One of the most difficult clinical cases I encounter is the "non-bypassable patient". Firstly, let's consider there is such a patient - our vascular surgical colleagues in Boston claim that non-bypassable in one surgeon's hands might be bypassable in another's. What can be done for the patient with critical limb ischemia, tissue loss, where there are no interventional or surgical options? How can we avoid an amputation or should we? I have tried Pletal, calcium channel blockers, HBO, and intrathecal anesthesia to provide a temporary sympathectomy, with varying results.

I completely argee; this topic demonstrates the need to find a vascular surgeon who is willing to go below the ankle for angioplasty and bypass. In my facility, there is one vascular surgeon in particular who is known for 'going the extra mile' and is willing to attempt distal vascular procedures even when his collegues and partners have written the patient off as non-bypassable, and he seems to generate consistantly positive outcomes. In today's world of a multidisciplinary team approach, you want to make certain that the vascular surgeon on the 'team' is willing to go the distance.

My experience reflects both of yours. There is a wide range of training and experience with both vascular surgeons and interventional cardiologist. At times I will have a "nonbypassable" patient from vascular but an interventionist would be able to perform silver hawk or excimer laser to open the PT artery. Other times it would be vice versa. Key is to understand their experience, training, but most importantly comfort level and the overall goals for limb salvage. Or we must accept that when a patient with Diabetes Mellitus and critical limb ischemia or relative ischemia who is considered "nonbypassable" is the natural history and marker of disease state of long standing diabetes of which at this point cannot be changed despite best efforts.

I agree, at some point it is necessary to accept that despite your best available interventions, salvage is no longer a viable alternative. It is important to realistically evaluate the potential functional outcome with limb salvage vs. amputation, as well as the patients over all health.

Amputation, while unfortunate, may yield the best overall outcome with earlier return to activity and therefore greater overall quality of life for the patient.

I am so glad to hear someone else taking advantage of this specialty. Interventional Cardiologist are a DPMs best friend in my opinion. They are use to working in small arteries around in the heart, so it is a natural transition for them in the foot and ankle. We are lucky to have one of these specialist at our hospital, and they have done some amazing work. 

 

As an example, we had a patient with three vessel occlusion, and this IC opened up not one, not two, but ALL THREE arteries! The patient healed extremely well after this heroic revasc.

 

 

Given this presence in our hospital, our first consult for revascularization is always to Interventional Cardiology. In fact, our service hasn't called upon Vascular Surgery in over two years as a result.

Dear Lee,

It is my personal belief that, "non-bypassable limb" will be an obsolete terminology.

Yes, if a patient does not have a distal "target" (a part of artery where the bypass conduit is connected), it is considered a "non-bypassable" limb today.

Having said that, there are so many tools in the vascular interventionalists hands these days, I am guessing that the presence/absence of "target" won't matter.

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Let me present a case. This 87yo patient had a gangrenous toe with cellulitis. The angiogram showed "no distal target." Her first vascular surgeon said, "there is no target, so BKA is the only option." 

I felt that she would benefit from a second opinion, so I sent her to another vascular surgeon, who is up-to-date on the latest endovascular treatments. To make a long story short, the surgeon took the patient to a cath lab, inserted the guide wire through the calcified plaque using the Crosser (ultrasound-based entry device), then used the Silverhawk athrectomy device to open up the anterior tibial artery. Afterwards, I amputated the gangrenous toe. One year later, she is still walking her dog every morning, with her own two legs. 

It's exciting to be able to save these ischemic limbs, which would have been amputated a few years ago. I work with all of them; vascular surgeons, interventional cardiologists and interventional radiologists. I think it's important to know the right people who share the same "limb salvage" philosophy and go the extra distance to save these legs with you.

Kazu,

Congratulations on being able to save that particular patient.  However, you have to understand that in most places around the country, there are still those "MDs" that feel that bypassing an obstructed artery is the only way to go.  Also, I should say that for most DPMs, they do not adequately know how to communicate with the PCPs and other medical specialists for these type of patients.  For example:

83 year old patient presented in-hospital consultation.  Known severe DM history with open ulcer to posterior right leg.  All wound precautions and pressure relieving surfaces were obtained (my hospital has all the Hill-Rom Low Air Loss Beds).  Patient has extensive history of ASO.
Patient is discharged from hospital to SNF.  2 weeks after D/C, paitent came to wound center with a complete and necrotic right heel and non-healing right hallux pressure ulceration.  What do you think happened?  (I am fortunate to have 2 very good interventiional cardiologists who are willing to try to get as distal as possible; I also have 2 vascular surgeons who are so tied into Cordis (J & J) that they do not wire below the knee (and wont use Boston Scientific, FoxHollow, Spectranetics, etc...and the cath lab has it all)

Basically, patient went for AKA.  Interventional cardiologist was unable to wire through the plaque and ultimately, patient lost his leg.

Why do I tell this story?  BECAUSE if the PCP and the patient's previous DPM had actively been watching the PVD/DM, then this could have been everted, even 3-5 years ago....This stuff still goes on and on and on EVERYWHERE in the country.  We ARE the gatekeepers for PAD/PVD....why don't more of our colleagues take an active role??

I understand that you have to "play nice" with all the local doctors and be careful about the "politics" involved with the rivalry among vascular specialists.

Having said that, I believe that I have to be the patient's advocate. If I believe a particular patient of mine is getting treatment recommendations out-dated, or not in line with the standard of care, I am not afraid to send the patient for the 2nd and 3rd opinion, ESPECIALLY if the survival of their limb is at stake.

As one of my mentors taught me, "you live and die with your patients." It's a loaded and dramatic quote, but I believe it is our job to look out for the best interest of our patients.

I completely agree with you, that those of us that practice limb salvage need to have our patients WITH their limbs.

I feel terrible and "did I do enough?" every time I hear that a patient of mine needs to have his/her limb amputated.  I try to do everything I can from interventional endovascular to HBOT to exercise as much as possible.....its always a battle...but I like to fight it.

 

Here is something new on the horizon from BioMet Biologics.  A phase two trial,  off-label unpublished as of yet, was concluded last year.  The target patient population was a limb with critical limb ischemia.  This was in the patient that was non-bypassable and was not amendable to arthrectomy.  

Hip marrow aspirate is obtained, spun down to concentrate  the marrow stem cells with that cellular layer collected.  This concentrate is then injected into the calf to stimulate small arterial vessel formation.  The thought process is to stimulate increased arterial inflow to benefit the patient.

I have tried this twice this year with one decent outcome.  which was decreased ischemic pain, no limb loss, and increased ambulation. The patient started feeling some relief three weeks after the procedure.  In the other patient, the procedure just did not increase the perfusion enough and the patient eventually  proceeded to a BKA.

Karr 

(Click Here for a press release on this topic)

 

Interesting. I used a variation on that theme recently in a patient with a chronic gastroc tear with persistent pain.  He had an Achilles partial rupture in addition to the gastroc tear, so after i repaired the Achilles tendon,  I used the GPS system to generate some platelet-rich-plasma (PRP) which in then  injected under fluoro into the area of maximum tenderness in his calf (which i'd previously marked with an injection of radiopaque dye).

 

My general thought process as to the mechanism of action in this has been to flood an area of chronic injury with a concentration of inflammatory cells, cytokines, and growth factors to stimulate healing --much like we do when we convert a chronic wound to an acute wound in a chronic wound care patient.  In this particular case, he is about a week post-op now and relates to a significant decrease in his discomfort in his calf following the treatment.... so far so good. I'll keep everyone posted!

 

I've used the marrowstim on numerous occasions to augment various arthrodesis procedures --but i never thought about its possible application in angiogenesis --exciting stuff!!  I'll have to give it a try!

 

Thank you for the kind comment.  

Ryan has very good insight in the tendon therapy he discussed.  Actually, starting back in 2006-7 in some South America soccer teams first and then in some  European soccer league teams they are using, off the record, GPS for muscle and tendon injuries.  For those soccer fans, that is how an over weight, popular Argentine soccer player came back very fast from a thigh injury in 2007.  I believe this stays "off the record" because FIFA considers red blood cell therapy doping.  The PRP is primarily a platelet concentrate as well as the marrow concentrate - mostly stem cells.

Karr 

To follow Dr. Karr's comments:

Stem cell injections in critically limb ischemia have been tried in various parts of the world. I've heard that in Kyoto University in Japan, where it all started, has a "Department of Regeneration Medicine."

Recently I've talked to many Japanese researchers doing this "angiogenesis attempt with stem cell injection", and they almost uniformly tell me that, the rest pain predictably goes away, but the wound healing endpoint and other objective parameters (SPP, ABI, TCOM values etc) tend to be unchanged or all over the map.

I am afraid that we have many more years of research and refinements to be done, before we can rely on the stem cell therapy for CLI (Critical Limb Ischemia). By the way, our institution is a part of multi-center trial on the stem cell/CLI study, and we hope to contribute for the discovery of something useful and helpful for our CLI patients.

As mentioned somewhere else on this thread, I think "Non-bypassable patient" is a misnomer, or an out-dated term, since we have the capability to revascularize most limbs using the combinations of surgical bypass, angioplasty/stenting, and athrectomy. Perhaps "Non-revascularizable limb" or "Non-reconstructable ischemia" may be more appropriate?

Just my 2 cents...