Chapters Transcript Video ALI Management Back to Symposium Uh, I guess we're changing gears a little bit, going to discuss ALI management. Just wanna confirm, you guys can hear me. We hear you great. Fantastic. So when we speak about acute limb ischemia, really we're talking about that rapid decrease in blood flow, uh, acute occlusion, usually embolic, but anything that causes acute occlusion, and it threatens the viability of the limb. It's important when examining these patients, what you're looking for physical findings. We talked about the five P's pain, pulselessness, pallor, paresthesia, and paralysis. And it's important when we evaluate these patients to get an idea of what level of limb threat exists and what's the time frame to be able to reestablish perfusion if possible, and to try to compensate for that loss of perfusion. So, it's important, you're looking at um the, the, what's involved in terms of the extremity to assess that viability of that limb as you start making a revascularization or your future plan. The incidence of acute limb ischemia is 1.5 cases per 10,000 individuals, and usually we see them in our older individuals. That rate goes up in our older individuals. But I think what's really important is to understand that we're looking at a one-year amputation-free survival with open surgical revascularization over years is about 62% and really high mortality rate, somewhere between 15 and 20%, amputation rate between 10 to 15%, uh 10 to 15%. And again, these were his historical numbers. Well, because really no randomized trials now with these new technologies. The assessment of these patients, I think it's very important using the Russeford classification to see if that patient is stage 1, which is viable and not immediately threatened. Usually here in this situation, you're looking for Doppler signals. You're looking for no sensory loss, no, no paralysis, and complete, uh, no loss of strength. To 2A marginal limb threatened where you may have some mild sensory loss, and then 2B and 3 is really when we start getting into the difficult situations where you start having not only sensory loss, but some mild muscle weakness. And at this point is, you know, you need to make that differentiation between 2B and 3 and how much time you have to reestablish flow and is there still a chance of Recovery in terms of that extremity. Here's a treatment algorithm uh looking at acute limb ischemia. We'd like to start with intravenous heparin, uh, from there, try to classify into the different types of classifications and see how that patient does. And at that point, uh, we're going to decide if that patient is at level 3, it's going to be irreversible. We're looking at amputation at that point. 2B, 2A, I think. We've become much more aggressive now with 2B of trying to revascularize those patients and our institution really work close together uh with uh endovascular open techniques to try to see what we need to do to revascularize this particular patient, knowing that that patient may require other procedures such as fasciotomies as necessary. So a lot of times then we start with that, with heparin and then move towards a revascularization strategy. I think there's been a big. Uh, paradigm shift now in terms of using other forms of catheters and techniques to try to reduce that thrombus burden and revascularize that patient. So what we went from really Fogerty balloons and occlusion balloons to now being able to aspiration devices and other forms of devices to try to reestablish flow and Our early experience at the institute really started with neurointegral catheterters, and that's really when we kind of made that transition, started really growing and using some of these 5 French, in those cases, there were 5 French catheterters to attempt to revascularize, particularly our older patients that were not great surgical candidates and working with our surgeons and really looking at this as a paradigm shift to try to treat these patients, I think. When we look at the devices that are available, I think we had for many years predominantly used lysis. I think the importance with lysis is not every patient is a lysis candidate. There's significant risk of, of bleeding, uh, particularly intracerebral bleeding, and also with lysis, um, you, you have to worry about the time it would take to reestablish flow. So you needed really almost 24 hours in most cases to try to reestablish flow, and that patients may not have that amount of time if they're in that 2B. The category. Uh, we then saw, uh, a real lytic catheters such as the Androjet. We could use this with or without lytics and the pearl registry really gave us the, the, the data that, hey, we could do this as a single setting. So now you're going from lysis catheters as a, a two-day type procedure to maybe using real lytic catheterters to try to get this done in one sitting. And then, uh, you know, the original Rotorex device really used in Europe because of its aspiration uh uh. Ability to be used particularly with that, that form of aspirating as much of this acute thrombus as well as atherectomy at the same time in some of these patients. Uh, aspiration catheters based on vacuum and again looking at those indigo catheters really were the first on the, on the market and we've now seen a huge kind of proliferation of these technologies. We can go up to 12 French catheters in the right situation depending on what we like to treat and With surgical vascular radiation using Fogerty catheters and now newer catheters, and I, I, I, I know I'm going to exclude many because there's so many different new catheters on the market, but I'd like to say that most of them are based on aspiration. They're going to be based on some kind of mechanical removal of thrombus. Usually using some type of basket, and then you may see some form of floor rest. So I would, I highlight here the Arctic device because it uses floor rest in a basket, a pounce device using a basket again, and aspiration devices all put together to try to treat acute limb ischemia. Here you can just some idea of some of these devices and what they look like and the different abilities. I'm gonna show a case. She's an 84-year-old female. She presented with right foot pain localized to the dorsum that was progressing over the last week. Uh, we evaluated her. Uh, at, at this point, I can tell you she was, uh, really Rutherford one. she did have symptoms, but sensory and motor was intact. You can see, uh, at the time of her, um, angiogram that she had occlusion of that popliteal artery with reconstitution of the tibial vessels. In this particular patient, we did a CT 6 thrombectomy, so a thrombectomy catheter. And again, the techno the technique here was really get a uh sheath access, they come down and get your wire, stay in the, in the lumen. Uh, then push your catheter right to the edge of the lumen and then slowly advance your catheter. Again, these catheters are going to be slow and soft to be able to advance them through thrombus, and if you run into a lesion, that's really where you may feel some resistance. This particular patient, you can see how the catheter just, uh, slowly advanced, and you're getting aspirating as you go through this. Sometimes you may withdraw a little bit to get into flowing blood and then continue as to not occlude the catheter. Now there's a lot of other technology. That will help accelerate that thrombus from getting aspirated. Now the question is, what do you do with the tibial vessels? My personal technique is I like to use a wire. In this particular case, I'll use, um, you know, a wire, usually a roadrunner wire, may then place an 014 wire and try to secure each one of these tibial vessels and then aspirate into each one of them to try to clear the origin of those vessels, and that's what we see here selectively as each one at a time. In this particular case, when we finished, we did have some dis umboli to the anterior tibial. We were able to then go down with uh another uh aspiration catheter and really aspirate and get that uh open uh with a pretty good result and pretty quick, and you get to see what the changes is the patient's symptoms resolved. Uh, you know, there's a lot of studies now. The biggest one is probably the Stride trial. Again, this is using the pum catheters, but it showed really high technical success, limb salvage at a year, and really improvement in quality of life, all of which I think are very important, as we start comparing to those changes. So, I'd like to conclude and just say acute limb ischemia is really a critical condition, high mortality, high risk of. Limb loss. I think now we have a lot of different technologies to help treat these patients. I think it's important to understand how to assess these patients, to figure out which patients are best candidates to be treated, understand what, how much time you have to treat those patients. I think it's important to be working as a team, particularly if you may need um uh a fascio. Or other type of work in, in terms of, of getting and reperfusing these patients. I think there's a number of catheters that are coming out into the market now, and I think it's important to understand what catheters you have, what are the what are, how to use them, and to choose then uh these, these catheters as we start trying to treat these patients and managing acute lymb ischemia. With that, thank you. Great. Thank you. Thank you, Tino. You know, I always, I tell my fellows, you know, when I do ALI cases, um, I usually just let my surgical colleagues know ahead of time cause I feel like it's easier for them just to know, I tell my plan and then again, you never know. Most of these patients, if you catch them early enough, they don't need fasciotomies or any other type of compartment care, but it's just nice to have that communication online. Um, so, you know, I really appreciate it and I know that, um, Mark, for your practice, you know, you guys have such a great integration with vascular surgery that, um, you know, you all can work together for these type of situations. Yeah, I think it's really important. I, I love what you said, and that is reach out. I let people know, hey, this patient is here. Let them, you know, be, uh, uh, no one wants to find out like when there's a critical situation. Yeah. And again, having the team carefully assessing the patient because you, you know, I've come to the point that you really. Don't know when the patient may develop compartment syndrome. So you really have to be kind of thinking about it. You have to be assessing them, and it's always good to have two or three people kind of weighing in and making sure we don't miss this. Yeah, exactly right. And then the other part, you know, this, I think it's really, you know, highlighted by your talk is how much we've moved a single session. You know, we, we didn't talk about drip catheters overnight like we used to do early on and so it's really been a paradigm change and the numbers led the way, but I think you highlighted that really nicely, just being able to get people in and installed on the table, you know, versus that delayed hope that the drip works. Yeah, great. So, Tina, we really thank you for taking the time. We hope you have a speedy recovery and um for those in the audience, I hope you see uh Tino walking. I don't know what you'll be doing on a, on a little scooter at at I sit. I don't know where you'll be somewhere in a wheelchair maybe, but uh you'll be there, I'm sure. I'll do what I can. Thank you very much. I apologize I apologize that I'm not there and I'll see you guys soon. OK, my friend. Safe, safe, safe travels, everybody. Published Created by
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