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
Endo vs open surgery for diabetic
ulcers
PTA
25%
75%
Stenosis
Total Occlusion
p = 0.053
Stent
37%
Stenosis
63%
Total Occlusion
# 1. Patency
• Patency of angioplasty is worse than
bypass in diabetic ulcer patients
Angioplasty
patency is worse!
• YES
# 1. Patency
• BUT ARE BYPASSES THAT GREAT???
• 30-40% of bypasses develop stenoses with in 1 yr (Seminars of Vascular Surgery
2012 25:108-114)
• 20-80% of successful patent bypasses have recurrent or persistent ulcers
or wounds at 1 yr (Seminars of Vascular Surgery 2012 25:108-114)
• Too late or bypass flow is not enough
• Non-ischemic ulcer
• Occluded bypass does not necessarily mean amputation or recurrent
ulcer
# 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
# 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)
# 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
#2. Periprocedural mortality and
morbidity
#2. Periprocedural mortality and
morbidity
• Large prospective NSQIP analysis of >2500 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 2012:25:108-114
#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 2012:25:108-114
#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 2012:25:108-114
#3. Multiple run-off vessels and distal
pedal circulation
#4. Burning bridges?
You will be
burning bridges!
#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
#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....
#4. Burning bridges?
• BASIL is very good in thai food
#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
#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.
#5. Not all diabetic ulcers with vascular
stenoses or occlusions need
revasculariztion
• An unnecessary bypass may be worse than an unnecessary angioplasty
Ask Uncle Google…
Thank you
Division of Vascular and Endovascular surgery
The Ottawa Hospital and University of Ottawa
Round 1
Rebuttal
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
TASC guidelines are
lesion-centric and do
not emphasize the
importance of
weighing comorbid
factors and life
expectancy
#6. If you don’t 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
Evolution