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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