At the ilegx Collaboration Day, attendees learnt about the best management therapies for diabetic foot care and vascular reconstruction in critical limb ischaemia patients and for the second year running, the symposium broadcast edited live cases treating superficial femoral artery lesions to the Far East and North America in an event named Endovascular Electronic Education, sponsored by Abbott Vascular.
In the morning, three edited live cases were showcased to the Far East. The first case was performed by Andrej Schmidt in Leipzig, Germany, the second procedure was carried out by Peter Goverde in Antwerp, Belgium, and the third case was performed by Josef Tacke in Passau, Germany. The Abbott Supera stent system was used to treat occlusion and total occlusion of the superficial femoral artery and proximal popliteal artery.
Schmidt, Goverde and Tacke were present to answer questions from the audience at CX and those watching the live broadcast in the Far East.
Responding to questions about how a physician chooses a stent, Schmidt said: “In some cases it is clear—if it is a calcified lesion, for me it is clear that a drug-eluting balloon might not be so good, we know this from our data, and the Supera stent is the stent of choice.” He added that more data are required to make the stent selection process more comprehensive.
In the afternoon, edited live cases were broadcast to North America.
Early referral, fast track care and multidisciplinary work: key approach to save limbs
The ilegx initiative, launched in 2008, was created in response to the increasing number of lower limb amputations which are mostly due to type II diabetes. Michael Edmonds (London, UK) who is one of the founders of ilegx, introduced the “diabetic foot care” session, which was organised in conjunction with the King’s College Hospital Open Access System, with a presentation which highlighted the importance of early diabetic foot referral and interdisciplinary work as an effective approach to reduce the number of lower limb amputations, flagship principles of the ilegx initiative. He said: “Up until recently, the diabetic ischaemic foot has defeated every health care system in the world. However, a strategy which combines early referral and interdisciplinary working has led to improvements in care.” With this in mind, he commented, “ulcers can now be healed and amputations can be prevented.”
Edmonds also referred to the importance of organising a “fast-track” service in a “one-stop” visit, comprising clinical assessment, same-day investigations and urgent management to treat infection and revascularise the foot, when dealing with cases of “diabetic foot attack.” “This is best carried out in a diabetic foot clinic which can see the ischaemic patient in an open access system without delay and has rapid availability of debridement and intravenous antibiotics to treat infection and control the septic vasculitis.” He also said that diabetic foot patients who experience repeated crises from the rapid onset of infection need a special form of such easily accessible care provided by the diabetic foot clinic. “Such integrated fast track care can rapidly restore the circulation, limit tissue necrosis, save the limb from amputation and provide complete recovery from the foot attack,” he commented.
An interdisciplinary team including podiatrists, nurses, orthotists, microbiologists, interventional radiologists and surgeons—including vascular surgeons, orthopaedic surgeons and plastic surgeons—is the ideal team required in the management of diabetic foot, Edmonds noted.
He also mentioned that to complete an effective management of diabetic foot, follow-up and rehabilitation are required.
Interdisciplinary views on diabetic foot care
A vascular surgeon, an interventional radiologist and a podiatrist from King’s College Hospital, London, UK, shared with CX delegates their best practices treating diabetic foot.
Vascular surgeon Hisham Rashid, said that “the incidence of type II diabetes mellitus is increasing across the world with an expected rise in 2030 to more than 12% in a large population of the world.”
This is a worrying figure taking into account that “a major amputation rate is significantly higher in diabetic patients,” he noted.
Rashid told CX delegates that aggressive revascularisation with angioplasty, bypass or hybrid techniques is essential for limb salvage and reduction of major amputation rate. He mentioned that at King’s College Hospital, 77% of cases are treated with angioplasty and 23% with distal bypass. He said that distal bypass surgery “plays a major role in revascularisation, especially in patients presenting with significant tissue loss and when angioplasty is not feasible.” Hybrid techniques in “no-option” critical leg ischaemia have also proven very effective in preventing major amputation in this challenging group of patients, he commented.
At King’s, Rashid noted, revascularisation using distal and ultra-distal bypass has a very good outcome with a one-year amputation rate of 3.4% and 30-days mortality rate of 1.5–1.7%. At one-year, “mortality is significantly influenced by end-stage renal failure and age rather than diabetes mellitus,” he said.
Interventional radiologist Dean Huang, said that the concept of “foot attack” and “time is tissue” in diabetic patients means that treatment of an infected ulcer should be handled as an emergency with the management of a multidisciplinary team. At King’s College Hospital, “we follow this approach; we work on the basis of rapid access to diagnosis, rapid access to intervention and follow-up of interventional and surgical procedures.” From the interventional radiologist perspective, he said, “rapid access to imaging diagnostics enables the selection and planning of the optimal strategy.” Ultrasound, CTA and MRA have their place and angiography remains the gold standard, he commented. “Prompt definitive treatment with radiological intervention and/or surgical bypass to revascularisation for healing in conjunction with wound care and antibiotics is the key to achieve prevention of amputation,” Huang noted. “The threshold of what can be treated with endovascular procedures is shifting as more sophisticated devices appear on the market.”
Podiatrist Jennifer Tremlet, spoke about the different techniques used at King’s College Hospital to heal diabetic foot wounds. “Diabetic foot patients are complex cases, they experience extensive tissue loss and infection. In order to achieve successful wound healing, they require intensive wound care and rigorous monitoring.” She said that, depending on the complexity of the wound and the type of patient, they use different multi-modal techniques including debridement, larvae therapy, hydrosurgery therapy topical negative pressure therapy, split skin grafts and pressure relief.
Foot care and arterial reconstruction
At a session on foot care and arterial reconstruction, Christopher Attinger (Washington, USA) said that using the angiosome principle to guide revascularisation is a critical component for optimising wound healing. He explained that the angiosome concept divides anatomic regions into three-dimensional blocks of tissue fed by source arteries and creates a framework for understanding tissue perfusion, predicting wound healing, and planning surgical interventions. Therefore, “understanding the boundaries of an angiosome and the vascular connections between source arteries provides the basis for limb salvage to optimise revascularisation to ischaemic areas and promote wound healing.”
Mauro Gargiulo (Bologna, Italy) spoke on the need to have multidisciplinary guidelines to support the treatment of critical limb ischaemia. He referred to a consensus document that has been recently published on the treatment of peripheral arterial disease in diabetes written by the Italian Societies of Diabetes (SID, AMD), Radiology (SIRM) and Vascular Endovascular Surgery (SICVE). The consensus, published in Nutrition, Metabolism & Cardiovascular Disease (Aiello A et al, 2014; 24: 355–369), higlights that “the prevalence of peripheral arterial disease is high in diabetic patients and, associated or not with peripheral neuropathy, can be found in 50% of cases of diabetic foot.” Gargiulo said that the document summarises indications for revascularisation, revascularisation techniques and details on follow-up of revascularised patients, among other topics.
In the same session, Bijan Modarai spoke about effective cell therapies for revascularisation of critical limb ischaemia and Roberto Ferraresi discussed patient-centric revascularisation strategies.
At the end of the ilegx Collaboration Day a roundtable consensus on the role of drug-eluting balloons for the treatment of superficial femoral artery including data from the IN.PACT SFA, ILLUMINATE, Levant 2 and BIOLUX-PI studies was held. Vascular News will be reporting on the outcomes of this discussion.