1. Assoc. Prof. Vinko Vidjak, MD, PhD, Medical School Zagreb
Annual Meeting of the TSIR, Antalya,11-13 March 2016.
Importance of forming Centers for diabetic foot
Assoc. Prof. Vinko Vidjak, MD, PhD,
Medical School Zagreb
Clinical Department for Diagnostic and Interventional Radiology
Clinical Hospital Merkur
Zagreb, Croatia

2. √ Disclosure Speaker name: Vinko Vidjak
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Disclosure
Speaker name: Vinko Vidjak
I have the following potential conflicts of interes to report:
consulting: Boston S
employment in industry
stockholder of a healthcare company(s)
owner of a healthcare company(s)
other(s)
I do not have any potential conflict of interest √

3. DM is the leading cause of lower limb aputations worldwide
Annual Meeting of the TSIR, Antalya,11-13 March 2016
DM is the leading cause of lower limb aputations worldwide
40% amputees die within 2 years

4. 315.900 adult pts in Croatia have DM (9,2%)
Annual Meeting of the TSIR, Antalya,11-13 March 2016
adult pts in Croatia have DM (9,2%)
Annual expenditure DM treatment is 11,49% of the healthcare budget (2,5 billion HRK annually)
Average cost of treatment of 1 DM pt. / 1 year is ,44 HRK
85,72% of those costs are spent on the treatment of complications
Expected increase of DM pts (until 2030.) to 10,5%
Novo Nordisk Croatia 2010
Inhabitants:
4.3 mill
Complication type Cost HRK %
PAD %
Diabetic foot %
85.72% is spent of the treatment of complications
Novo Nordisk Croatia 2010

5. Slavonija, Baranja and west Srijem
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Slavonija, Baranja and west Srijem
ihabitants
DM patients
courtesy Silvija Canecki-Varžić, dr.med

6. Chronic complications – CHC Osijek Structure of direct costs
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Chronic complications – CHC Osijek Structure of direct costs
Izvor: Canecki-Varžić S, Miljković G. Prijedlog projekta Regionalni centar za endokrinologiju, dijabetes i bolesti metabolizma u dvorcu Batory, 2011; podaci KBC Osijek, cijene HZZO, srednja vrijednost pojedinih zahvata
courtesy Silvija Canecki-Varžić, dr.med

7. Annual Meeting of the TSIR, Antalya,11-13 March 2016
Diabetic foot
The rate of amputation in diabetic patients in the Osijek - Baranja County
Amputation
9.62 / 1000 patient / 1g
9-16x higher than in the UK
courtesy Silvija Canecki-Varžić, dr.med

8. “...85% of amputation can be prevented by
Annual Meeting of the TSIR, Antalya,11-13 March 2016
???????
“...85% of amputation can be prevented by
early detection & appropriate treatment”!
D.Scheinart LINZ 2013

9. institution treats all of DM peripher. vascular complications
Annual Meeting of the TSIR, Antalya,11-13 March 2016
- Dedicated BTK (endovascular) procedures are
performed at 7 centers in Croatia
- only in 5-7 with skilled physicians 1
In only 3% pts referred to IR consult
DM pts protocol not using the PtcO2 machine
!!!!!!!!
IR procedure in 0,7% hospital pts 6 1 ??
institution treats all of DM peripher. vascular complications 1

10. MSCT angiography COLOR DUPLEX US MR angiography
Annual Meeting of the TSIR, Antalya,11-13 March 2016
MSCT angiography
COLOR DUPLEX US
MR angiography

11. Interdisciplinary apr.
Annual Meeting of the TSIR, Antalya,11-13 March 2016
System of care
Interdisciplinary apr.
- care specialist: podiatrists, surgeons, internal medicine, physicians), invasive vascular physicians (interventional cardiologists, interventional radiologists, vascular surgenons),…

12. IR Cooperation in the field of diabetic foot:
Annual Meeting of the TSIR, Antalya,11-13 March 2016 IR
Interventional Quarter ISSUE- 2009
Cooperation in the field of diabetic foot:
EASD – European Association for the Study of Diabetes
CIRSE – Cardiovascular and Interventional Radiological Society of Europe
…both disciplines regarding the ability to treat DM complications
…exploring possible future treatment options
…guest lectures
…guidelines revision
…educational programs

13. Italian Diabetic Foot Care Network
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Italian Diabetic Foot Care Network
Concept - DFC
Diabetic foot centers
Level 1
Level 2
Level 3
Diabetic Center
Diabetic Foot Center
Specialised Diabetic Foot Clinic
Education
Primary Prevention
Primary prevention
Treatment of ulcers
Drainage of flemmon
Minor amputation
Surgical debridment
Dressing
Off-loading
Secondary prevention
Vascular Procedures
PTA
By-pass
Acute Surgery
Surgery diabetic foot deformity (Charcot)
courtesy dr Marco Manzi

14. Annual Meeting of the TSIR, Antalya,11-13 March 2016

15. ( “endo first” or “open first” )
Annual Meeting of the TSIR, Antalya,11-13 March 2016
How to choose appropriate revascularization treatment for the patient with PAD
( “endo first” or “open first” )
PATIENT SELECTION
Best revascularization option is suggested by TASC classification
(TransAtlantic InterSocietal Consensus on Peripheral Arterial Occlusive Disease)
2000- TASC
2007- TASC II
TASC revision..
TASC is a result of cooperation between 16 societies in USA, Europe, Australia TASC IIb Technical Update
The Inter-Society Consensus for the Management of PAD (TASC II) Working Group intends to elaborate on the original TASC II guidelines concerning the role of endovascular techniques in relation to open surgery based on the TASC classification, and to include guidance on more severe lesions than those covered in the TASC II publication. There is also an intention to include a tibial lesion classification.

16. Extensive Angioplasty in the Treatment
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Extensive Angioplasty in the treatment of ischaemic diabetic foot ulcers:
clinical results of a Multicentric Study of 221 consecutive diabetic subject
Faglia E. et al.: Journal of Internal Medicine 2002
Extensive Angioplasty in the Treatment
of Ischemic Diabetic Foot Ulcers
Multicentric trial, 191 patients with DF-ulcers and PAD
• In 94,2% angioplasty of infrapopliteal arteries
major amputation rate 5,2 %
• Clinical follow-up mean 14 ± 7 months
recurrent foot-ulcers in 7,9%

17. Annual Meeting of the TSIR, Antalya,11-13 March 2016
PATIENT SELECTION
Interventional procedures are the first treatments proposed for most PAD patients.
PAD could be treated with endovascular interventions:
From 1998 to 2007 endovascular interventions quadrupled for CLI and doubled for claudication.
In the same period significant reduction in amputations occured although patients had significantly more comorbidities.*
*Egorova NN. Et al. An analysis of the outcomes of a decade experience with lower extremity revascularisation including limb salvage, lenghts of stay and safety.J Vasc Surg (4):
TASC is a result of cooperation between 16 societies in USA, Europe, Australia TASC IIb Technical Update
The Inter-Society Consensus for the Management of PAD (TASC II) Working Group intends to elaborate on the original TASC II guidelines concerning the role of endovascular techniques in relation to open surgery based on the TASC classification, and to include guidance on more severe lesions than those covered in the TASC II publication. There is also an intention to include a tibial lesion classification.

18. Minimally invasive methods of treatment
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Minimally invasive methods of treatment
Bioapsorbable stent
Long term patency of
below- the- knee arteries
Drug eluting stents (DES)
Bare stents
Drug eluting ballons (DEB)
Angioplasty (PTA)

19. Specific angiosome revascularization
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Revascularization of a Specific Angiosome for Limb Salvage: Does the Target Artery Matter?
Neville RF et al. Ann Vasc Surg 2009
Specific angiosome revascularization
Direct revascularization (= bypass to the artery directly feeding the ischemic angiosome) of the angiosome specific to the anatomy of the nonhealing wound leads to:
- A higher rate of limb salvage and healing

20. Angiosomes 6.day 15.day 45.day 60.day 75.day courtesy dr Marco Manzi
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Angiosomes
6.day
15.day
45.day
60.day
75.day
courtesy dr Marco Manzi

21. institution treats all of DM peripher. vascular complications
Annual Meeting of the TSIR, Antalya,11-13 March 2016
The rate of amputation in diabetic patients in the Osijek - Baranja County
Amputation
9.62 / 1000 patient / 1g
9-16x higher than in the UK
In only 3% pts referred to IR consult
IR procedure in 0,7% hospital pts
DM pts protocol not using the PtcO2 machine
institution treats all of DM peripher. vascular complications
Cooperation in the field of diabetic foot:
EASD – European Association for the Study of Diabetes
CIRSE – Cardiovascular and Interventional Radiological Society of Europe

22. 2010. two hospitals merged and Diabetic Foot Clinic is formed
Annual Meeting of the TSIR, Antalya,11-13 March 2016
2010. two hospitals merged and Diabetic Foot Clinic is formed
Clinic for Metabolism diseases and DM
Educational base of the School od Medicine
Croatian referral center for DM
WHO partner institution for DMl
Clinical Hospital Merkur
Educational base of the School od Medicine
WHO referral transplant center
Croatian education center for IR

23. Formation of Diabetic Foot Clinic-DFC covers
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Formation of Diabetic Foot Clinic-DFC covers
Complications prevention
Earlier diagnosis of stenotic and occluded arteries
Better DM (vascular) complications treatment
Reduced number of amputations
Better multidiscipline cooperation
Reduction of treatment costs
Patient information

24. Formation of Diabetic Foot Clinic-DFC covers
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Formation of Diabetic Foot Clinic-DFC covers
Clinic for Metabolism diseases and DM
DM pts policlinic
Angio clinic
Internal medicine support in DM treatment
Clinical department with 25 beds, 5 of those for DFC
Clinical Hospital Merkur
General surgery
Vascular surgery
Invasive cardiology
Non-invasive X-R diagnostics
Invasive radiology
Physical therapy

25. Annual Meeting of the TSIR, Antalya,11-13 March 2016
Concept of DFC
Need for: regular interdisciplinary meetings to analyze complex cases and treatment strategies
revascularization team: diabetologist, general surgeon, vascular surgeon, interventional radiologist
reconstruction team: diabetologist, vascular surgeon, plas surgeon!, orthopaedist!
meeting of regular daily team: diabetologist, nurse, physical therapist
Goals
- benefit-damage ratio of each type of treatment
- revascularization of at least one below-the-knee artery to the foot
- reperfusion and sanation of open wounds
- more important to achieve clinical reperfusion than morphological

26. PATIENT WITH DM AND VASCULAR COMPLICATIONS
Annual Meeting of the TSIR, Antalya,11-13 March 2016
PATIENT WITH DM AND VASCULAR COMPLICATIONS
ASYMP.; INTER. CLAUD
CLI
PULS, ABI,, TcPO2,
PULS, ABI,, TcPO2,
PULSE OK,
ATENUATED ABI <0.9
TcPO2>50 or 30-50
ABSENT PULSE 1 ili 2
sat ABI <0.9,
TcPO2<50 mmHg
ABSENT PULSE,
TcPO2 < 40 mmHg,
ABI<0.9
COLOR DOPPLER
ANGIO (DSA) + PTA
BYPASS, distal PTA post bypass
CLEAR FINDING
INCONCLUSIVE FINDING
IF REVASCULARIZATION NOT POSSIBLE
TcPO2 – revascularization indication:
>50 mmHg – good tissue perfusion, not indication
31-50 mmHg – selective indication, claudications, ulceration <30 mmHg – definite indication, critical ischaemia
CLI TcPO2 <30-50mmHg
Bulgarian Endovascular Course 2011

27. PATIENT WITH DM AND VASCULAR COMPLICATIONS
Annual Meeting of the TSIR, Antalya,11-13 March 2016
PATIENT WITH DM AND VASCULAR COMPLICATIONS
ASYMP.; INTER. CLAUD
CLI
COLOR DOPPLER
ANGIO (DSA) + PTA
BYPASS, distal PTA post bypass
CLEAR FINDING
INCONCLUSIVE FINDING
IF REVASCULARIZATION NOT POSSIBLE
1xyear follow-up
(6 mj?)
MSCT or
MR ANGIO
Stable pain and lesion
Progresion of pain, lesion and infection
Kidney function?
Calcifications
FOLLOW-UP
REVASCULARIZATION
MEDICAL TREATMENT
AMPUTATION
Bulgarian Endovascular Course 2011

28. Clinical Hospital Merkur
Annual Meeting of the TSIR, Antalya,11-13 March 2016 At
Clinical Hospital Merkur
PAD, DMel and ? IR

29. IR Therapy - IR subspecialization mentorship
Annual Meeting of the TSIR, Antalya,11-13 March 2016
IR Therapy
- IR subspecialization mentorship
- Ambulatory IR consultations
IR experience
More than 800 angio therapeutic + diagnostic procedures anually
Treatment types: PAD (pta/stent), PTA/stent on other arteries, subintim rec., transpedal ap., CAS, EVAR, BTK, reocclusive techniques (mechanical, aspiration thrombectomy, JET st,.....), cutting balloon, DEB, embolisation, TIPSS, (thrombolysis), vein procedurs, billiary, urogenital, digestive interventions, CT guided drainage,....

30. Minimally invasive treatment
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Minimally invasive treatment
percutaneous transluminal angioplasty ( PTA)
drug eluting balloon (DEB)
bare stent
drug eluting stent (DES), - bioabsorbing stent
subintimal angioplasty
percutaneous end/arterectomy - cryoplasty
”cutting balloon”
thrombectomy (mech., aspir.)
transpedal approach
- laser recanalization

31. Opportunity for targeted therapy
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Optimal Tibial Recanalization - Angiosome Concept
Opportunity for targeted therapy

32. Annual Meeting of the TSIR, Antalya,11-13 March 2016

33. Annual Meeting of the TSIR, Antalya,11-13 March 2016

34. Annual Meeting of the TSIR, Antalya,11-13 March 2016

35. Annual Meeting of the TSIR, Antalya,11-13 March 2016

36. Annual Meeting of the TSIR, Antalya,11-13 March 2016

37. Annual Meeting of the TSIR, Antalya,11-13 March 2016
Multilevel disease

38. Successfully recan. limbs 89% Successfully recan. art. 76%
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Patients (N) / 56
Age (yr)
62±11
Rutherford IV
57%
Rutherford V
17%
max lesion length
12cm
occlusion
70%
Successfully recan. limbs
89%
Successfully recan. art.
76%
Patients (N) 56
Mean follow up (mon)
12±4
improvement
72.4%
unchanged
24.1%
worsened
3.4%
bypass
0 %
amputation minor
24%
amputation major
CLI Patients treated at our department from May
CLI Diabetic Patients
Percentage of Diabetics
Follow up on 34 PATIENTS SCHEDULED FOR AMPUTATION 56
34 / 56
60%

39. Annual Meeting of the TSIR, Antalya,11-13 March 2016
husbad

40. Heads of radiology departments, doctors, administration hospital
Annual Meeting of the TSIR, Antalya,11-13 March 2016
State administration's
blind people
Heads of radiology departments, doctors, administration hospital

41. Conclusions : Task of Db foot Center
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Conclusions : Task of Db foot Center
- Promotion of interdisciplinary approach in diabetic foot treatment
- One place full service providing , to the patients with DM and chronic foot impairment
- Good interdisciplinary cooperation
- Treatment of complications and rehabilitation with the intent of preserving integrity of the extremities

42. Annual Meeting of the TSIR, Antalya,11-13 March 2016
Conclusions : Task in Db foot Center IR
- primary goal of CLI treatment - ↓ number (extent) of amputations) and preserving the functional status of the leg
- to be qualified for providing of significant number of different minimally invasive procedures, if it would be indicated
- angiosome aimed revascularization
- keep patency long enough for the ischaemic lesion to heal and pain to regress
- “multilevel” disease (AFS+BTK)
- simultaneous revascularization

43. Thank you for your attention!
Annual Meeting of the TSIR, Antalya,11-13 March 2016
Thank you for your attention!