For the motion: Endovascular Therapy is a better option for limb salvage in diabetic ulcer treatment

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For the motion Endovascular Therapy is a better
option for limb salvage in diabetic ulcer
treatment

• Dr. Prasad Jetty
• Division of Vascular and Endovascular Surgery
• The Ottawa Hospital
• University of Ottawa

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Endo vs open surgery for diabetic ulcers
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1. Patency

• Patency of angioplasty is worse than bypass in
  diabetic ulcer patients
• YES

Angioplasty patency is worse!
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1. Patency

• BUT ARE BYPASSES THAT GREAT???
• 30-40 of bypasses develop stenoses with in 1 yr
  (Seminars of Vascular Surgery 2012 25108-114)
• 20-80 of successful patent bypasses have
  recurrent or persistent ulcers or wounds at 1 yr
  (Seminars of Vascular Surgery 2012 25108-114)
• Too late or bypass flow is not enough
• Non-ischemic ulcer
• Occluded bypass does not necessarily mean
  amputation or recurrent ulcer

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1. Patency

• With good surveillance post angioplasty one can
  identify restenoses early and can easily and
  safely repeat the endovascular intervention and
  thus rival the patency rates of bypass procedures

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1. Patency

• Are vasculopaths really looking for high 5 and 10
  years patencies?
• 1 year mortality of patients with CLI is 25
  (American College of Cardiology, Canadian
  Cardiovascular Society 2005, 2009 updated
  guidelines)

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1. Patency

• Therefore angioplasty may only need to be patent
  long enough until the patient dies from another
  cause or at least long enough to allow for ulcer
  healing, and can easily be repeated if it recurs

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2. Periprocedural mortality and morbidity
ELDERLY
DIABETES
CORONARY DISEASE
COPD
SMOKER
RENAL FAILURE
DYSLIPIDEMIA
HYPERTENSION
OBESE
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2. Periprocedural mortality and morbidity

• Large prospective NSQIP analysis of gt2500
  patients revealed bypass has 20 periprocedural
  complication rate, and 49 readmission rate at 6
  mos (65 are bypass related)
• (LaMuraglia et al. Significant periooperative
  morbidity accompanies contemporary bypass
  surgery. Eu J Vasc Endo vasc Surg 2012
  43(5)549-55)
• Conte et al. Diabetic Revascularization Do we
  have the answer Semin Vasc Surg 201225108-114

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2. Periprocedural mortality and morbidity

• 10-20 of bypass develop incisional wound
  complications
• metaanalysis 12 decline in ambulation and 15
  loss of independent living post bypass surgery
• (LaMuraglia et al. Significant periooperative
  morbidity accompanies contemporary bypass
  surgery. Eu J Vasc Endo vasc Surg 2012
  43(5)549-55)
• Conte et al. Diabetic Revascularization Do we
  have the answer Semin Vasc Surg 201225108-114

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2. Periprocedural mortality and morbidity

• Complications post angioplasty is 2 (groin
  hematomas, pseudoaneurysms) and the patient is
  discharged the same day)
• (LaMuraglia et al. Significant periooperative
  morbidity accompanies contemporary bypass
  surgery. Eu J Vasc Endo vasc Surg 2012
  43(5)549-55)
• Conte et al. Diabetic Revascularization Do we
  have the answer Semin Vasc Surg 201225108-114

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3. Multiple run-off vessels and distal pedal
circulation
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4. Burning bridges?
You will be burning bridges!
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4. Burning bridges?

• BASIL trial
• Concluded that survival is worse in pts who had
  endo-first failures followed by rescue bypass vs
  bypass-first pts

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4. Burning bridges?

• Flawed logic- Selection Bias
• Pts who failed angioplasty have selected
  themselves out as higher risk
• Problems with BASIL
• Extremely highly selective- only 1/10 patients
  randomized actually got the procedure they were
  suppose to get (does not represent the usual
  vascular population)
• Interventional radiologists did the endo
  procedures vs vascular surgeons
• Procedures done 12-14 years ago - OUTDATED!!
• There are some good things about BASIL....

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4. Burning bridges?

• BASIL is very good in thai food

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5. Do all diabetic ulcers with vascular stenoses
or occlusions need revascularization?
NO
Loss of sensation- prone to injury Demyelination
and atrophy of intrinsic muscles Disruption of
normal bony architecture Resultant abnormal
pressure points Impaired immunity and delay in
healing Micro vascular ischemia Macro vascular
ischemia
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5. Not all diabetic ulcers with vascular
stenoses or occlusions need revascularization

• some will heal with conservative therapy
• It is difficult to know exactly who will benefit
• Tendancy for vascular specialist to revascularize
  in the setting of concomittant vascular disease
  and therefore some patients maybe receiving
  revascularization when it may not be necessary.

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5. Not all diabetic ulcers with vascular
stenoses or occlusions need revasculariztion

• An unnecessary bypass may be worse than an
  unnecessary angioplasty

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Ask Uncle Google
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Thank you

• Division of Vascular and Endovascular surgery
• The Ottawa Hospital and University of Ottawa

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Round 1
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Rebuttal
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TASC 2 Classification

• Type A endovascular procedures are recommended
• Type B endovascular procedures are recommended
  unless an open revascularization procedure
  (surgery) is required for other lesions in the
  same anatomic area
• Type C open revascularization procedures are
  recommended. Endovascular procedures are only
  recommended in patients who have a low healing
  potential following surgical revascularization
• Type D endovascular procedures are not
  recommended as first-line treatment

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TASC guidelines are lesion-centric and do not
emphasize the importance of weighing comorbid
factors and life expectancy
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6. If you dont embrace endovascular therapy
someone else will

• It is crucial that the vascular surgeon embraces
  endo and leads innovation in the field otherwise
  we are going towards extinction

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Evolution
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