the role of surgery in the treatment of pad · richard neville, md, facs: consultant –graftworx,...

The Role of Surgery in the Treatment of PAD

Richard Neville, MD, FACSAssociate Director, Inova Heart and Vascular Institute

Vice-Chairman, Department of Surgery System Chief of Vascular Services

Inova Health SystemFalls Church, Virginia

Faculty Disclosures

Richard Neville, MD, FACS: Consultant – Graftworx, W.L. Gore; Grant/Research Support – Medtronic, W.L. Gore; Scientific Advisory Board – Graftworx, Tissue Analytics, W.L. Gore

Brand names are included in this presentation for participant clarification purposes only. No product promotion should be inferred.

Role of Surgery in today’s PAD practice• Surgical bypass

– Femoral-popliteal bypass rarely– Femoral - Tibial bypass

• Iliofemoral thromboendarterectomy (femoral bifurcation disease)• Hybrid surgical revascularization (inflow and outflow revascularization)• Failed endovascular intervention• Innovations have occurred in surgical therapy

– Distal Vein Patch for prosthetic bypass– Heparin bonded grafts and patches– Deep venous arterialization for lack of distal arterial targets– Remote monitoring technologies

Symptoms: Claudication

• Pain– Reproducible– Functional muscle– Relieved by rest

• Significance– 75% stable– 10% amputation (increased with DM, tobacco)– Mortality – 30%

• Surgery rare for claudication

Emperor Claudius (AD 54) Claudicare – to limp

Symptoms: Limb threatening (CLTI)

• Rest Pain– Distal foot/toes– Unilateral– Burning at night – can’t sleep– Dependent rubor

• Tissue loss– Non-healing ulcer– Gangrene

• Surgery for 25%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

VQI Centers Mean = 31% bypass

National pattern of LE revascularization

100% Endo

100% Bypass

VQI Centers

Surgical Bypass as first therapy

• Patient– Reasonable life expectancy and level of function

• Indication for revascularization – Significant tissue loss (> 2cm)

• Arterial anatomy – Long segment (tibial) occlusions– Common femoral artery disease

• Failed endovascular therapy

Bypass as the initial option for PAD

• Survey of endovascular surgeons• Indications for a bypass first approach to PAD

• Common femoral artery pathology

• Extensive foot gangrene/sepsis

• Young patients and those requiring soft tissue reconstructions where durability is paramount

• Long, infrageniculate occlusion with a single, distal tibial target vessel.

Lawrence PF, Chadra A, Eur J Vasc Endovasc Surg (2010) 39, S32eS37

Arteriography important to plan surgical therapy

• Distal tibial occlusive disease• Limb Center– 533 initial diagnostic– 276 primary interventions

Technique for bypass• Inflow artery• Outflow artery• Conduit– Large saphenous– Small saphenous– Arm vein– Prosthetic• ePTFE• Dacron

– Cryopreserved vein

But, surgical bypass has changed…..

J Vasc Surg 2000;31S:192-274

And, bypasses are more challenging……

• Absence of saphenous vein– 30% in CLI practice– 50% after failed prior bypass

• Poor quality vein• No good target artery for the bypass

Prosthetic graft failure

• Technical first month• Hyperplasia 6 to 24 months• Atherosclerosis beyond 24 months

Improved prosthetic graft performanceDistal Vein Patch

Neville , et al. Am J Surg 1997;174:173-6.

Improve prosthetic graft performanceHeparin-bonded ePTFE

Reduce platelet deposition

Reduce thrombus formationReduce myointimal hyperplasia

Heyligers, et al. J Vasc Surg. 2006;43:587-591. Lin, et al. J Surg Res. 2004;118:45-52.

Distal Vein Patch bypass

Minimal incisionsLength not an issue

HePTFE vs Saphenous vein for tibial bypass

Neville RF, et al. J Vasc Surg. 2012;54(4):1008-1014.

Primary Patency

Conduit length not an issueIliac to contralateral AT

DVP bypass with common-ostium dAVF

DVP bypass with Deep Venous Arterialization

Femoral bifurcation disease

• Endarterectomy has been the gold standard for atherosclerotic disease of the CFA.• Endarterectomy alone may be sufficient for patients with disabling claudication • Those with tissue loss and more extensive lesions likely require additional

revascularization (hybrid procedure)

CFA endarterectomy: TechniqueIncisions Endarterectomy Tack endpoint Patch closure

Iliofemoral endarterectomy

Ilio-femoral endarterectomyFollow up arteriogram – 8 monthsPatch intact, no restenosis

Complications after CFA endarterectomy• 1843 patients (NSQIP, 2005-2010)• Indication

– Claudication 64% – CLI 36%

• Mortality 3%• Morbidity 11%

– Superficial infection 6%, – Deep infection 2%– Dehiscence 0.8%

• Independent predictors of morbidity• Obesity• Steroid dependence

Nguyen BN, Neville RF, et al. J Vasc Surg 2015;61(6):1489-91

Hybrid procedures CFA endarterectomy with endovascular Rx

• Femoral endarterectomy with proximal/distal endovascular revascularization• Multilevel revascularization through one point• Iliac endovascular interventions possible• Femoral-popliteal-tibial interventions possible• Decrease in morbidity and length of stay

Doslouglu H Vasc Endovasc Surg Sharafuddin MJ Vasc Endovasc Surg Chang RW J Vasc Surg.

Amputation: one of the first procedures in surgical history

Ambrose Pare (16th Century)

Pecoraro RE, Reiber GE Pathways to limb amputation. Basis for prevention. Diabetes Care. 13.

Primary amputation: May be the right choice

• Non-ambulatory• Dementia• Faulty wound healing: 14% • Gangrene: 40% • Infection: 41%

• 50% not due to a vascular cause

Amputation principles

Lisfranc

Chopart’s

Symes

• Optimal biomechanics• Maximize viable tissue• No pressure points• Early ambulation

Below knee amputation: Design is key

“Life altering, not life ending”

Role of Surgery in today’s PAD practice• Surgical bypass

– Femoral-popliteal bypass rarely– Femoral - Tibial bypass

• Iliofemoral thromboendarterectomy (femoral bifurcation disease)• Hybrid surgical revascularization (inflow and outflow revascularization)• Failed endovascular intervention• Innovations have occurred in surgical therapy

– Distal Vein Patch for prosthetic bypass– Heparin bonded grafts and patches– Deep venous arterialization for lack of distal arterial targets– Remote monitoring technologies