The CX ilegx Collaboration Day course has been designed to update attendees on the latest treatment strategies developed to avoid the increasing number of unnecessary lower limb amputations—flagship principles of the ilegx initiative. Delegates will learn about the King’s College Hospital open access vascular diabetic foot care pathway—an effective approach which incorporates early diabetic foot referral and interdisciplinary work—which is showing promising results saving limbs.

Delegates will also hear about revascularisation strategies of the ischaemic foot with the latest data in the field; and will have the opportunity to discuss in more detail, in two roundtables led by experts, the controversy of “Leaving something in” or “Leaving nothing behind” in the superficial femoral artery. This subject will be exposed in the CX Main Programme – Peripheral Arterial Controversies (two days before ilegx).

In the commentary below, Michael Edmonds (King’s College Hospital, London, UK), who is one of the founders of ilegx and co-director of the CX ilegx Collaboration Day course, explains the King’s College Hospital pathway. He also writes about the value of endovascular techniques for diabetic foot care and critical limb ischaemia treatment.

This is followed by an interview with Cliff Shearman (University of Southampton, Southampton, UK), co-director of the ilegx Collaboration Day. He talks about what he believes the take-home message from this year’s CX ilegx Collaboration Day will be.

Commentary by Michael Edmonds, ilegx course director

Early referral, fast track care and multidisciplinary work: Key approach to save limbs

The ilegx Collaboration Day will include an account of a modern successful approach to the diabetic ischaemic foot in the King’s College Hospital (London, UK) open access vascular diabetic foot care pathway, which has resulted in greater than 90% limb salvage rate.

This approach is based on a new understanding of the natural history that has led to a novel classification of the ischaemic diabetic foot, emphasising the importance of the diabetic neuroischaemic foot as well as the critically ischaemic foot. This pathway is operated by an interdisciplinary team comprising surgeon, physician, podiatrist, nurse and orthotist and provides integrated care focused on a diabetic foot clinic. The diabetic foot can deteriorate with alarming speed and for this reason the clinic provides open rapid access to accelerate urgent assessment and to proceed quickly to state-of-the-art interventions in the revascularisation of not only the critically ischaemic foot but also the neuroischaemic foot. This includes prompt decision making within the interdisciplinary team as to proceed to endovascular or open vascular surgery (or both in a hybrid technique), involving revascularisation of both legs and increasingly, pedal arteries. The diabetic neuroischaemic foot is particularly characterised by ulceration and complicating infection and within this interdisciplinary diabetic foot service, modern techniques in wound care and aggressive treatment of infection with surgical debridement and parenteral antibiotics are also important. 

The value of endovascular techniques for diabetic foot care and critical limb ischaemia treatment
There is a crucial role for endovascular techniques to revascularise the foot, whether it is to restore blood flow in order to help diabetic ulcers to heal, or longer-term as a treatment for critical limb ischaemia.

It is agreed that the critically ischaemic foot should be urgently revascularised so as to save the limb either by endovascular procedures or open vascular surgery. However, controversy exists when there is a diabetic patient with a neuroischaemic foot ulcer that is not healing in a moderately ischaemic limb. These patients are often not getting the benefit of endovascular procedures in a timely fashion.

Although the neuroischaemic foot would not have got into trouble unless it had been subjected to minor trauma—which is often unsensed because of nerve damage—it is important to understand that, having got into trouble, the ulcer cannot be healed because the blood supply to the foot  cannot be increased. Thus there is a crucial role for below-the-knee endovascular procedures to improve the blood supply, even if it is a temporary increase, to get such ulcers healed. Once such ulcers are healed it will not matter if subsequently there is restenosis.

Interview with Cliff Shearman, ilegx course director

In this year’s CX iLegx Collaboration Day, what do you think the take home message will be?

Shearman: Avoiding amputation is relatively easy; it is about early treatment and not ignoring the problem. The biggest barrier to success is poor organisation and lack of awareness of the seriousness of the problem. Solving the problem improves outcomes, improves quality of care and saves a lot of money.

This year’s ilegx roundtables will discuss revascularisation strategies in the superficial femoral artery; do you believe you should “Leave nothing behind” or “Leave something in”?  

Shearman: Better understanding of the biology of diabetic vascular disease will lead to better therapies. While it is appealing to consider therapies, which do not leave anything behind, we have to understand what the main effect (short- and medium-term) of an intervention is on the plaque to design the optimum therapy.

About ilegx

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.

ilegx is a collaboration of like-minded health professionals, patients and care workers who share the view that too many legs are amputated and many of these are completely unnecessary.

The ilegx mission is to attract attention and draw awareness to the need for an improvement in health care in order to lower unnecessary major amputation of legs.

The CX ilegx Collaboration Day will take place at the Charing Cross Symposium on Thursday 30 April – Grey Learning Centre, Olympia Grand, London, UK

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This year, the Charing Cross Symposium is launching the CX Live Case method. Thomas Zeller (Universitäts-Herzzentrum Freiburg – Bad Krozingen, Bad Krozingen, Germany), course director of the CX Live Peripheral Arterial Cases, will link the live case demonstrations from Bad Krozingen with topics to be discussed in the CX Main Programme – Peripheral Arterial Controversies at the Charing Cross Symposium 2015.

 

Starting with shorter and simpler lesions, Zeller and his team will aim to demonstrate the value of drug-coated balloons against plain old balloon angioplasty. Beyond this, longer and also calcified arterial stenoses will be tackled. The audience will see which stents are selected, and whether atherectomy pre-stent is thought to be beneficial. Zeller will show which stent devices can reach longer lesions and into the popliteal artery, and which require pre-treatment with adjunctive therapies. The value of drug-eluting stents will also be demonstrated, and the management of in-stent restenosis and its correction by mechanical means will be shown.

In this interview, he explains the value of live case presentations at conferences and the importance of relating the CX Live Peripheral Arterial Cases to the topics of the CX Main Programme – Peripheral Arterial Controversies, and encourages audience interaction in this session.

What are the benefits of including live case presentations in medical conferences?

Live case presentations—provided they are unbiased—support the transfer of clinical science into clinical practice. New technologies and treatment algorithms can be demonstrated (supplementing talks and roundtable discussions) and the potential limitations and advantages in daily routine can be highlighted. With live case presentations; conference audience gets a better and practical impression of how new technologies can be implemented in the interventionalist’s routine.

What are the benefits of having the CX Live Peripheral Arterial Cases relate to what is discussed in the CX Main Programme – Peripheral Arterial Controversies?

The attendee gets immediate insights into the clinical application and potential pitfalls of new interventional strategies, which have been discussed in the CX Main Peripheral Programme (The CX Main Programme – Peripheral Arterial Controversies will take place on 28 April 2015, a day before the CX Live Peripheral Arterial Cases). Every new technology imposes a learning curve which might become shortened if the attendee gets advice from experienced operators who have already gained experience in the application of interventional strategies or use of those new technologies.

The live cases for the Charing Cross Symposium have been selected based on the topic of a given session to enable the panel and audience to discuss these topics with the operators.

The CX Main Programme – Peripheral Arterial Controversies dedicates a session to the discussion of revascularisation strategies in the superficial femoral artery; which key controversies will you try to shed light on with the CX Live Peripheral Arterial Cases session in this field?

In the CX Peripheral Live Cases, the main issue of controversy to discuss is the potential role of drug-coated balloons and drug-eluting stents for the treatment of the superficial femoral artery. We will analyse whether (or not) these devices are worth the costs compared to standard treatment (plain old balloon angioplasty and bare metal stenting). Moreover, the role of spot stenting in a drug-coated balloon setting will be discussed and finally the potential role of vessel preparation prior to the use of drug-eluting technologies.

What techniques and technologies will be demonstrated at the CX Live Peripheral Arterial Cases session?  

We will show interventions dealing with drug-coated balloons and provisional stenting, stenting of kink zones, vessel preparation with debulking devices, how to treat in-stent reocclusions, etc.

The CX Symposium advocates strong audience interaction; how will you encourage participants’ interaction in the CX Live Peripheral Arterial Cases session?

Audience interaction has to be pushed by the moderators and panellists. We as operators will be open to questions from the audience and we will also invite the audience to express their own experiences with the interventional techniques, which will be shown during the live case transmissions.

The CX Live Peripheral Arterial Cases session will take place at the Charing Cross Symposium on Wednesday 29 April – Grey Learning Centre, Olympia Grand, London, UK

Click here to see the CX Main Programme Sessions

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Benjamin Starnes (Seattle, USA) told the audience attending yesterday’s mini symposium on acute aortic transection that intravascular ultrasound (IVUS) was an important tool in the management of patients with blunt aortic injury undergoing thoracic endovascular aortic repair (TEVAR) because it helps to ensure accurate sizing of the endograft and prevent rupture. The session also reviewed the differences between image-based classifications of blunt aortic injury.

Starnes reported that, over the past decade, endovascular repair of patients with blunt traumatic aortic injury has become the “predominant approach to fixing these injuries”, but added that there were “unique challenges” to using the endovascular approach. He said: “One of challenges is the dynamic nature of the aorta. There are some interesting data from blood-letting studies in Yorkshire pigs that show significant decrease in aortic diameter accompanying induced haemorrhagic shock, with a dose-dependent effect.”

According to Starnes, aortic diameter is also known to increase after resuscitation and the area with the greatest change in size is the area that is most commonly injured in blunt trauma (ie. the isthmus and descending aorta). He added: “CT angiography is used for diagnosis of these injuries and axial slices from the initial scan are often used for planning and sizing of the repair. While using IVUS at the time of repair to better characterise the injury, we noticed a difference in the aortic diameter with systolic variation [compared with the diameter observed on the initial CT angiography]. This then begs the questions “Is initial CT angiography appropriate for sizing the endograft in these patients?” and “Is that endograft going to be undersized once that patient is fully resuscitated?”

Starnes and colleagues, therefore, conducted a retrospective chart review of patients with blunt aortic injury who underwent TEVAR at their level-one trauma centre to determine if there was a difference between the aortic diameter observed on diagnostic CT angiography and that observed on IVUS at the time of the repair. The inclusion criteria were initial admission or pre-admission CT angiography, IVUS at the time of repair, and a post-implant CT angiography. Of the 26 patients who were treated at the centre during the study period (July 2007–July 2011), three patients did not have post-implant CT angiography information, one patient was converted to surgery, and six patients did not receive IVUS—leaving 16 patients available for assessment.

There was a significant difference of 2.4mm between mean aortic diameter with initial CT angiography and mean aortic diameter with IVUS: 21.7mm vs. 24mm, respectively (p=0.004). Starnes noted: “When we look at post-implant CT angiography compared with initial CT angiography, there is again a highly significant difference of 3mm (p=0.0001). But, when we compared post-implant CT angiography with IVUS, there was no difference.” He added that when they reviewed theoretical graft diameters, there was a significant difference of 2.4mm (p=0.003) between the size of the graft that would be chosen based on the initial CT angiography and that based on IVUS at time of repair. There was also a significant difference in graft size between post-implant CT angiography and initial CT angiography (3mm; p=0.0002), but no difference in size between post-implant CT angiography and IVUS.

“I believe IVUS is a critical and important tool for the management of patients with blunt aortic injury,” Starnes concluded.

Ali Azizzadeh (Houston, USA) also presented data at the mini symposium, reviewing the long-term effects of intentional stent graft coverage of the left subclavian artery (in patients with blunt aortic injury undergoing TEVAR). He said that in a review of 82 patients undergoing TEVAR at his centre between September 2005 and July 2012, 50 received intentional stent graft coverage of their left subclavian artery. Azizzadeh reported: “Intentional coverage of the left subclavian artery during TEVAR for blunt aortic injury appears safe without compromising mental or physical health outcomes. Furthermore, left artery stent coverage does not increase the long-term risk of upper extremity symptoms or impairment of normal activities.”

Does intramural haematoma exist?

As well as presenting data for the role of IVUS in the management of patients with aortic, Starnes also reviewed the classification of the injury. He reported that he and his colleagues developed a new image-based classification system for these types of injury because they believed the current classification system, by the Society for Vascular Surgery (SVS), was “lacking”. Starnes explained: “The SVS system has four grades of injury—grade one, intimal tear; grade two, intramural haematoma; grade three, pseudoaneurysm; and grade four, rupture—but does not provide for any treatment recommendations because grades one to three are treated the same and we do not believe grade two exists. In a review of 140 aortic transections at our centre, we did not see a single case of intramural haematoma.”

Therefore, they developed a new classification system based on the presence or absence of an aortic external contour abnormality. Under this new system, intimal tear (intimal defect and/or thrombus of

However, Michael Dake (Stanford, USA) commented that there was a lack of consensus surrounding intramural haematoma as unlike Starnes and colleagues, Rabin and colleagues did recognise the existence of intramural haematoma and classified it as being a “grade one” injury (in contrast to the SVS classification). He added that Osgood and colleagues, in an another system, classed intramural haematoma as being “grade 1B” but he noted that they did not find any patients with that type of injury in their series. Dake reported, regardless of how it was classified, recent publications have suggested that: “Intramural haematoma without associated peri-aortic component, contour abnormality, or pseudoaneurysm may be conservatively managed with appropriate follow-up imaging.”