ulcerated plaque(Relative) - (Unfavourable anatomy)
Long segment & multi-focal
stenosisLong segment Occlusions
(thrombolysis)
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PTA Contra-indications
(Relative) - If large vessel at ankle is availablefor bypass
- Heavy eccentric calcification
- Lesion in essential collateral vessel
- Stenosis with thrombus
Percutaneousrevascularization
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Post PTA recurrence are seldom worse thanbefore, does not interfere with the originalplanned surgery.
In 25% Femoro - popliteal PTFE Graft,
Popliteal gets occluded when bypass
closes
Adar etal
Percutaneousrevascularization
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THROMBOLYSIS is an alternateattemptable modality of treatment in
PVDSafe if cases are selected properly
Cannot be used in all cases.
Various methods are used to administerthrombolysis
Acute ischemia of lower limb is one area
Percutaneous revascularization
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Intra-arterial Thrombolysis
Restores blood flowIdentifies underlying lesion
Thrombotic or embolic occlusion
Native artery or bypass graft
Percutaneous revascularization
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THROMBOLYSIS - CONTRAINDICATIONS
Absolute -Active internal bleedingIrreversible limb ischaemia
Recent stroke, craniotomy
Mobile L-V thrombus
Percutaneousrevascularization
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THROMBOLYSIS CONTRAINDICATIONS
Relative - H/o GI bleed
- Recent major surgery/CPR/Trauma
- Diastolic BP >125 mm
- DM Proliferative Retinopathy
- Sub acute bacterial endocarditis
- Coagulopathy- Post partum state
Percutaneous revascularization
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Stents: Contra indications
- Diffuse aortic disease- Extravasation of contrast after PTA
- Non compliant lesion on angioplasty
- Diffuse iliac disease
- Aortic tortuosity & aneurysm- Diffuse long segment small caliber external
iliac or femoral artery
Percutaneousrevascularization
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Stent Complications (10%)
- Almost all are minor
- Puncture site injury- Distal embolization
- Stent dislodgement
- Pseudo anemysm formation- Vessel rupture
Percutaneousrevascularization
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Dr. Rajdeep Agrawal
Percutaneous TransluminalAngioplasty (PTA) in Peripheral
Vascular DiseaseAORTO ILIAC Percutaneous
Transluminal Angioplasty
- Optimizes inflow for bypass
- Excellent patient tolerance
- Short recovery period
- No worsening of vascular status if fails
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AORTIC OCCLUSSIONS
- Relatively uncommon
- Younger population who smoke
- Claudication and impotency
- Risk of propagation of clot to renal and
mesenteric artery
Percutaneous revascularization
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ABDOMINAL AORTIC STENOSIS
- Isolated - relatively uncommon
- More frequent in women with hypoplasticaortas
- PTA and Stent can be tried and are useful if thelesions are amenable
- Otherwise Grafts can be placed- Even thrombolysis could be attempted with
angioplasty
- Large thick atherosclerotic lesions could be
common
Percutaneousrevascularization
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Percutaneousrevascularization
AORTO ILIAC STENTING
Indications - Residual stenosis > 30% after
percutaneous revascularizationOr if a gradient >10mm persists
Dissection
Highly eccentric stenosisRecurrent Stenosis post PTA
Iliac artery occlusion
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ILIAC ARTERY STENOSISPTA
- PTA with/without stent
- Focal, uncalufied sterosis 10cm) respond less favorably
STENTS
- Residual pressure gradient (30%)
- Flow limiting dissection flap
-
Restenosis (acute or subaiute)
Percutaneous revascularization
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ILIAC ARTERY OCCLUSIONS
- Bilateral Surgery treatment
- Primary stent placement
- PTA followed by stent
- Thrombolysis followed by stent
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INTERNAL ILIAC STEONSIS
- Isolated buttock claudication
- Impotence
- PTA is the choice
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CFA STENOSIS
- Isolated is uncommon without history ofinjury (eg. Catheterization)
- Endarterectomy choice simple, LA andconscious sedations
- Durable than PTA
Percutaneousrevascularization
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Ext. Iliac Artery stenosis - before,after dilatation, after stent
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Femoro popliteal
- Lesion 3 times commoner than iliac
- Occlusions 3 times commoner than
stenosis
- 80% of the stenosis are
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Femoro popliteal
- 10 cm upper limit to select cases
- Stents disappointing beyond thatlength of stenosis
- Covered (PTFF) grafts have a promise
- Over 5 years 15-20% new Femoropopliteal occlussions develop
Percutaneousrevascularization
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Narrowed superficial femoral arterybefore & after dilatation
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Femoropopliteal stenosis:
- PTA is less durable than bypass.- Bypass 5 year patency rate is about 80%
- Complication of PTA is 10%, surgical repair
required in 2% cases
Percutaneous revascularization
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Femoropopliteal stenosis
-Stents useful in proximal Superficial FemoralArtery
- Stents restenosis in distal SFA or poplitealartery due to extrinsic compressions (eg.
Addutor canal) is possible- Long term consequences of placing flexible
stents across joints is unknown.
Percutaneous revascularization
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Femoropopliteal occlussions:
- Long segment or complete SFA occlusions doesnot respond well to any widely available
endovascular technique
- Amplatz thrombectomy catheter excellenttechnical access, but long term patency ismodest or unknown
- Covered stents - results disappointing
- Endovascular stent grafts show most promise
Percutaneousrevascularization
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Femoropopliteal occlusions:- PTA is effective for short solitary occlusions,
< 10cm long, not involving SFA origins ordistal popliteal artery
and tenders occlusions
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Femoropopliteal occlusions:- Upper SFA occlusions stent if PTA is sub-
optimal
- PTA long term patency rates may besubstantially less than clinical patency rates
- Technical failure almost always results frominability to cross the lesion with guide wire.
Percutaneous revascularization
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Infra-popliteal revascularization -Indications
Absence of pedal pulses minimal orasymptomaticIf collaterals are not well developed orlimitation of activity resultsFocal lesionsLimited in diffuse disease,If short term patency is desired sufficient toheal superficial ulcerations or amputationsites
Percutaneousrevascularization
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Infra popliteal revascularization
Early results - Not impressive
Manipulations - Easier with DSA
& road mapping
Increased popularity - Safe & Successful
Decision with surgeon
Inflow lesions Treatment first
Percutaneousrevascularization
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Tibial Artery Obstructions:
Infra popliteal PTA is almost always performed forlimb salvage
- Short term patency may be sufficient to allow healingof an ischemic ulcer or amputation site or to avoidamputation
- PTA is not particularly effective if run-off vessels arenot visualized. Liberal Heparin use must to maintainpatency
Percutaneous revascularization
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STENTS RESULTS
- Technical success rate 90-100%- Cumulative 5 year vessel patency 94%
- Clinical success 93%
- (PTA 65% & 70%)
Percutaneous revascularization
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Infra-popliteal revascularization
Indications
- Limb threatening Ishcemia
(Disabling claudication, Rest pain, Ulcer, Gangrene)
- ABI < 0.5 Ischemic rest pain or ankle pressure
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Stent
An expandable metallic helicaldevice which is permanentlyimplanted in the artery.
MechanismThe prosthesis acts as a scaffold
to hold the artery open
Prevents recoil of the vessel
Reduces Restenosis
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Newer Techniques OfAngioplasty
Atherectomy
Directional
Percutaneous Rotational
TEC
LASERStent
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Directional Atherectomy
It excises the atheromatous
plaque material into very fineslices which can be retrievedoutside body
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Percutaneous Rotational
Atherectomy (Rotablator)
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LASER
A LASER produces an intense beamof light in uniform wavelength that
can be precisely focused to deliverhigh energy levels to a small area
It converts solid plaque to gaswhich is soluble in blood
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Stent Complications (5-10%)
Groin hematoma
Pseudo AneurysmEmbolization of thrombus
Acute stent thrombosis
DissectionVessel perforation
Percutaneousrevascularization
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IDDM Reduce insulin
First case
5% Dextrose, Blood sugar,
Insulin (1-3 units/ hr) or more for higher
blood glucose levels
No protamine zinc insulin should be used
Protamine antagonizes the heparinanticoagulation
Hybration to prevent aute tubular necrosis
Percutaneousrevascularization
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Cost effectiveness of PTA compared tosurgical reconstruction
PTA - Bypass - 53% in Disabling Claudication
75% in critical ischemia
A cost effective analysis demonstrated that performing
PTA as a initial procedure is more desirabletechnically feasible cases and reserving bypasssurgery for those PTS in whom PTA fails, or recurswould save more lives, limbs and money.
Percutaneous revascularization
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Cost effectiveness of PTA compared tosurgical reconstruction
In technically feasible cases PTA would be thepreferred option
Reserve bypass surgery for those PTAs in whom
it fails, or recursIt would save more lives, limbs and money.
Percutaneous revascularization
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Complications:
Vasospasm - Nifedipine start well beforeprocedure
- Intra-arterial Nitroglycerins,in the vessel to be treated(100 to 200 mg) before dilation
Flow limiting dissection flap Employ Stent
Percutaneous revascularization
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Complications:
Post PTA occlusion
Repeat PTA & thrombolytic therapyOR Repeat PTA Stent
Arterial rupture Reinflation of baloon across
rupture
,followed by surgical repair
Percutaneous revascularization
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Medical Therapy
Exercise program
Risk factor modifications
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Results of percutaneous therapy
Site & DiseaseOf arterialstenosis
Therapy
Success% of
Technic
1 yearpatency
(%)
3 yearpatency (%)
AbdominalAorta
PTA 95 ? ?
Iliac PTA 95 80 70
Iliac Stent 95 90 85Iliac occlusion Stent 80 70 65
Two year limb salvage of 60 to 80%
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Results of percutaneous therapy
Site & DiseaseOf arterialstenosis /occlusion
Therapy Success% of
Technic
Oneyear
patency(%)
Threeyear
patency(%)
Proximalfemoral
Stent 95 85 75
Femoro
poplitealOcclusion
Lysis,
PTA
80 50 40
Tibial stenosis PTA 90 - -
Two year limb salvage of 60 to 80%
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Aorto-iliac Occlusions:
Aorto bifemoral bypass- Extra anatomic
- Endarterctomy
- 5 year patency - 85 to 95%
Surgical revascularization - 1
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Infra inguinal occlusions:
- Autologous veins or PTFE grafts are used
PTEF above Hunters canal for SFA
- Saphenous Vein below knee, for tibial or peronealocclusion
- 5 yr patency 60% - above
- Below knee 3 yr patency and limb salvage 58 to92% respectively
Surgical revascularization - 1
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AORTIC OCCLUSSIONS
- Aorto bifemoral graft with endarterectomyaxillo bifemoral graft or thorarofemoral graft
- Re-construction with endovascular stent graftis feasible long term results unknown
Surgical revascularization - 2
L Li b I h i
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Lower Limb Ischemia -Approach to Therapy
Direct arterial reconstruction.
Endarterectomy
Vascular bypass
Endovascular (minimally invasive)intervention
Lumbar sympathectomy
L Li b I h i
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Lower Limb Ischemia -Results of Direct Reconstruction
Aorto illiac reconstruction - early graft patency of
about 98%, operative mortality 3%:5years graft
patency of 85-90%.
Femoro popliteal bypass - early graft patency of
over 90%, with mortality of 2-5% : 5 year patency
of about 75%.
Infrapopliteal/ paramalleolar bypass - earlypatency of about 90% with 2% mortality. 5 year
patency of 55%
LIMB SALVAGE about 90%
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OPERATIONS
Depends on the site of occlusion and
the physical state of the patient.
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Aorto-iliac occlusion
Limited involvement : Iliac Endartectomy
Marked involvement : Aorto-femoral bypass
Aorto-iliac occlusion patient unable to undergosurgery;
1 iliac artery involved : femoro-femoral or
ileo-femoral bypass
Both iliac arteries involved : Axillo-bifemoralbypass
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Atheroscleroticnarrowing ofaortic bifurcation
Aortobifemoralgraft to bypassstenosis
Femoral & Profunda Femoris
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Femoral & Profunda FemorisOcclusion
If conservative measures not suitable,PTA may be possible
For more severe disease, angioplasty orbypass maybe used
Femoropopliteal bypass graft is the
most usual operation Saphenous vein graft gives the best
results
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Superficialfemoral arteryocclusion withprofunda femorisstenosis providing
poor collateralcirculation
Femoropopliteal
graft used tobypass theoccluded area
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Occlusion below popliteal
Bypass to tibial vessels, even down tothe ankle can be met with reasonable
success. Most successful is with long saphenous
vein in the in situfashion.
If saphenous not available, can usePTFE (Polytetrafluoroethylene) graft.
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PROSTHETIC MATERIALS
Aortoiliac bypass - Dacron
Femoropopliteal - Autogenous veins
(Long saphenous best)If not available - PTFE orglutaraldehyde-tanned, Dacron
supported, human umbilical vein Profundoplasty - Vein/PTFE/Dacron
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Treatment of A/C Occlusion
Embolectomy - Using Fogartys catheter ->Catheter passed beyond emblous, ballooninflated & pulled back till blood comes
Direct Embolectomy - Artery exposed,transverse incision, clot removed.
Intra-arterial Thrombolysis - TPA preferred.
Arteriography done and a catheter embeddedin clot - Thrombolytic agent infused overseveral hrs
S i l E b l t
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Surgical Embolectomy
Relatively simple procedure Done under LA, small incision in the
groin, using Fogartys cath.
Problems1. Blind procedure, can be traumatic
2. Not successful in 10 30% cases
3. Inefficient in multistenosed artery
4. Complete removal of thrombusdifficult in leg arteries
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Post PTA MX
Antiplatelet agents
LMW Heparin X 7 10 D
IV / oral Trental
Statins
Aggressive control of riskfactors
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Conclusion
In Diabetic foot, PVD contributes toamputation by impeding the delivery ofantibiotics, Oxygen, nutrients & by
delaying wound healing & the ability tofight infection.
Aggressive therapy with debridement,antibiotics,good control of Diabetes &
when indicated revascularisation resultsin salvage of > 90% of threatened limbseven in high risk patients