Limb Preservation for the Vascular Specialist : From Wound Care to Wound Closure

This book is a comprehensive guide to the essentials of arterial, venous, wound care, and multidisciplinary approaches to prevent major amputation and manage patients with critical limb threatening ischemia (CLTI). Limb preservation has become increasingly prioritized as endovascular techniques, equipment, understanding of multidisciplinary wound care, and other medical treatments have rapidly evolved. Quite often, these patients have CLTI, which is a primarily chronic arterial disease that carries a higher mortality rate than most cancers and cardiovascular diseases. Additionally, complex venous issues contribute to patients losing their limbs, causing significant morbidity to patients and immense cost to the medical system. Many of these patients have diabetes, kidney problems, and hypertension. Due to the advances in the treatment of CLTI and complex venous diseases, medical professionals have been able to decrease major amputations, which cause the higher mortality rate described above. The knowledge of all the approaches, techniques, and management of these patients, however, has been slow to be disseminated. Acting as a structured journey to all aspects of limb preservation, this book begins by covering the basics of understanding wound care patients. This involves beginning wound care management and properly diagnosing the potential underlying processes with non-invasive imaging. From here, clinical pearls and detailed guidance on considering arterial, venous, and lymphatic therapies are covered. Chapters then move into arterial and venous treatment algorithms, from unique to complex approaches, technique tips and tricks, infection and complication management, and future options. Understanding some of the newer approaches such as deep vein arterialization and hybrid surgical approaches is integral in the discussion. Finally, authors cover evaluating the wound post-procedure and long-term, deciding when re-intervention/surgery or amputation (and which type) is needed, and how to tackle the medication management of these complex patients (such as antiplatelets, anticoagulation, diabetes, and nutrition). Chapters are written by a multidisciplinary group of experts, all with an eye towards limb preservation. This is an ideal guide for endovascular specialists, surgeons, podiatrists, infectious disease specialists, and endocrinologists to be able to successfully increase the likeliness of limb preservation for their patients with CLTI and related conditions. Preface Contents 1: Introduction References 2: Seeing a Patient with a Wound 2.1 Mastering the Wound Care Physical Exam 2.1.1 Vascular Exam 2.1.2 Infection 2.1.3 Foot Deformity and Soft Tissue Breakdown 2.1.4 Direct Assessment of the Wound 2.2 How to Classify the Wound 2.2.1 When Should I Consider Venous or Mixed Wounds? 2.2.2 Managing Neuropathic Wounds 2.3 Mixed Wounds: How to Manage? 2.4 Basics of Debridement of Wounds 2.4.1 Debridement of What Exactly? 2.5 Basics of Dressings and When to Make a Change 2.6 When Should I Culture? 2.7 When Should I Biopsy? 2.8 How Do I Biopsy a Wound? 2.9 When Should I Not Debride? 2.10 Identifying and Managing Calciphylaxis 2.11 When Do I Wound Vac? 2.12 Offloading 2.12.1 Options for Offloading 2.12.2 When to Make a Change? 2.13 Oxygen Therapy in the Treatment of Chronic Wounds 2.13.1 The Simple SALSA Wound Treatment Guideline: Vertical and Horizontal Approach 2.13.2 Hyperbaric Oxygen Therapy 2.13.3 Topical Oxygen Therapy 2.14 Skin Substitutes and Matrixes Demystified 2.15 This Patient Needs to be Admitted Now 2.16 Soft Tissue Reconstruction Options 2.16.1 Reconstructive Options 2.16.1.1 Primary Intention 2.16.1.2 Secondary Intention 2.16.1.3 Skin Grafts 2.16.1.4 Adjacent Tissue Transfer 2.16.1.5 Regional Flaps 2.16.1.6 Free Flaps 2.16.2 Amputation Optimization References 3: Determining the Appropriate Workup 3.1 When to Utilize ABI, Arterial Duplex, and Advanced Anatomical Imaging 3.1.1 When Should I Order ABI, Toe Pressures, or Arterial Duplex? 3.1.2 The Role of PVR and Segmental Pressure Studies 3.1.2.1 Segmental Pressures 3.1.2.2 Pulse Volume Recordings 3.1.3 Role of TBI, TCP02, or Skin Perfusion Pressures 3.1.3.1 Toe Brachial Index 3.1.3.2 Tissue Oxygen Testing 3.1.3.3 Skin Perfusion Pressure 3.1.4 When and Why Do I Need Cross-Sectional/Anatomic Imaging? 3.1.4.1 Arterial Duplex 3.1.4.2 CT Angiography 3.1.4.3 Magnetic Resonance Angiography 3.1.5 Superficial and Deep Venous Imaging 3.1.5.1 Venous Insufficiency Ultrasound Testing 3.1.6 When Should I Consider CT or MR Venography? 3.1.6.1 Putting it All Together 3.2 Interpreting the ABI, TBI, and Toe Pressures: Know the Pitfalls 3.2.1 Ankle-Brachial Index 3.2.2 Toe Brachial Index 3.2.3 Toe Pressures/TcPO2 3.2.4 Pitfalls When Interpreting ABIs 3.3 Interpreting the CT and MRI: Know the Limitations 3.3.1 CT and MRI: Arterial Imaging 3.3.1.1 CT Arteriography (CTA) 3.3.1.2 Contrast-Enhanced MR Arteriography (CE-MRA) 3.3.1.3 Non-Contrast MR Arteriography (NC-MRA) 3.3.2 CT and MRI: Venous Imaging 3.3.2.1 CT Venography (CTV) 3.3.2.2 Contrast-Enhanced MR Venography (MRV) 3.3.2.3 Non-Contrast MR Venography (ncMRV) 3.4 Pedal Duplex Imaging and Advanced Intraoperative Ultrasound 3.4.1 Pedal Anatomy (Figs. 3.9 and 3.10) 3.4.2 Pedal Acceleration Time (PAT) 3.4.3 Pedal Flow Hemodynamics 3.4.4 Advanced Intraoperative Duplex Ultrasound References 4: Beginning and Managing Underlying Comorbidities 4.1 Peripheral Arterial Disease Medications 4.1.1 Introduction 4.1.1.1 Lifestyle Modification and Risk Reduction Tobacco Cessation Diet Modification Exercise Therapy 4.1.1.2 Medical Optimization Lipid-Lowering Therapies Antihypertensives Glucose-Lowering Therapies 4.1.1.3 Antithrombotic Therapy 4.1.1.4 Symptomatic Treatment Cilostazol Pentoxifylline 4.1.1.5 Compression Therapy 4.2 Conclusion 4.2.1 Primary Recommendations for Medical Management of Pad 4.3 Lymphedema Management 4.3.1 Treatment Options References 5: Infectious Disease Evaluation and Management 5.1 When Should I Call Infectious Disease? 5.2 Is there Osteomyelitis? 5.2.1 What Imaging Do I Order for Osteomyelitis? 5.2.1.1 Is MRI with Gadolinium Contrast Enhancement Required? 5.2.1.2 Other Imaging Modalities 5.3 When Do I Start Antimicrobials? 5.4 Demystifying Wound Cultures 5.5 When is Infection Control the Top Priority? 5.5.1 Prioritizing Source Control 5.5.1.1 Infection in DFU and PAD 5.5.1.2 Debridement Before Revascularization 5.5.2 Lower Extremity Threatened Limb Classification System 5.5.2.1 Utility of the WIfI Threatened Limb Classification 5.5.2.2 Prognostic Value of WIfI 5.5.2.3 Importance of Restaging 5.5.3 Case Example 5.5.3.1 Treatment 5.6 Conclusion References 6: Arterial Revascularization 6.1 Aortoiliac Revascularization 6.1.1 Hypogastric Considerations 6.1.2 CERAB and C-CERAB 6.1.2.1 Conclusion 6.1.3 When to Consider Aortobifemoral and Femoro-Femoral Bypass? 6.1.3.1 Aortobifemoral Bypass 6.1.3.2 Femoro-Femoral Bypass 6.2 When to Choose Alternate Access 6.2.1 Pedal Approach 6.2.1.1 Why Choose Pedal Access for Peripheral Arterial Intervention? Clinical Evaluation Access 6.2.1.2 Primary Pedal Intervention Postoperative Care Postoperative Complications 6.2.1.3 Use of Extra-Vascular Ultrasound (EVUS) for Pedal Access and Guiding Therapy Introduction Ultrasonic Features of Arteries EVUS for Pedal Access Ultrasonic Features of Endovascular Therapeutic Devices Needles and Wires Catheters and Sheaths Balloons Atherectomy and CTO Crossing Devices Stents Ultrasonic Features of Chronic Total Occlusion (CTO) Conclusion 6.2.2 Femoro-Popliteal Access and Closure 6.2.2.1 Introduction 6.2.2.2 Popliteal Access 6.2.2.3 Antegrade SFA Access 6.2.2.4 Retrograde SFA Access 6.2.2.5 Case Example 6.2.3 Arm Access for Peripheral Arterial Disease 6.2.3.1 Device Selection for Radial Access 6.2.3.2 Limitation and Bailouts for Upper Extremity Access 6.2.3.3 My Sheath Is Stuck, Now What? 6.2.3.4 Axillary and Brachial Access and Closure 6.3 CO2 Tips and Tricks 6.3.1 Advantages 6.3.2 Disadvantages 6.3.3 General Principles of CO2 Angiography 6.3.3.1 Patient Monitoring 6.3.3.2 Carbon Dioxide Delivery 6.3.3.3 Imaging Parameters 6.3.3.4 Technique for Standard Aortogram and Lower Extremity Runoff 6.3.4 Complications/Adverse Effects 6.3.4.1 Conclusion 6.4 Dealing with Heavy Calcium 6.4.1 Tricks for Rock Hard Superficial Femoral Artery and Popliteal Complete Total Occlusions 6.4.1.1 Access 6.4.1.2 Crossing 6.4.1.3 Treatment 6.4.2 When Should I Consider Intravascular Lithotripsy? 6.4.2.1 Case: Courtesy of Sreekumar Madassery, MD 6.4.3 When to Use Laser? 6.4.3.1 Laser History and Background 6.4.3.2 Laser Technical Details 6.4.3.3 Laser Atherectomy in Calcified Arteries 6.4.3.4 Tips 6.5 Crossing Devices 6.5.1 Trial Results 6.5.2 Clinical Utilization 6.5.3 Conclusion 6.6 Managing In-Stent Restenosis 6.6.1 Classification 6.6.2 Crossing In-Stent Occlusions 6.6.3 Management 6.7 Femoropopliteal and Femorotibial Bypass 6.7.1 Patient Selection 6.7.2 When and Why Axillofemoral Bypass? 6.7.3 Axillofemoral Bypass Technique 6.8 Percutaneous Femoropopliteal Bypass: Detour Approach 6.8.1 Challenging Lesion Characteristics 6.8.2 The Innovative DETOUR Procedure 6.8.3 Technique 6.8.3.1 Procedure: Proximal Anastomosis 6.8.3.2 Procedure: Distal Anastomosis 6.8.4 Conclusion 6.9 Hidden Thrombus 6.9.1 Atherectomy Versus Mechanical Thrombectomy 6.9.1.1 Introduction 6.9.1.2 Hidden Thrombus 6.9.1.3 Mitigating Risk 6.9.1.4 Case Example 6.9.2 Heparin-Induced Thrombocytopenia (HIT) and Thrombolysis Management 6.9.2.1 Diagnosis 6.9.2.2 Management 6.9.2.3 Thrombolysis (Fibrinolytic) Management in Patients with HIT 6.9.2.4 Contraindications of Thrombolysis Medication: Alteplase (TPA) 6.9.2.5 Thrombolysis Protocol 6.10 Tibial Calcium Management 6.10.1 Device Selection 6.10.1.1 Tibial Disease 6.10.2 Non-POBA Balloons 6.10.2.1 Cutting and Scoring Balloons 6.10.2.2 Chocolate 6.10.2.3 Intravascular Lithotripsy 6.10.2.4 Serranator 6.10.2.5 Tips 6.10.3 Tibial Scaffold Options 6.10.3.1 Indications for Below-the-Knee Stenting 6.10.3.2 Contraindications for Below-the-Knee Stenting 6.10.3.3 Current Tibial Scaffold Options with Trial Data and Future Tibial Stent Platforms TACK Dissection Repair 6.11 Distal Popliteal and Trifurcation Disease Management 6.11.1 Single Stent Technique/Provisional (Fig. 6.57) 6.11.2 Culotte Technique (Fig. 6.58) 6.11.3 T-Stenting (Fig. 6.59) 6.11.4 Mini-Crush Technique (Fig. 6.60) 6.11.5 Kissing Stent Technique (Fig. 6.61) 6.12 Distal Emboli Management 6.12.1 Introduction 6.12.2 Prevention 6.12.3 Treatment 6.12.4 Case Example 6.13 Blue Toe Syndrome Management 6.13.1 Physical Examination 6.13.1.1 Evaluation 6.13.1.2 Treatment 6.14 Drug-Eluting Technology 6.14.1 Paclitaxel: Where Are We Now? 6.14.1.1 Introduction to Paclitaxel 6.14.1.2 Overview of Paclitaxel-Coated Balloons 6.14.1.3 Overview of Paclitaxel-Coated Stents 6.14.1.4 Safety of Paclitaxel-Coated Devices 6.14.1.5 Paclitaxel Dosing and Potential Mechanisms of Harm 6.14.1.6 Analyses Published After the Katsanos et al. Meta-Analysis 6.14.1.7 Conclusions 6.14.2 Unmet Needs: Future of Limus-Based Therapy 6.14.2.1 Introduction to Limus-Based Therapy 6.14.2.2 Differences between Paclitaxel and Limus-Based Compounds 6.14.2.3 Limus-Based Therapy for Coronary Revascularization 6.14.2.4 Prior Unsuccessful Attempts at Applying Limus-Based Therapy in the Peripheral Endovascular Intervention 6.14.2.5 Optimizing the Formulation and Pharmacokinetics of Limus-Based Therapy 6.14.2.6 Conclusions 6.15 Popliteal Artery Aneurysm 6.15.1 Background 6.15.2 Identification of PAA and Indications for Surgery 6.15.3 Treatment 6.15.4 Surgery Versus Stenting 6.15.4.1 Current SVS Clinical Practical Guidelines 6.15.4.2 Conclusion 6.16 Common Femoral Artery 6.16.1 Endovascular Versus Surgical 6.16.1.1 Introduction 6.16.1.2 CFA: Endarterectomy Data 6.16.1.3 CFA: Endovascular Treatment Data 6.16.1.4 Meta-Analysis Data (Endovascular CFA Treatment Versus CFE) 6.16.1.5 Conclusion 6.16.2 When I Prefer Surgery 6.16.2.1 Why Is the Treatment of the CFA Controversial? 6.16.2.2 When Do I Operate on CFA Disease? 6.16.2.3 What Is My Approach to Surgery on the CFA? 6.16.2.4 What Is the Postoperative Patient Management After CFA Repair? 6.17 The Solo Profunda 6.17.1 Anatomy 6.17.1.1 Surgical Exposure Conventional Approach Lateral Approach Posterior Approach 6.17.2 Profundoplasty 6.17.2.1 Indications 6.17.2.2 Technique 6.17.3 Profunda Bypass 6.17.3.1 Considerations 6.17.3.2 Outcomes of Profunda Revascularization Bypass Profundoplasty Open Vs. Endovascular 6.18 Don’t Mess with the Profunda... Unless 6.19 Pedal Surgical Bypass 6.19.1 Introduction 6.19.2 Patient Selection 6.19.3 Inflow Selection 6.19.4 Outflow Selection 6.19.5 Conduit Selection 6.19.6 Operative Technique 6.19.7 Outcomes 6.19.8 Alternatives to Pedal Bypass 6.19.9 Target Limitations 6.19.10 Conclusion 6.20 Intravascular Ultrasound-Based Femoropopliteal Atherectomy Selection 6.20.1 Calcified Plaque 6.20.2 Fibrous Plaque 6.20.3 Soft Plaque 6.20.4 Case Example 6.20.4.1 Courtesy of Sreekumar Madassery, MD 6.21 Below-the-Ankle Atherectomy 6.21.1 Case Courtesy of Sreekumar Madassery, MD 6.22 What Is My Endpoint on Angiogram? 6.23 Orphan Heel 6.23.1 Introduction 6.23.2 Diagnosis 6.23.3 Treatment 6.24 Deep Vein Arterialization 6.24.1 When to Consider DVA? 6.24.2 Advent of Percutaneous DVA 6.24.2.1 Patient Selection/Evaluation 6.24.2.2 Two Types of DVA 6.24.2.3 Detailed Technique Description 6.24.2.4 Dealing with Stubborn Valves 6.24.2.5 How Low Can I Stent? 6.24.3 Post-DVA Considerations 6.24.3.1 Antiplatelet and Anticoagulation Medications 6.24.3.2 Restenosis and Reintervention 6.24.3.3 Pharmacological Viewpoint 6.24.3.4 Covered Stents 6.24.3.5 Skin Changes: Edema, Cyanosis, and Necrosis 6.24.3.6 Pain Management 6.24.3.7 Patency Assessment/Duplex Ultrasound 6.24.3.8 Reinterventions and Techniques 6.24.3.9 Amputation Strategies 6.24.3.10 Wound Care 6.24.4 When to Never Perform Deep Venous Arterialization 6.24.4.1 Patient Selection Process 6.24.4.2 Clinical Experience and Expert Opinion 6.24.5 What I Wish I Knew About DVA 6.24.5.1 New Information/Lack of Information 6.24.5.2 Clinical Experience and Expert Opinion 6.24.6 What to Tell the Patient, Family Member, and/or Referring Provider 6.25 Hybrid Deep Vein Arterialization 6.25.1 Definition of No Option 6.25.2 MAC Classification 6.25.3 Venous Arterialization 6.25.3.1 Selecting TADV vs HYSA 6.25.3.2 Data 6.25.4 LimFlow System for Venous Arterialization 6.26 No-Option Aortoiliac Patients Still Have Options 6.27 Inequalities in Limb Preservation 6.27.1 Introduction 6.27.2 Racial Disparities in PAD 6.27.3 Gender Disparities in PAD 6.27.4 Regional and Global Inequalities of PAD 6.28 BEST-CLI Trial: in Limb Preservation 6.28.1 An Endovascular Specialist’s Thoughts 6.28.2 A Vascular Surgeon’s Thoughts References 7: Venous Interventions 7.1 Primary Treatment Strategy in Superficial and Deep Venous Disease 7.1.1 Work-up 7.2 Superficial Venous Disease 7.2.1 Introduction 7.2.1.1 Clinical Evaluation 7.2.1.2 Treatment Strategies Endovascular Intervention Outcomes Complications Peri-Ulcer Varices Management Case Example Conclusion 7.3 Deep Venous Disease 7.3.1 Introduction 7.3.1.1 When to Treat Deep Veins 7.3.1.2 Work-Up Iliac Vein Compression Imaging Findings Suggestive of Iliac Vein Compression Treatment (When to Stent) Iliac Vein Occlusion Treatment (When to Stent) Stent Placement Below the Inguinal Ligament Tips and Tricks IVC and Iliofemoral Occlusions Equipment Venous Recanalization Procedure Steps Stenting the ILIAC Venous Confluence Complications 7.4 Reconstruction of Chronic Iliocaval Occlusion 7.4.1 Introduction 7.4.2 Etiologies 7.4.3 Clinical Presentation of Iliocaval Disease 7.4.4 Endovascular Management of Chronic Iliocaval Occlusion 7.4.5 Pre-procedural Considerations 7.4.6 Intra-procedural Considerations 7.4.6.1 IVC Filter Management 7.4.6.2 Stenting Across Filters 7.4.6.3 Advanced Recanalization Techniques Post-procedural Management and Pharmacotherapy 7.4.6.4 Conclusion 7.5 Surgical Options 7.6 Compression Therapy 7.6.1 Compression Therapy in Wound Care: Why and How 7.6.2 Why Compression Therapy? 7.6.3 Types of Compression Therapies 7.6.3.1 Contraindications to Compression Therapy 7.6.3.2 Complications from Compression Therapies References 8: Post-Revascularization Management 8.1 Follow-Up Planning 8.1.1 Scope 8.1.2 Initial Follow-Up 8.1.3 Monthly Wound Checks 8.1.4 Assessing Plateaus and Return to Non-healing: Four-Month Visit 8.1.5 Amputations 8.1.6 Minor Amputation Follow-Up 8.1.7 Major Amputation Follow-Up 8.1.8 Life After Healing 8.1.9 Death 8.2 Monitoring the Wound 8.2.1 Angiography Is Not Enough 8.2.2 Approaches to Wound Monitoring 8.2.3 Our Approach 8.2.4 Additional Considerations 8.3 Summary References 9: When Is the Wound Closed? 9.1 Should I Reintervene? 9.2 To Stage or Not to Stage, That Is the Question 9.3 Summary References 10: Long-Term Imaging 10.1 How to Follow Arterial Wounds? 10.1.1 Long-Term Imaging Follow-Up 10.1.2 Arterial 10.1.2.1 Peripheral Arterial Disease 10.1.3 Conclusion 10.1.4 Bypass Follow-Up 10.1.5 EVT Patients 10.2 How to Follow Venous Wounds? 10.2.1 Venous 10.2.1.1 Deep Venous Diseases 10.2.1.2 May-Thurner Syndrome 10.2.2 Iliocaval Stent Reconstruction 10.2.3 Chronic Venous Disease References 11: Long-Term Medical Management 11.1 Arterial Disease Management 11.1.1 Medical Management of PAD 11.1.2 Walking Program 11.1.3 Antithrombotic Therapy in Stable PAD 11.1.4 Antithrombotic Therapy Post-Revascularization 11.1.5 Putting It Together 11.1.6 Medication Failure Versus Non-responders 11.1.7 Statin Therapy 11.1.8 Cilostazol 11.1.9 PCSK9 Inhibitors 11.1.10 Hypertension Management 11.2 Venous Disease Management References Correction to: Venous Interventions Correction to: Chapter 7 in: S. Madassery, A. Patel (eds.), Limb Preservation for the Vascular Specialist, https://doi.org/10.1007/978-3-031-36480-8_7 Index