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Think Feet!
Diabetic Foot Protection ServiceTallaght Hospital, Dublin, Ireland
Sean Tierney
Vascular surgery @ Tallaght
1990’s
Vascular surgery @ Tallaght
Ischaemia
Vascular surgery @ Tallaght
Meta-analysis (pop pedal bypass)
• N=1,2320 (79 studies)
• @ 5 years• 1o patency 63%• 2o patency 71%• Limb salvage 78%• * 5 yr mortality ~50%
Albers et al J Vasc Surg. 2006 43:498-503.*Hinchcliffe et al Diabetes Metab Res Review 2012
Vascular surgery @ Tallaght
2000
Vascular surgery @ Tallaght
The problem
Vascular surgery @ Tallaght
Arterial supply
Poitier et al, Eur J Vasc Endovasc 2011
• PAOD prevalence 9.5% - 13.6%
• (~ 50% with ulcer)• distal > proximal • Medial artery
calcification more common
Vascular surgery @ Tallaght
Mechanism of ulceration
Neuropathy
Deformity
Trauma
Ulcer
Vascular surgery @ Tallaght
Vascular disease
Neuropathy
Deformity
Trauma
UlcerHealing
Vascular surgery @ Tallaght
Vascular disease
Neuropathy
Deformity
Trauma
UlcerHealing Limb loss
Ischaemia
Infection
Vascular surgery @ Tallaght
Choices
Structural & neuropathy
Offload
Ischaemia
Revascularisation
Infection
Drain, debride, ABx
Vascular surgery @ Tallaght
The solution
Vascular surgery @ Tallaght
How?
Vascular surgery @ Tallaght
When?
Vascular surgery @ Tallaght
When?
Where?
Vascular surgery @ Tallaght
Where?
Vascular surgery @ Tallaght
Who?
Vascular surgeryNursing
Admin
Vascular surgery @ Tallaght
Who?
Vascular surgery @ Tallaght
Partners
Vascular surgery @ Tallaght
Who else
Vascular surgery
Orthotics
NursingAdmin
Vascular surgery @ Tallaght
2009
Vascular surgery
Orthotics
NursingAdmin
Vascular surgery @ Tallaght
Who else
Vascular surgery
Orthotics
Nursing
TVN
Admin
Vascular surgery @ Tallaght
Who else
Vascular surgery
Orthotics
Nursing
TVN
Podiatry
Admin
Vascular surgery @ Tallaght
Who else
Vascular surgery
Orthotics
Nursing
TVNPodiatry
Endocrine
Admin
Vascular surgery @ Tallaght
Who else
Vascular surgery
Orthotics
Nursing
TVNPodiatry
EndocrineOrthopaedics
Admin
Vascular surgery @ Tallaght
Who else?
Vascular surgery
Orthotics
Nursing
TVNPodiatry
EndocrineOrthopaedics
Rehab
Admin
Vascular surgery @ Tallaght
2008
Vascular surgery @ Tallaght
Risk assessment for foot ulceration
Structural
Skin and soft tissue
Innervation
Perfusion
Vascular surgery @ Tallaght
Full assessment
Vascular surgery @ Tallaght
Perfusion assessment
Vascular surgery @ Tallaght
Imaging
Vascular surgery @ Tallaght
Debridement & dressing
Vascular surgery @ Tallaght
Facilities
Vascular surgery @ Tallaght
Debridement & dressing
Vascular surgery @ Tallaght
Debridement & dressing
Vascular surgery @ Tallaght
Infection
• Clinical rather than microbiology
Osteomyelitis• Probes to bone• MRI ?• Bony destruction
Vascular surgery @ Tallaght
Offload
Vascular surgery @ Tallaght
Offload
Vascular surgery @ Tallaght
Offload
Vascular surgery @ Tallaght
Delay
30 60 90 120 150 180
56 days to funding sanction
12 223
+71 days to supply
7 296
sanction
supply
121( (21 -379) in total
0 days
Vascular surgery @ Tallaght
Prioitisation
Vascular surgery @ Tallaght
Vascular Intervention
Vascular surgery @ Tallaght
Pedal Bypass surgery
• 1998-2008
• N= 28 (4 asynchronous bilateral)
• M:F = 5:1• Mean age 63y (37 – 92)• Autologous vein used in
all patients
Good et al Ir J Med Sci 2010
Vascular surgery @ Tallaght
Pedal Bypass surgeryPrimary graft patency
0
20
40
60
80
100
0 6 12 18 24 30 36 42 48 54 60
Time after surgery (months)
Gra
ft pa
tenc
y as
a p
erce
ntag
e Primary patency
Good et al Ir J Med Sci 2010
Vascular surgery @ Tallaght Primary & Secondary graft patency
0
20
40
60
80
100
0 6 12 18 24 30 36 42 48 54 60
Time after surgery (months)
Gra
ft pa
tenc
y as
a p
erce
ntag
e Primary
Secondary
Pedal Bypass surgery
Good et al Ir J Med Sci 2010
Vascular surgery @ Tallaght
Pedal Bypass surgery
0
20
40
60
80
100
0 6 12 18 24 30 36 42 48 54 60
Lim
b su
rviv
al a
s a
perc
enta
ge
Time after surgery (months)
Limb Salvage
Good et al Ir J Med Sci 2010
Vascular surgery @ TallaghtPatient Survival after Popliteo-pedal bypass
0
20
40
60
80
100
0 6 12 18 24 30 36 42 48 54 60
Time after surgery (months)
Surv
ival
as
a pe
rcen
tage
Pedal Bypass surgery
Good et al Ir J Med Sci 2010
Vascular surgery @ Tallaght
Innovation
Vascular surgery @ Tallaght
Tibial artery disease
Vascular surgery @ Tallaght
Tibial artery disease
Vascular surgery @ Tallaght
Tibial artery disease
Vascular surgery @ Tallaght
Tibial angioplasty - results
• 2010 - 2013• 61 limbs in 53 patients • Tissue loss • TASC D• 36/53 Diabetic
O Connor et al ASGBI 2014
Vascular surgery @ Tallaght
Tibial angioplasty - results
• 2010 - 2013• 61 limbs in 53 patients • Tissue loss • TASC D• 36/53 Diabetic
O Connor et al ASGBI 2014
• Technical success 81.3%• Adjuncts:
– Minor amputation/debridement n=12– Thrombectomy(Rotoarex) n=6– Thrombolysis: 6/61 limbs
Vascular surgery @ Tallaght
Tibial angioplasty - followup
@ 17months (range 1-42)• Major Amputation 10% (6/61 limbs)• Reoperation rate 20%
– Re-angioplasty– Bypass
@ 3 years• Survival 72% • Amputation free survival 64%
O Connor et al ASGBI 2014
Vascular surgery @ Tallaght
Tallaght data
Nason et al. Ir J Med Sci 2013
Vascular surgery @ Tallaght
Amputations
AKA
BKA
0
2
4
6
8
10
12
Study Period
ControlPeriod
Nason et al. Ir J Med Sci 2013
Vascular surgery @ Tallaght
Length of stay
15 days 12 days
Nason et al. Ir J Med Sci 2013
Vascular surgery @ Tallaght
Total bed days used
2842
2485
Bed Days Used
Control Period Study Period
13%
Nason et al. Ir J Med Sci 2013
Vascular surgery @ Tallaght
Total bed days used
2842
2485
Bed Days Used
Control Period Study Period
€300,000
*€ 890 per dayNason et al. Ir J Med Sci 2013
• Total Contact casting• Seamless communication
– > shared electronic record• Staff orthotist• Budget centralisation• Development of community podiatry
www.perfuse.net@theseant
http://www.slideshare.net/stierneyhttp://goo.gl/jmtHb3
