Block Birmingham 2015 v2

“Integrating a Multidisciplinary
Approach for CLI Patient Care”
Alan Jay Block, DPM, MS, FASPS,
FACFAS
Assistant Professor Dept Of Orthopeadics
The Ohio State University
Medical Board Kent State University
Editor-in -Chief The Journal of the American
Society of Podiatric Surgeons
Past President The Ohio Foot & Ankle Medical
Association
[email protected]
TIME IS TISSUE
 85% of lower extremity amputations in patient with
diabetes are preceded by ulceration
 5 year mortality rates after LEA range from 51-76%
Amputation
(Impact!!)
 180,000 Amputations per year in USA
 20%-25% (1/4) all diabetics-lifetime
 30 Day perioperative mortality
BKA - 5-8%
AKA - 8-12%
 18 - 24 month overall mortality - 40-50%
 Amputations are NOT benign!
Treating PVD
Treatment for
severe PVD in
the 1800’s
Treating PVD
Treatment for
severe PVD in
2015
Patient:.
Podiatrist:
Plaque Excision performed by Abe Parail,
M.D. at Grant Medical Center 2/9/06
Totally occluded Dorsalis Pedis Artery is
choking off the blood supply to Jamie’s foot,
creating a non-healing foot ulcer.
Plaque Excised from Jamie’s occluded
Dorsalis Pedis Artery
Restored blood flow to Jamie’s foot after plaque was
excised from the occluded Dorsalis Pedis Artery.
(Post-SilverHawk Plaque Excision)
ABI 0.2
ABI .75
Patient:
Referring Physicians:
FoxHollow SilverHawk Plaque Excision performed 2/15/06 at Grant Medical
Center by Peter Amsterdam, M.D.
Thomas’ Super Femoral Artery is occluded, limiting blood
flow to his entire leg and creating an ischemic foot.
(Pre-SilverHawk Plaque Excision)
Large quantities of plaque were excised from Thomas’
peripheral arteries using the FoxHollow SilverHawk
Blood Flow restored to Thomas’ Super
Femoral Artery after FoxHollow SilverHawk
Plaque Excision
(Post-SilverHawk Plaque Excision)
BLOCKAGE AT THE TRIFURCATION
Patient: Robert
Referring Podiatrist:
FoxHollow SilverHawk Plaque Excision performed by Peter Amsterdam, M.D. at Grant 8/9/06
PRE
Pre-Procedure Angiogram reveals a totally
occluded Popliteal Artery and Below the Knee
Arteries, preventing blood flow to Robert’s foot.
(Pre-SilverHawk Plaque Excision)
POST
Post-Procedure Angiogram reveals a widely patent Popliteal
Artery and Below the Knee Arteries, providing blood flow to
Robert’s foot!
(Post-SilverHawk Plaque Excision)
Which Would You Rather?
Percutaneous
Surgical
“For some reason, it is
considered conservative
treatment to chop someone’s
leg off and aggressive
treatment to even do an
angiogram”
“Craig M. Walker, M.D.”
Medical Director
Cardiovascular Institute of the South
Amputations
 Less than 20% get an angiogram
 Only 50% get an ABI
 Most of these patients do have limb salvage
options
It is not conservative treatment to amputate!
GLOBAL WARNING
 8.3% of the U.S population is diabetic
 4.9% of the Population of India
is Type 2 (61,300,000)
 6.7% of the Population of China is
Type 2 (90,000,000)
 1 In 400 Children and adolescents in
the USA is Diabetic and Obese
Treating The Disease
Global Warming
PAD Amputations
Less than half of amputees ever walk again
Less than 25% if it is an above the knee amputation
5 – 9% die in the hospital
25% require nursing home placement
One third of amputees lose the remaining leg within
18 mos.
 In the United States, the amputation rate is
increasing.





 Hospitalized patients with diabetes are 28 x more likely to
have an amputation
ALEXANDER GRAHAM BELL
DARWINS THEORY OF EVOLUTION???
“ You See
What You
Look for and
You
Recognize
What You
Know ’’
Lawerence
Harkless, DPM
`
Primary Amputation is Still
Rampant
 An often quoted 2005 study showed
that over 50% of patients that
received an amputation did not have
any vascular evaluation.1
 A more recent study published in 2012
looking at a series of over 20,000
Medicare patients receiving amputation,
54% did not receive any vascular
procedure including diagnostic
angiogram.2
1. Allie, David. Eurointervention. May , 2005.
2. Goodney, et al. Circ Cardiovasc Qual Outcomes. 2012; 5:94–102.
ANKLE-BRACHIAL INDEX (ABI’s)
Mortality in Patients With Severe* PAD
Relative 5-Year Mortality
Patients (%)
100
80
47
60
56
38
40
14
20
0
Breast
Cancer2
Colon/Rectal
Cancer2
NonHodgkin’s
Lymphoma2
* Ankle Brachial Index <0.4
1 McKenna
2 Ries LAG
M et al. Atherosclerosis. 1991;87:119-128.
et al. SEER Cancer Statistics Review, 1973-1998. National Cancer Institute. September 2000.
PAD1
TREATING SOCIETY
Dissimenation of Information
Psychology
 Technology
Pathology
Paradigm Shift
 Only 31% of wounds heal
 85% of amputations are
preceded by a foot ulcer
 80% of hospital admissions
for diabetics are for infected
foot ulcers
 Half the size in 4 weeks
 Vanderbilt Calcium Score
 Calcium=CLI= Amputation
Restore the flow!!!
Patient Background
83 yr old female
Non-healing toe wound
– tissue loss,
gangrenous
Rest pain
Smoker
Left ABI – 0.40
Stent in renal artery
Performed By: Dr. Mark Picone, Heart Hospital of Austin, Austin, TX
Plaque Excision Procedure
Pre
Performed By: Dr. Mark Picone, Heart Hospital of Austin, Austin, TX
Post
Time is Tissue
Pre
60-days post
Good distal flow to toes, resulting in healing of toe ulcer
Performed By: Dr. Roger Gammon, Austin Heart Hospital, Austin, TX
Contact information
 Alan Block
 [email protected]
COMMINUTED PILON
49 Y.O. Train wreck
10 Months S/P Pilon FX
Casted for 8 months
KIDNEY/PANCREAS TRANSPLANT
IMMUNOSUPPRESSIVE DRUGS
DIABETIC/Peripheral Vascular Disease
Contact information
 Alan Block
 [email protected]