Division of Endovascular Interventions

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Presentation transcript:

Division of Endovascular Interventions Mount Sinai Hospital New York 2/26/17

History and Physical 84 year, Female HTN, type 2 DM, CAD < 100 feet claudication distance x 2 months. Also reports pain with elevation of the right foot and relieved with dependency. BP - 144/76 mmHg Pulse - 64/min Right DP and PT - monophasic signal on doppler exam

Labs and work up Hb- 11.0 g/dl Platelets- 131K INR- 1.1 Creatinine- 1.85 ABI - right 0. 46, left 0. 68

Strategy Left CFA access 6F,45 cm crossover sheath Therapeutic anticoagulation- Bivalirudin Lesion crossing - Antegrade wire escalation Pedal access for retrograde approach Directional atherectomy followed by Balloon angioplasty Drug eluting stent for flow limiting dissection

Critical Limb Ischemia (CLI) Critical limb ischemia is defined as presence of rest pain, ulcer or gangrene attributable to objectively proven arterial occlusive disease. Symptom duration >2 weeks Physiological testing - Ankle pressure <40 mmHg, Toe pressure < 30 mmHg, ABI <0.4 (Rest pain) - Ankle pressure <70 mmHg, Toe pressure < 50 mmHg (for tissue loss) - TcPo2 < 30 mmHg

Critical limb ischemia (CLI)

Not every lower extremity ulcer is arterial

Wifi classification

Wound, Ischemia, Foot infection

Spectrum of lower extremity PAD presentations

Risk factors for CLI

Incidence and Prevalence of CLI Incidence 0.35%, Prevalence 1.33%

Bypass vs. Endovascular

BASIL

Ongoing RCT’s

Infrapopliteal disease - guidelines

Percutaneous Transluminal Angioplasty

Drug Eluting Balloon trials

Drug eluting stent trials

Drug eluting stent meta-analysis

PADI - 5 year outcomes

Angiosome directed therapy

Angiosome directed therapy

Angiosome directed therapy

Importance of Pedal-plantar arch

Importance of Pedal-plantar arch

Pedal plantar loop and single patent below knee vessel

Pedal plantar loop and single patent below knee vessel

Wound blush and healing

Wound blush and healing

Wound blush and healing

Multidisciplinary field

Overall management strategy

Isolated Tibial disease vs. Multilevel disease

Isolated Tibial disease vs. Multilevel disease