Jun Li, MD, details the prevalence, epidemiology, and treatment plans for patients with critical limb ischemia.
Hello. My name is julie and wanted an interventional cardiologist working a Parma in Cleveland. First off, I want to thank dr Roger go to holland for the invitation for this talk today. We will be talking about chronic limb threatening ischemia and mobilization of the team to help save limbs. These are my disclosures today we'll be talking about the prevalence and epidemiology of CLT I. Diagnostic testing and what are some of our treatment options? C. L. T. I. Is defined by the presence of peripheral artery disease or PhD in combination with rest pain, gangrene or also lasting at least two weeks in duration. Yeah. P A. D. Can be defined by him. A dynamic data such as ankle brachial index or A. B. I. Or toe brachial index or T. B. I. Or other imaging modalities such as cT scan or duplex. In terms of the wound, it can vary, it can be a very small ulcer as you can see in the first panel to involving the entirety of the first digit and the second panel or even the entirety of the forefoot and the third picture. Mhm. P. A. D afflicts more than 8-10 million individuals in the United States and over two million patients worldwide. C. L. T. I. Has an estimated prevalence of at least two million patients in the United States. This is a very important Disease to recognize as 1/5 of the patients with clt. I end up having major limb loss at one year after diagnosis. A quarter of these patients are actually deceased at one year. This has significant implications on our hospital readmission rates, quality of life measures and overall mortality in our patient population. What are some of the diagnostic test that you can obtain as a primary care physician ankle brachial index and to break you index A. B. I. N. T. V. I remain a very easy first step to assess profusion in the leg. A. B. A. Is more reliable for what we call in flu disease, such as the iliac artery or federal pop latino artery. To break you index allows a more in depth analysis of the blood flow into the organ of interest, in which case is the toe foot or the heel. Here is an example of a patient with critical limb ischemia where the profusion to the ankle bilaterally is above 1.00 Or normal. However, if you look in detail at the toe itself is 0.38 on the right and 0.31 on the left, consistent with essentially small artery disease involving the Bologna vessels. Why is the analysis of toe brachial index important? Our very own medicine, Uber and Tar command have previously shown that the presence of a normal A. V. I. Or even nine compressible vessel is present in about 30 to 40% of patients With significant tibial disease, either involving 12 or three vessels below the knee. When we did a further analysis, what we found was that the majority of patients had non diagnostic ankle pressure. However, if we look further into the toe brachial index, the T. B. I. On the bottom panel, we can identify more patients with C. L. T. I. And the involvement of disease vessels below the knee. We typically use a ratio of less than or equal to 0.7 as predictive of the presence of tibial disease. What about other diagnostic testing? Trans cutaneous oximetry. TCP 02 measures oxygen diffusion from capillary beds to the epidermal layer of skin. However, it can be erroneous in the presence of edema, increased oxygen consumption locally because of inflammation bazaar constriction from patients being cold or the presence of a callous at the site of testing. We can increase the accuracy of TCP 02 by giving patients 100% 02. For example, if a patient is testing at 30 millimeters of mercury on ambient air but increases degraded in 100 millimeters of mercury on 100% 02 it suggests an adequate arterial inflow. However, the presence of a local barrier uh is seen to oxygen diffusion. This can be in the form of a Dema or basal constriction. Overall limitations though accessibility, this test is not widely available to all of our patients perry wound oxygen levels are likely hired in the oxygen to the wound itself and, lastly like like positioning and temperature can affect the overall reliability of this test. Skin perfusion pressure is another non invasive tests that we can use to identify CLT I uh blood pressure is applied to the leg and the laser Doppler is applied to the area of interest. The pressure at which the laser probe identifies the return of blood is recorded. A variety of very small studies have evaluated wound healing in comparison to the value that we get from Spp Generally 30 to 40 millimeters of mercury have been used as thresholds for successful wound healing. Nonetheless, limitations apply again. Accessibility uh that widely available across our system um challenging technically because it has to be very highly controlled testing environment in terms of temperature and light uh to avoid vessel constriction, patients need to cooperate nicely to avoid artifacts as well. So in general we do recommend obtaining an A. B. I. And T. V. I. As the first step to making the diagnosis of C. L. T. I. What is the second step then involvement of the CLT I. Team members from a profusion perspective. Either endovascular or interventional cardiology or vascular surgery, wound management, involvement of podiatrist vascular medicine along with our wound care nurses as well, switching gears a little bit, we will review a case presentation to show the involvement of multiple team members in the management of a patient with CLT I. This is a 67 year old gentleman. He has a scheme, a cardio myopathy hypertension, the slip anemia and diabetes. He was seen by our podiatry colleagues for non healing wound on the right lower extremity. For months. He was actually offered an amputation by another facility patient was then transferred to university hospitals in Parma. For a second opinion. He underwent urgent fourth digit amputation and I. And D. Vascular surgery, then engaged the endovascular team for revascularization options. Here you can see the medications that he was on. He was on an ace inhibitor. We added D. A. P. T. As well as a statin and a beta blocker. Apologies for the gruesome picture, but here's his wound. After extensive I and D. Was already performed by our podiatry colleagues. And here you can see based on the A. B. I. T. V. I. A. B. I was 0.68. Again, with normal being 1.0 and A. T. B. I. Of 0.45 with less than 0.7 is being suggestive of significant disease. Based on his presentation. We knew that the patient had to come for a angiogram and intervention in the catholic. The first two pictures show focal lesions in the superficial femoral artery, which we successfully opened with drug coated balloons and then we took pictures of the bologna vessels which shows involvement of the post syria tibial as well as the peroneal artery. After a discussion with our podiatry colleagues. The conclusion was that a muscle flap was going to be utilized to help heal the tendons that are currently exposed so our primary target was to open up the post syria tibial artery and the peroneal artery. So we traversed from the top to the bottom. This is my wire going through the peroneal artery uh through the pedal arch here and then back up into the posterior tibial artery. This technique was utilized specifically because the origin of the posterior tibial artery was ambiguous. We don't oftentimes use this technique only really in dire circumstances where we can identify the proximal cap of our chronic total occlusion. After that, we perform balloon angioplasty of the entire peroneal artery and TP trunk as well as the posterior tibial artery. And here's our final angiogram showing intact flow into both the peroneal artery as well as the P. T. R. A. B. I. T. B. I then improved from 0.68 and 0.45 before the intervention to 0.87 and 0.57 after it is an invention and this was his intra operative pictures from his muscle flap. So here you can see the podiatrist have swung the calf muscle flap into the foot to cover the area of the attendant. A skin graft was then taken from the thigh to cover the open area and the calf. This was him three months later. Then six months later and then finally one year after his intervention, he was completely healed. As you can see based on this case presentation that CLT ay management truly is comprehensive. Once the patient is identified by to have CLT I, they should be evaluated by either endovascular services or vascular surgery services. One care associates are very important for us to help heal these patients adequately last but not least, the management of comorbidities and cardiovascular risk factors. Using gold directed medical therapies to decrease morbidity and mortality. Overall, comprehensive vascular services are available throughout the greater Cleveland area. Here. You can see all the available services we have throughout. And all of us are just a phone call away as you know, thank you for your attention.