dr Bishop. All right. So today we're going to talk about limb salvage and importantly, um trying to save as many lives as possible. These are my disclosures. So why limb salvage peripheral artery disease afflicts over 8-10 million individuals in the United States And 200 million patients worldwide. See LTI or chronic limb threatening. Ischemia has an estimated prevalence of about two million patients in the United States alone. 1/5 of these patients have limb lost at one year after diagnosis and a quarter of them were actually deceased at one year as well. Significant implement implications on hospital readmissions, quality of life measures as well as mortality. Major amplification results in a five year mortality rate of 40%. Mortality is even higher once you reach over the age of 70 Reaching 44% at one year and as high as 85% of five years. So if we're able to save their limbs were actually able to improve their survival curve. As we can see Following major amputation, more than 50% of patients remain ambulatory. Less than 50% of patients remain ambulatory. This is adversely affected by high B. M. I increased frailty as well as pre functional status as well. This is why limb salvage remains important in our practice. So we'll start with the first case 61 year old morbidly obese gentleman. He has diabetes hypertension, peripheral artery disease, History of bilateral from Pat Bypass in 2019 for clarification, complicated by an infected graft of the left leg and the entire graph was actually removed. Subsequently. He had a non healing ulcer on the right heel. Had a BK at another facility. He presented to us with a second for a second opinion regarding a non healing. Well now on the left lower extremity and that had been present for about 2-3 months. He has already trialed wound back with one of our local podiatrists without success. And this is his wound. Um Some of our proprietary colleagues will probably do a little bit better than I would commenting on exactly how this wound looks but certainly very deep. And as we found out later, he actually has evidence of osteomyelitis as well. Um here you can see on the A. B. I. T. B. I. Uh the toe breaking, the index is 0.11 and an ankle break. Your index of 0.44. So pretty significant. Ischemic disease here. So we went to uh and took pictures. So starting from the top here on the left hand side, you can see the common iliac artery is Peyton. There's actually a very triangulated bifurcation here. You can see the aortic into iliac and and how how the angular ation is. Uh This subsequently factors into how we end up performing our procedure. The external iliac artery here labeled is severely diseased with the common femoral artery that is 100% included. This is then followed by a complete occlusion of the SF A. As well. This does reconstitute this totally. And you can see a very small hint of a posterity tibial artery with our injection from the top here. So what are our options here? So essentially this is a two step process. So we obtained retrograde access into the distal sF A. Across the common femoral artery. And we actually ended up snaring this sheath, this catheter in the aorta because we couldn't get our sheath up and over due to the angular ation of the iliac arteries. Uh Long and short. We ended up ballooning the common femoral artery and the S. F. A. With good outflow into the S. F. A. And then we turn our attention to the infra pop a little segment here you can see in the 4th, 5th and 6th panel. The political itself is also 100% included. Uh There's reconstitution just at the distal part. Political. The interior tibial artery is painting approximately. And it looks like it has a pretty decent run off. In the very last right hand panel. The dorsal pedis itself is included. The post stereotypical itself is also included approximately. So, what is our strategy now? So, we ended up going retrograde as well. And this is actually now we're moving down to the knee joint. We ended up going retrograde initially. Through the post stereotypical artery. I could not reconnect into the public still. So we went retrograde through the anterior tibial artery. And here in our second video uh is us nearing the wire from the retrograde system. We ended up ballooning this entire thing. And here you can see a very good re establishment of the papa till as well as the S. F. A. And finally the common femoral artery. Um His A. B. I. T. V. A. Improved to 0.70. So still some deficiency in the gradient. But his toe brachial index actually improved pretty drastically to 0.53. Uh This was only a couple of weeks ago. So this is his most updated picture again. He has the osteomyelitis which I talked with the podiatrist. Uh It's going to be treated with antibiotics for now and then eventually might require uh some excision of the parts of the bone that's infected. Moving on to case two a 74 year old gentleman with hypertension disability. Me and an ischemic cardiomyopathy COPD with ongoing smoking. Ah He has final chi infosys. So this is a patient with gangrene of the right lower extremity digits. A heel ulcer as well as breast pain. He was offered BK in another facility after C. T. A. Was performed that showed bilateral sF. A. Inclusions in the right political inclusion. He presents again to us with a concern for BK. And second opinion regarding revascularization options. And I do apologize for the extremely tremendous pictures here. So here you can see essentially right gangrene developing in the 4th and 5th digits of the right foot as well as gangrene of the second digit, there's a small heel ulcer. The FBI was performed at another facility. So there's no I can't commit in tow break your index. But the FBI itself is 0.18. So even worse in this situation. And here you can see the pictures from the external iliac artery um is diffuse the disease, but afterwards after intervention when I pulled back there was no significant gradient under. So and we did that intervene on the external iliac artery. Here, the S. F. A. Itself is included, as you can see in the second panel and then it reconstitutes briefly in the pop material. And after crossing the S. F. A. You can see uh below the knee disease also severely disease. There's chronic inclusions in all three vessels. Um The posterior tibial itself is actually essentially nowhere to be found. The anterior tibial artery reconstitutes in the proximal to mid segment and then it does provide the distal segment. But again the dorsal is penis itself here appears to be included. The peroneal is also nowhere to be found. So the patient has essentially a desert foot with no flow into the toes or into the heel. So we proceeded with angioplasty of the sf a pop latino artery. Um This did require some stenting. So two stents were placed for residual dissections. And here you can see the final pictures due to the complexity of the bologna disease. This was a staged procedure. So when we came back, we went to integrated directly down into the Sf, a public radio artery. And here, you know, uh we think that this might be the popular radio artery. But when you take a more orthogonal view, what we were actually looking at was this branch. This this is a collateral. So the true political itself is included right here. And then we took one dedicated uh foot picture where you can see still that this still 80 runoff. So our approach in this situation was actually to go into the 80. Here's a couple of pictures of how we might obtain access under floor of Skopje guidance. Most of our access is actually obtained with ultrasound guidance. Uh this is one example of a fluoroscope guidance where we place the wire retrograde. Um unfortunately the wire did not truly connect from the 80 and the the interior tibial into the pop material itself. And here you can see in the first movie, Arpa political segment has a catheter that's essentially pretty much outside of the artery. Um so we used the retrograde wired and to mark exactly where the vessels are. In the second movie, you can see the anterior tibial wire has gone into the peroneal itself. So it's actually gone up and into the perennial rather than going into the political. So we you leave that as a marker so that we can know exactly where to penetrate with our integrated system. And unfortunately despite doing that it didn't connect. So what was our next option? So here you can see. And the third and the fourth movie I'm using the wire from the anti grade um peroneal. So now we have the wire from the anterior tibial into the perot neo. And we're using that wire to essentially what we call stick the wire to go up into the peroneal. Which gives us a better in line access to penetrate into the popular video distal occlusion. And here you can see in the very last movie we're Externalizing our retrograde wire. We proceeded with intervention. This did require a stent in the teepee trunk as well. We did actually try to open up the post stereotypical artery as well. Unfortunately could not find the true lumen. Um So this was his uh end flowed out. So you can see very good outflow into essentially what would become the dorsal is peter's as well as some collateral flow into the ah hell. And this achieved him an A. B. I. Of 1.1. He actually ended up getting A. T. M. A. So he no longer has T. B. I. S. And here you can see his wound. This was actually just taken this past monday. So almost completely healed on tm. A. And the hell actually looks phenomenal so real quickly on some data, what are what what's our data supporting endovascular procedures versus venus bypass. So looking at a meta analysis performed in 2000 and 18 44 studies with a total of 8600 patients with CLT ay necessitating infra inguinal revascularization. Sorry for the table. Um So for the infra pop Little disease um The primary patton C. At one year for surgical bypass using GSP was 87%. Unfortunately, when you use non alta cartilaginous graphs, it was down to 77% in this meta analysis. Primary paciencia. If you were to perform endovascular procedures below the knee Drug eluting stents afforded a patent, see rate of 73% at one year. This does go down with bare metal stents 50%. And then petey alone, which is what we still use traditionally for most of our patients survival. Major amputation. Uh And then uh amputation. Free survival at two years was actually similar amongst the endovascular and venus bypass patients importantly, prosthetic bypass patients had a significantly higher rate of limb loss compared to the other two cohorts. Major amputation. One year, I was 24% versus 11 verse percent. So if you had a venus can do it as opposed to a prosthetic can do it. You had a significantly better benefit with major amputation. Unfortunately venus can do its are not always available as we all know. The venus can do it maybe of course quality or may have already been used for a prior bypass or in our very first patient. It was already used before and had already been taken out and more importantly, there's significant heterogeneity in the study cohorts because it is a meta analysis, there's a very high risk of bias patients are not randomized for endovascular versus venus bypass. So patients with endovascular approach 1st may have an increased co morbidity compared to those that undergo bypass. Um In these studies. And what about long segment inclusions like our second patient were completely occluded from the common firm roll all the way into the tibial. So when we look at the VQ I analysis of patients with CLT Ay involving the infant's articulate vessels. Uh This is actually analyzed. 2566 patients, 500 of those who were bypassed and the remainder were endovascular revascularization. A multi variant analysis showed a higher primary patent see rate in the endovascular arm and that was statistically significant. There was no difference though in overall major amputation or mortality. So more is to come by cli uh will probably tell us a little bit more about whether in that bypass or endovascular therapies should be the first choice or the second choice um or if they're going to end up being equivalent. So more of that to come. So, final thoughts, I'm getting kicked off. Final thoughts in the vascular therapies can provide durable outcomes for patients with CLT I high comorbidities and our anatomy should be offered endovascular options as the method of limb salvage and we have a limb salvage advisory council between the Endovascular Service, the vascular surgery service, as well as the podiatrist services. This is a multidisciplinary team discussion to help provide patients with an opportunity to save a life. These are the patients that really are on the brink of a. B. K. A. Uh due to a vascular disorder and they were actually undergo multiple uh you know, multidisciplinary discussion as a team over zoom uh to discuss what our other options that we might have for our patients. It really takes a village. And these are your vascular specialists in your area. Thank you.