UNIVERSITA’ CAMPUS BIO-MEDICO DI ROMA

CATTEDRA ED UNITA’ OPERATIVA DI

CHIRURGIA VASCOLARE

Francesco Spinelli

Reinterventi dopo terapie endovascolari

No conflict of interest related to this presentation

Disclosure

UNIVERSITA’ DI MESSINA

U.O.C. e Scuola di Specializzazione di Chirurgia Vascolare

Direttore: Prof. Francesco Spinelli

Torino 26-29

settembre 2004

IL RUOLO DELLE

RIVASCOLARIZZAZIONI

CHIRURGICHE

FRANCESCO SPINELLI

IL RUOLO DELLE RIVASCOLARIZZAZIONI CHIRURGICHE

PROCEDURE DOPO INSUCCESSO EV1999 - 2003

BYPASS FEMORO-DISTALI 15• 6 interventi in urgenza per ischemia acuta

• 9 interventi per progressione della malattia

• MORTALITA’ 4

2 pz dcd con arto amputato

• AMPUTAZIONI 4

0

25

50

75

100

'06 '08 '10 '12

CLICLI post-failed EV

PERSONAL EXPERINECE

REFERRAL SURGICAL CENTRE

CLI patients POST FAILURE OF EV

Up to 40% (average 32%)

of CLI Pts after failure of PTAInt Angiol. 2011 Apr;30(2):156-63.

Early and one-year results of infrainguinal bypass after failure of endovascular therapy.

Spinelli F, Stilo F, Benedetto F, De Caridi G, La Spada M.

Unit of Vascular Surgery, Department of Thoracic and Cardiovascular Surgery, University of Messina, Italy.

CLI after multiple EV failures is seldom a benign condition

EARLY RESULTS of DISTAL REVASCULARIZATIONS 2004-2012

(Average 181 procedures/year)

MortalityAmputation

Occlusion

P< .05 P ns P< .001

Occlusion and restenosis after PTA are not entirely benign;

one-third of patients had deterioration of their tibial artery runoff.

Nolan BW

2011Dosluoglu

2012

EXTREME SURGERY

ULTRADISTAL BYPASS to POOR OUTFLOW

12

TASC guided consensus 2011: open surgery only

for EV failures

Selective use of endo-first and open-first strategies in 302 pts from March 2007 to

Dec 2010

Endo-first was performed in 187 (62%), open-first in 105 (35%), and 10 (3%) had

hybrid procedures.

Endo-first was performed in very selected cases:

(1) 5-cm to 7-cm occlusions or stenoses in crural vessels;

(2) TASC II A, B, or C;

(3) no impending limb loss.

At 5 years, endo-first and open-first revascularization strategies

had equivalent LS rates and AFS in CLI patients when properly selected.

[Epub ahead of print]

From Dec 2002 to Sept 2010, 433 CLI pts (Rutherford IV-VI)

514 limbs (EV: 295 patients, 363 limbs; BP: 138 patients, 151 limbs).

Survival Amputation-free survival Limb salvage

30-day mortality 2.8% in the EV and 6.0% in the OR (P = .079)

Endovascular first approach is safe

if performed in appropriate clinical & anatomical conditions.

A wise EV-first approach on the appropriate patients gives a clear

advantage over open Bypass

Rutherford 5-6

- TASC II D anatomy

- Extensive calcification

- Poor outflow

PREDICTIVE CRITERIA

None

One or more

High-risk pt

Good risk pt

no vein

vein available

BYPASS

ENDOVASCULAR

Last Personal Experience

from January 2004 to December 2012

1360 procedures

557 EV procedures 41%

95 hybrid or combined procedures 7%

708 Bypass grafts

52%

1/3 of pts after EV

failure

(17% of all CLI pts)

2/3 of pts first line bypass

(35% of all CLI pts)

Patients 1216 Bilateral 144 ♂ 841 ♀ 375 mean age 71.3

118 of these pts(50%)

Started as claudicants!On the base of

Predictive Factors

0

10

20

30

40

50

60

70

80

90

Primay patency Secondarypatency

Limb salvage Survival

76

8487

77

One year results

MEAN cumulative follow-up (36 months)

Conclusions

The best results of EV in CLI patients are in cases properly

selected on the base of clinical and morphologic factors

The era of “endovascular first” for all infrapopliteal lesions

is over

Both overly endovascular treatments and open bypass after

EV failure have poor outcomes

By offering a primary open bypass to 1/3 of our patients, we

could achieve limb salvage 87% and cumulative survival 69%

@ 36 months

Most patients are well treated by EV, but the worst are not