This year, the ilegx multidisciplinary team, continuing in its aim to reduce the number of leg amputations, broadcast—for the first time—edited live below-the-knee endovascular procedures to the Far East, in association with Abbott Vascular. Also, as part of the ilegx programme, the King’s College Hospital Open Access System showed the latest treatment options for diabetic foot. Innovative methods of foot revascularisation were also discussed and a guidewire tutorial was taught.

The morning session titled “Electronic Endovascular Education—Edited live cases broadcast online to the Far East”, chaired by Max Amor (Essey-les-Nancy, France) and Roger Greenhalgh (London, UK) showed delegates three complex below-the-knee procedures from Germany, Italy and France.

The first case was performed by Andrej Schmidt in December 2012 in Leipzig, Germany. The second procedure was carried out by Roberto Ferraresi in March 2013 in Milan, Italy, and Eric Ducasse undertook the third case in Bordeaux, France, in March 2013. Ducasse said: “In the past decades we have seen major advances in the treatment of below-the-knee lesions with dedicated materials and retrograde approaches to peripheral arterial disease.” For this case, Ducasse showed below-the-knee techniques using Abbott Vascular materials. He showed a retrograde approach through the peroneal artery followed by guide wire proximal recapture and successful balloon angioplasty.

After each case, Dierk Scheinert, Leipzig, Germany; Flavio Airoldi, Sesto San Giovanni, Italy; Ferraresi, and Ducasse, answered questions, via video link, from delegates watching in the Far East. Questions came from Japan and India, and also from Tunisia.

At the end of the session, Greenhalgh told delegates: “This Electronic Endovascular Education session has been a wonderful experience with great educational value. I have to thank these physicians from Germany, France and Italy for those fantastic results and for sharing with us all that can be done to save legs.” 

He added: “This experience forms part of the CX ilegx Collaboration Day and ilegx stands for interdisciplinary management of legs because we are concerned that too many legs are being amputated,”

Greenhalgh told CX Daily News: “In these times of economic difficulties—when flight costs are on the rise—this online educational experience could be a cost-effective way of sharing education. We would like to invite the participants of this experience to share their opinion via twitter or facebook on whether this should be a pattern to be followed in future CX meetings” 

King’s College Hospital Open Access System aims to save diabetic foot

The King’s College Hospital Open Access System, London, UK, “includes a multidisciplinary team of podiatrists, nurses, microbiologists, vascular surgeons, orthopaedic surgeons, diabetologists and interventionalists dedicated to providing an urgent, immediate treatment to patients who are at risk of developing necrosis, gangrene and losing their legs,” Michael Edmonds, King’s College Hospital, told CX Daily News. “The two drivers for this—in diabetic patients—are infection and ischaemia. Rapid diagnosis of infection and rapid treatment will prevent the progression of the necrosis. At the same time, the vascular system should be addressed and we should go forward with revascularisation, either with angioplasty or bypass, depending on the degree of the circulation problem as soon as possible,” he added. Edmonds presented an update entitled “Rapid referral and treatment within the concept of the diabetic foot attack” at the CX ilegx session.

Physicians with different specialties from the King’s College Hospital Open Access System also gave presentations at the ilegx Collaboration Day on their experience treating diabetic foot as a multidisciplinary team.

Jason Wilkins, London, UK, presented a modern interventional approach to the diabetic foot. He told delegates, “The modern interventional approach to the diabetic foot begins with teamwork and recognition of patient-centred care being at the forefront of the team approach. Ischaemia with neuropathy or infection is considered an emergency and robust patient pathways are mandatory in providing timely intervention.”

Wilkins highlighted that revascularisation was a basic requirement for successful treatment and amputation prevention. “Revascularisation may be surgical, radiological or a combined approach according to the presentation and nature of disease and distribution,” he commented.

According to Wilkins, modern techniques and equipment provide the interventionalist with excellent tools for revascularisation with angioplasty, stenting and recanalisation of multiple long occlusions. He said: “The understanding and availability of modern equipment and techniques along with an effective multidisciplinary and timely approach to urgent revascularisation result in improved outcomes for our patients.”

Hisham Rashid, vascular surgeon, London, UK, presented “Distal and ultra-distal bypass: a discussion on the foot angiosomes—fact or fiction?”

Rashid told delegates that the angiosome concept was developed in 2006 by Attinger. He commented on a study—in press—that he undertook to evaluate the impact of the angiosome concept in a group of 142 diabetic and non-diabetic patients who underwent distal and ultra-distal bypass surgery for critical limb ischaemia with significant foot tissue loss. Rashid reported: “In this cohort of patients the healing and time to healing was not affected by the angiosome revascularised, but was significantly affected by the quality of the arterial pedal arch. In patients with no pedal arch, the healing was significantly slower and inadequate compared to the complete and incomplete pedal arch subgroups. However the amputation-free survival rates were similar in all groups.”

International input to limb salvage

Also, as part of the Kings College Hospital Access System programme, speakers from Europe and USA gave their views and experiences on limb salvage.

Carlo Setacci, Siena, Italy, talked on the latest guidelines on diabetic foot treatment: The Italian consensus document. Carlo Caravaggi, Milan, Italy, presented a new integrated surgical approach—based on timing—to reconstruct the diabetic foot.   Christopher Attinger, Washington, USA, told delegates about surgical care of the wound with debridement and planning of amputations and reconstruction. An interventional approach to the diabetic critical limb ischaemia patients vs. non-diabetics was presented by Roberto Ferraresi, Milan, Italy. David Armstrong, Tuscan, USA, spoke on techniques to correct foot deformity by surgical means.

Revascularisation challenges

In the afternoon, Roger Greenhalgh, London, UK, chaired the session on revascularisation challenges on the treatment of critical limb ischaemia.

Frank Vermassen, Ghent, Belgium, highlighted the importance of keeping vessel patency in the long run. He said: “Sustained patency of the wound-related artery is mandatory to optimise the chance for wound healing, to avoid repeat intervention and to preserve the limb.” Thomas Zeller, Bad Krozingen, Germany, said: “Patency is necessary but not sufficient for wound healing and ultimate limb salvage.” He added, “Drug-eluting balloons may be the solution to achieve the necessary patency levels within the extensive multivessel arterial disease typical of critical limb ischaemia.”

In the discussion, the question of using more than one balloon to achieve the necessary patency in critical limb ischaemia patients was raised. However, this approach would increase costs. Greenhalgh made the point that only patients with insurance companies willing to pay for this and patients who can afford it would receive the treatment.