Limb salvaging in critical ischemia can be treated with efficacy & safety-Dr.Micari Antonio

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Management of Peripheral Vascular Diseases

Limb salvaging in critical ischemia can be
treated with efficacy & safety-Dr.Micari Antonio

First choice of diagnosis is comprehensive examination by
the physician followed by ABI Diagnostic test

Effective collaboration between interventionalists and
surgeons in future will ensure better treatment
PVD is quite wide spread in Pakistan and more below the knee 
disease will lead to amputation - Prof. Khan Shah Zaman Khan

KARACHI: Limb salvaging in critical ischemia can be treated with efficacy and safety. First choice for diagnosis in peripheral vascular disease is critical examination by the physician followed by ABI diagnostic test, blood pressure measurement of both ankles and arms. CAD combined with PAD increases the morbidity and mortality, hence there is a need to introduce PVD intervention programme. This was stated by Dr. Micari Antonio Co-Director Cath Lab Maria Elenora Hospital Italy. He was speaking on management of peripheral vascular disease at a seminar held at National Institute of Cardiovascular Diseases (NICVD) Karachi during his recent visit to Pakistan. During the two day programme he also showed live demonstration of various interventional procedures to update and share his knowledge and expertise with the NICVD faculty.
Prevalence of peripheral vascular disease, he said, was very high. Critical ischemia and PAD treatment cost to USA is about one hundred two billion dollars annually. In Saudi Arabia almost 50% of the population is at risk of developing diabetes. He then referred to TSAC guidelines for critical ischemia and pointed out that if not treated 5-10% of the population will develop critical ischemia, 50% will die and the rest 50% will have amputation. We see different variety of cases and we have to use different materials. It is important that we must learn how to treat different arteries, he added.
Speaking about signs and symptoms of peripheral vascular disease he mentioned muscle pain in buttocks, thighs, loss of hair on the leg, feet, wound that will not heal, decrease in temperature of lower leg, change in leg colour, weak or absent pulse which then leads to gangrene. He also talked about Fontaine classification 1-4 and Rutherford classification from 0-6 i.e. starting from asymptomatic to major tissue loss. Apart from clinical examination and ABI test, Duplex Ultrasound is also quite helpful. MR angiography is not for all patients but it should be done in carefully selected cases. CT Angio is also quite helpful whereas plain X-ray also gives you lot of information. He also referred to Lesion Type 2007 guidelines by TSAC-II from Type A to D and stated that they get quite a few type D lesions these days. He then talked about Lilac procedure, ipsilateral femoral access. One should dilate, put the stent and get best results. Some patients have very complex lesions and in case of stent use, there is a risk that plaque will move to the healthy areas. One should treat from healthy to healthy vessels. Remove all disease lesions. He then depicted a few slides of occlusive lilac disease and bilateral lilac stent. Five years patency in TSAC lesion is 75% whereas one year patency is 90-96%. In the past Type-D lesions were for the surgeons. During the past five years we have done five cases of SFA angioplasty and now we do much more complex Type-D lesions, Dr. Antonio added.
As regards predictors of outcome Dr. Antonio mentioned technical equipments, armamentarium, and skills of the operator. Learning curve can be quite steep with some but one should aim the success rate of 80-85%. Degree of calcification is extremely important in outcome. He then discussed suboptimal angioplasty, sub-intimal angioplasty and the re-entry devices. One can get good reslts in short occlusion SFA. Stents are better than balloons however, stent fracture, rupture of stent could mean a nightmare. Be mindful of in-stent restenosis. He also highlighted the efficacy of drug eluting balloons and discussed in detail role of balloon based therapies in CLI. More than 10mm occlusions is very challenging. One should restore straight line blood flow to the feet and atleast ensure one vessel to the foot with good flow. Results of stents below the knee are not very good, he concluded.
His presentation was followed by lively discussion. It was pointed out that previously it was said that better leave the small lesions if they give no trouble. In vascular injury do not touch the vessel unless it gives you problems. Dr.Antonio remarked that five years ago we used to stent 30-35mm lesions but now these patients are coming back to us. Now we prefer drug eluting stents in upto 8-10mm lesions. Average drug eluting balloon is 5mm. There are new of techniques but in the past we had no data. Now there are many studies. People want to see the data based on guidelines but there was no such database in the past. Our approach in the past used to be if this technique works in PAD, we will use it but it is practiced no more. The information we are generating is not against the surgeons. We can do a much better treatment working together and I see more effective collaboration between the interventionalists and surgeons in the days to come which is good for the patient management. We should not look for one year or five years. Patients who come to us are in their 40s and 50s and they have much more life ahead. Changes in techniques are not taking place. In Europe the number of coronary interventions annually are now almost the same but PAD interventions are increasing. Amputation is very costly which may cost something like eighty thousand US dollars. In Europe we have one lac fifty thousand amputations every year and 60% of them are primary which is very bad.
It was also pointed out during the discussion that in Pakistan one may not get the same good results. Patients in Europe are educated, you have rehabilitation programmes but here most of the patients are not well educated and there is no rehabilitation programe as well. At this Dr.Antonio remarked that awareness, education, rehabilitation programme, care, exercise along with compliance with drug therapy are extremely important while angiologist role in the whole programme is only 20%.
Summing up the discussion Prof. Khan Shah Zaman Khan Director NICVD said that we are inviting experts from overseas to provide knowledge and their expertise to our faculty. CAD is now quite common and so is diabetes mellitus and hypertension. We also have lot of rheumatic and congenital heart disease. CAD, DM and Hypertension are the major killers in the developing Third world countries like Pakistan. We need to focus on primary prevention and encourage people to change their life style Peripheral Artery Disease is now quite wide spread and more disease below the knee will lead to amputation. We have started PVD Clinic twice a week at NICVD recently and see 15-20 patients in each clinic. We will be inviting more experts from abroad to visit Pakistan and encourage this programme.

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