Nurse and Technician Forum Part II Critical Limb Ischemia · Critical Limb Ischemia An...

Markus Haumer

Landesklinikum Baden-Mödling

Austria

L E I P Z I G I N T E R V E N T I O N A L

C O U R S E

2 0 1 7

Nurse and Technician Forum Part II

Critical Limb Ischemia: Optimal care, an interdisciplinary challenge

Disclosure

Speaker name:

Markus Haumer, MD

I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

I do not have any potential conflict of interest✔

Disclosure

[mmHg]

140 050 (70)

Ankle Pressure

Fontaine Stage

I IIIIIa IIb IV

0 41 3 52 6

Peripheral Arterial DiseaseGrading of Severity

0.9 0.0

Ankle Brachial Index

Rutherford Category

Asympt. Critical Limb IschemiaClaudication

Critical Limb IschemiaDefinitions

Fontaine Stage

IIa

4 65

Rutherford Clinical Category

Ischemic

Rest PainAnkle pressure

<70mmHg

Toe pressure

<50mmHg

TcPO2 <40mmHg

Skin perfusion

pressure <40mmHg

Ischemic

UlcerationAnkle pressure

<50mmHg

Toe pressure

<30mmHg

TcPO2 <20mmHg

Skin perfusion

pressure <30mmHg

Ischemic

GangreneAnkle pressure

<50mmHg

Toe pressure

<30mmHg

TcPO2 <20mmHg

Skin perfusion

pressure <30mmHg

Con

sens

usD

efin

ition

sfr

om

Per

iphe

ralA

cade

mic

Res

earc

h C

onso

rtiu

m(P

AR

C)

Pat

el M

R e

t al.

JAC

C 2

015;

65:9

31-4

1.

III IV

Ren

é M

agrit

te (

1934

)La

Mod

èle

Rou

ge

Critical Limb IschemiaDefinition and Perspective

Definition• Critical limb ischemia (CLI)

is equated with a need for

limb salvage.

Perspective• Arterial reconstruction and / or

major amputation are the

therapies ultimately available

to such patients.

Survival

Death

Quality of

Life

Limb

Salvage

ABI

Treatment of Critical Limb IschemiaNetwork of Aims and Options

Revascularisation

Wound

Management

Best Medical

Treatment

Survival

Death

Quality of

Life

Limb

Salvage

ABI


Survival

Death

Quality of

Life

Limb

Salvage

ABI

Revascularisation

Wound

Management

Best Medical

Treatment


Lifestyle Modification

Best Medical Treatment

Exercise

I Ila Ilb III IV

Local Therapy, Control of Infection, Amputation

Revascularisation

Prostanoids

Treatment of Critical Limb IschemiaGuidelines

Pain Control

Treatment of Infection

ESC Guidelines 2011 doi:10.1093/eurheartj/ehr211

Revascularisation

I Ila Ilb III IV

ES

C G

uide

lines

2011

doi

:10.

1093

/eur

hear

tj/eh

r211

Risk-Modification

Prostanoids, Amputation

Wound-Management

Treatment of Critical Limb IschemiaGuidelines

Footulcers in Diabetic PatientsDelivery of Care in Daily Practice in Europe

Pro

mpe

rsL

et a

l. [E

urod

iale

Stu

dy] D

iabe

ticM

ed20

08;2

5:70

0-7.

Referral

6-55% late referral (i.e. >3 months)

to a dedicated foot clinic

Pressure off-loading

0–68% casting in plantar

fore- or midfoot ulcers

Vascular imaging

14-68% in patients with ABPI <0.5

or persistent ulcer (i.e. >1yr) or after

major amputation; revascularization

in 43%.

Primary Amputation is still

common!Retrospective data (2009-2011) from

largest German healthcare provider

41.882 hospitalisations due to PAD

49% Critical Limb Ischemia (n=20.685)

10% Amputations (n=4.298)

Critical Limb IschemiaStill poor outcomes and lack of guideline adherence

Reinecke H et al. Eur Heart J 2015;36:932-8.

Ren

é M

agrit

te T

he A

nger

ofG

ods

(196

0)w

ww

.wik

iart

.org Acute limb ischemia, dissection,

hemorrhage, infarction and stroke

are emergencies.

Chronic critical limb ischemia

is an urgency.

„Time is tissue.“

„Helping fast is helping twice.“

Keep patients on a fast track

for vascular imaging and (repeat-)

revascularization.

Critical Limb IschemiaTime Issues

Timeline• Development of clinical disease:

days / years



days / years

• Patient care / Wound care:

weeks / months



days / years

• Patient care / Wound care:

weeks / months

• Hemodynamic evaluation,

vascular imaging and

revascularisation:

minutes / hours


Consider repeat-imaging

and -intervention!

Critical Limb IschemiaAn Interdisciplinary Approach

Interdisciplinary Core• Vascular medicine physicians

• Interventional cardiologists

• Interventional radiologists

• Vascular surgeons25%26%

49%

Attendees @ LINC 2016

(n ~ 5.000)

~80% of 120 (140) sites enrolling in

BEST-CLI Trial have multidisciplinary

CLI Teams [Endovascular Today 11/2015]

Complementary Disciplines• Podiatrist, wound manager,

diabetologist; microbiologist, plastic

/ orthophedic surgeon, prosthetist...

Probability of Healing

Per

fusi

on

„Flow-Team“

„Toe-Team“

Mod

if. A

fter

Rog

ers

LC, A

rmst

rong

DL:

Pod

iatr

y C

are,

Cha

pter

113

, Rut

herf

ord'

s V

ascu

lar

Sur

gery

,

7thE

ditio

n. E

lsev

ier

Inc,

201

0

„Whole Patient-Team“


NURSES AND TECHNICIANS

Teamwork matters

• Even an excellent

revascularisation can be

futile if it is not embedded

in an optimal environment of

patient care and follow-up.

Sisyphos at work


Isam

bard

Kin

gdom

Bru

nel

(180

6-18

59)

https:/

/en.w

ikip

edia

.org

A chain is only as strong

as ist weakest link!• The patient is in a weak position!

• The patient needs a

dedicated case-manager!

• The case-manager needs a

dedicated team!

• Communicate!

• If needed, every good team-player

can be a good team-leader!

• Enforce the team; if necessary,

expand the team!


Vin

cent

van

Gog

h S

unflo

wer

s(1

889)

Identification of CLI• Suspicion of ischemia

• Hemodynamic evaluation

• Anatomical evaluation


Identification of comorbidities• Contributors to tissue loss

• Diabetes, neuropathy,

infection, vessel pathology,

malnutrition...

• Contributors to strategy

• CAD; CHD; HTN; HLP;

CVD; CKDVin

cent

van

Gog

h S

unflo

wer

s(1

889)

Identification of CLI• Suspicion of ischemia

• Hemodynamic evaluation

• Anatomical evaluation


Critical Limb IschemiaDiagnostic Approach

ABI

Toe Pressure

TcPO2

SPP

CTA

MRA

iaDSA

DUS

„CLI“, first defined in 1982, was

intended to delineate a subgroup of

patients with a threatened lower

extremity primarily because of chronic

ischemia.

Perfusion is only one determinant of

outcome.

Risk stratification is based on three

major factors that impact amputation

risk and clinical management:

Wound, Ischemia, and foot Infection

(WIfI) .

Critical Limb IschemiaDiagnostic Approach

Mill

s JL

et a

l. J

Vas

cS

urg

2014

;59:

220-

34.

Rutherford 5 Rutherford 5 (6?) Rutherford 6

Ankle pressure 70mmHg Ankle pressure >200mmHg

Toe pressure 0 (30) mmHg

Ankle pressure 30mmHg

Toe Pressure 0mmHg

Ischemic wound

Mild infection

Ischemic limbIschemic toe

Critical Limb IschemiaNon-angiographic Workup

Critical Limb IschemiaRisk stratification according to WIfI

Estimate risk of amputation at 1 year for each combination

W...Wound; I...Ischemia; fI...foot Infection; VL...Very Low; L...Low; M...Moderate; H...High

Estimate likelihood of benefit of / requirement for

revascularization (assuming infection can be controlled first)

Mill

s JL

et a

l. J

Vas

cS

urg

2014

;59:

220-

34.

Rutherford 5 Rutherford 5 (6?) Rutherford 6

Ankle pressure 70mmHg Ankle pressure >200mmHg

Toe pressure 0 (30) mmHg

Ankle pressure 30mmHg

Toe Pressure 0mmHg

Ischemic wound

Mild infection

Ischemic limbIschemic toe

Critical Limb IschemiaNon-angiographic Workup

WIfI 121 / Stage 3 WIfI 320 / Stage 4 WIfI 330 / Stage 4

Critical Limb IschemiaValidation of risk stratification according to WIfI

Zhan LX et al. J Vasc Surg 2015;61:939-44.

Distribution of WIfI clinical stages 1

to 4 among amputation and limb

salvage cohorts

Incidence of major amputation and

1-yr amputation-free survival (AFS)

among WIfI clinical stages 1 to 4

Critical Limb IschemiaCost Issues

Amputation• There is no evidence for the

cost-effectiveness of primary

amputation.[Yost ML Endovascular Today 2014(5);29-36.

Barshes NR et al. J Vasc Surg 2012;56:1015-

24.]

• Total hospital cost of distal arterial

revascularisation for limb salvage

is significantly less than that of

primary amputation.[Panayiotopoulos YP et al. Diab Med

1997;14:214-20.]

Cumulative Relative Risk-ReductionTherapy RRR MACE/10a

40%

Smoking 50% 20%

Antiplatelets 25% 15%

Statins 30% 10%

LDL-C 100 70 20% 8%

ACE-I / ARB 25% 6%

ß-Blocker 25% 5%

Lifestyle Modification

Best Medical Treatment

I Ila Ilb III IV

Yus

uf S

Lan

cet

2002

;360

:2-3

.

Fon

arow

GC

et a

l. A

m J

Car

diol

2000

;85:

10A

-17A

.

Chronic Limb IschemiaModification of Risk – Medical Principles

Dam

ian

(†30

3 A

D)

Cos

mas

(†30

3 A

D)Critical Limb Ischemia

Conclusions

Early recognition matters!

Early revascularisation

matters!

Teamwork matters!

Keep the foot in the shoe!• There is only one single

case-report of a successful

leg-transplantation in

the literature![The Miracle of Cosmas and Damian]

Markus Haumer

Landesklinikum Baden-Mödling

Austria

L E I P Z I G I N T E R V E N T I O N A L

C O U R S E

2 0 1 7

Nurse and Technician Forum Part II

Critical Limb Ischemia: Optimal care, an interdisciplinary challenge

Nurse and Technician Forum Part II Critical Limb Ischemia · Critical Limb Ischemia An...

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