thanks Asmaa and Abdullah for your excellent comments, just one comment if you look at duplex scan in details you will see heavy calcified distal run off vessels, CTA will add minimal benefit in this situation as you will not be able to know whether the distal vessel is open or not in most cases , in these situation MRA will give you an excellent idea about the distal run off vessel. other option as Asmaa mentioned is diagnostic angiogram and proceed.
regarding the toe amputation, thanks Asmaa for the two interesting papers, there are multiple factors that is different from patient to patient to determine whether to amputate or not.
1- social issues
a- patient address: – how far is it from medical centre ( is patient likely to attend follow
up
b- caring family or friends , patient is reliable, understand wound managment, living
condition and financial situation)
2- Medical Co-morbidities
a- eysight ( diabetic retinopathy)
B- Fall hazard
C- Mental status
D- Diabetes control
5- Dialysis or not?
If you consider all these factors, you will get your answer whether to amputate immediately post -revascularisation or wait as Asmaa mention to auto-amputate.
hope it is clear and we are going to move to the second case.
Asmaa Saleh
6 months ago
Do you think CTA or MRA will give you a batter image of distal vessel and why?
CTA will give a better image of distal vessels.
MRA carries a higher risk of venous contamination and artifacts in smaller vessels.
In this patient, DSA combined with intervention can be an option if the patient is selected for endovascular revascularization intervention (lesser cost than MRA, lesser contrast than CTA).
What is the treatment options for this gentleman?
He is
-71 years old
-poor controlled type 2 DM,
-HTN, IHD
-Stage 3 moderate CKD
with infrapopliteal disease with a distal ATA run-off, and occluded PTA which fits the angiosomal region of the dry gangrenous 3rd toe (LPA).
So .. Endovascular vs open distal bypass.
*Endo:
seems favorable given the multiple comorbidites of the patient and BASIL-2 trial results, also it would give a chance to direct revascularization to lesion which would likely to improve healing, and assessment of collaterals and pedal arch.
Drawbacks in this patient is risk of CIN, but we can do CO2 based angioplasty or minimization of contrast dose with pharmacological adjuncts.
following revascularisation, would you proceed with amputation or leave it to autoamputate? on what base you take that decision?
I would wait for line of demarcation and separation, however no longer than 2 weeks, as dry gangrene can become infected which subsequently may lead to worsening of Pt’s condition, thus defeating the whole purpose of the revascularization intervention.
This is based on 2 papers
1-Cristopher A. Latz, Elizabeth Deluca, Srihari Lella, Harold D. Waller, Charles DeCarlo, Anahita Dua, Rates of Conversion from Dry to Wet Gangrene Following Lower Extremity Revascularization, Annals of Vascular Surgery, Volume 83, 2022, Pages 20-25
2-Al Wahbi A. Autoamputation of diabetic toe with dry gangrene: a myth or a fact? Diabetes Metab Syndr Obes. 2018 Jun 1;11:255-264. doi: 10.2147/DMSO.S164199. PMID: 29910628; PMCID: PMC5987754.
Well-done Eman, given the duplex scan results, do you think CTA or MRA will give you a batter image of distal vessel and why? question is for everyone
what is the treatment options for this gentleman?
and final question for this case before moving to the other case , following revascularisation, would you proceed with amputation or leave it to autoamputate? on what base you take that decision?
Q1: i think CTA will be better than MRA.
Q2: treatment options are revascularization with either endovascular or open surgical bypass.
Q3: if dry gangrene, i can wait for auto-amputation.
but if infected, i must do amputation.
Thanks Eman for your comment, patient has palpable femoral and popliteal pulses and absent distal pulses, ABPI of 0.4 , neuropathic and the gangrene is dry with no signs of infection.
Do we agree that patient has critical limb ischaemia? what is the criteria for CLI?
what is WIFI score? how does WIFI score help with decision making?
so his inflammatory markers are normal, eGFR of 45 and his duplex scans attached.
1 he assessment of pain site OCD character increase by elevating leg releaved by
He of smoking
2 examination general pulse bp
Local full vascular examination 4 limbs pulse character equality level
Abpi
3imvestigation
Full bld work
Ecg
Echo
duplex
Cta
71 years old gentleman, known poor controlled type 2 diabetic, hypertensive and IHD. presented to your clinic with right 3rd toe gangrene started 3 weeks ago with painful foot.
Full history include risk factors general and peripheral examination include colour temp pulsation capillary refill.
Started investigation CBC RFT LFT albumin Pt INR RBS HbA1c lipide profile ECG ECHO
ABI and Duplex or CTA as needed
Risk factor controll
Pain controll
Started BMT
Revasculraization according to anatomy
Q2.
No need for other image duplex is better in infrapop
Q3.
Teatment option endo
Q3. I wait for autoamputate with close monitoring because the gangrene is dry
Next: duplex study
Next: CTA for abdominal aorta and whole LL arteries
Esr
Crp
thanks Asmaa and Abdullah for your excellent comments, just one comment if you look at duplex scan in details you will see heavy calcified distal run off vessels, CTA will add minimal benefit in this situation as you will not be able to know whether the distal vessel is open or not in most cases , in these situation MRA will give you an excellent idea about the distal run off vessel. other option as Asmaa mentioned is diagnostic angiogram and proceed.
regarding the toe amputation, thanks Asmaa for the two interesting papers, there are multiple factors that is different from patient to patient to determine whether to amputate or not.
1- social issues
a- patient address: – how far is it from medical centre ( is patient likely to attend follow
up
b- caring family or friends , patient is reliable, understand wound managment, living
condition and financial situation)
2- Medical Co-morbidities
a- eysight ( diabetic retinopathy)
B- Fall hazard
C- Mental status
D- Diabetes control
5- Dialysis or not?
If you consider all these factors, you will get your answer whether to amputate immediately post -revascularisation or wait as Asmaa mention to auto-amputate.
hope it is clear and we are going to move to the second case.
Do you think CTA or MRA will give you a batter image of distal vessel and why?
CTA will give a better image of distal vessels.
MRA carries a higher risk of venous contamination and artifacts in smaller vessels.
In this patient, DSA combined with intervention can be an option if the patient is selected for endovascular revascularization intervention (lesser cost than MRA, lesser contrast than CTA).
What is the treatment options for this gentleman?
He is
-71 years old
-poor controlled type 2 DM,
-HTN, IHD
-Stage 3 moderate CKD
with infrapopliteal disease with a distal ATA run-off, and occluded PTA which fits the angiosomal region of the dry gangrenous 3rd toe (LPA).
So .. Endovascular vs open distal bypass.
*Endo:
seems favorable given the multiple comorbidites of the patient and BASIL-2 trial results, also it would give a chance to direct revascularization to lesion which would likely to improve healing, and assessment of collaterals and pedal arch.
Drawbacks in this patient is risk of CIN, but we can do CO2 based angioplasty or minimization of contrast dose with pharmacological adjuncts.
following revascularisation, would you proceed with amputation or leave it to autoamputate? on what base you take that decision?
I would wait for line of demarcation and separation, however no longer than 2 weeks, as dry gangrene can become infected which subsequently may lead to worsening of Pt’s condition, thus defeating the whole purpose of the revascularization intervention.
This is based on 2 papers
1-Cristopher A. Latz, Elizabeth Deluca, Srihari Lella, Harold D. Waller, Charles DeCarlo, Anahita Dua, Rates of Conversion from Dry to Wet Gangrene Following Lower Extremity Revascularization, Annals of Vascular Surgery, Volume 83, 2022, Pages 20-25
2-Al Wahbi A. Autoamputation of diabetic toe with dry gangrene: a myth or a fact? Diabetes Metab Syndr Obes. 2018 Jun 1;11:255-264. doi: 10.2147/DMSO.S164199. PMID: 29910628; PMCID: PMC5987754.
Well-done Eman, given the duplex scan results, do you think CTA or MRA will give you a batter image of distal vessel and why? question is for everyone
what is the treatment options for this gentleman?
and final question for this case before moving to the other case , following revascularisation, would you proceed with amputation or leave it to autoamputate? on what base you take that decision?
Q1: i think CTA will be better than MRA.
Q2: treatment options are revascularization with either endovascular or open surgical bypass.
Q3: if dry gangrene, i can wait for auto-amputation.
but if infected, i must do amputation.
Cta
Endovascular
Line of demarcation
Egfr greater than 30 I can proceed to cta
Clti yes tissue loss fountain 4
Apbi . 4
WiFi score wound 2 ischemia 3 infection 0
Acc to WiFi classificayion risk of amputation high
Revascularization high
Clti criteria pad+rest pain or tissue loss
Thanks Eman for your comment, patient has palpable femoral and popliteal pulses and absent distal pulses, ABPI of 0.4 , neuropathic and the gangrene is dry with no signs of infection.
Do we agree that patient has critical limb ischaemia? what is the criteria for CLI?
what is WIFI score? how does WIFI score help with decision making?
so his inflammatory markers are normal, eGFR of 45 and his duplex scans attached.
what is the next step of management?
Q1: yes patient has CLTI
criteria of CLTI include: rest pain/ minor tissue loss (ulcer)/ major tissue loss (gangrene)
Q2: WIFI score is an estimation of the patient risk for amputation and the need for revascularization
Q3: next step is to do CT angiography to plan intervention.
1 he assessment of pain site OCD character increase by elevating leg releaved by
He of smoking
2 examination general pulse bp
Local full vascular examination 4 limbs pulse character equality level
Abpi
3imvestigation
Full bld work
Ecg
Echo
duplex
Cta
71 years old gentleman, known poor controlled type 2 diabetic, hypertensive and IHD. presented to your clinic with right 3rd toe gangrene started 3 weeks ago with painful foot.
What is your next step of management?
Full history include risk factors general and peripheral examination include colour temp pulsation capillary refill.
Started investigation CBC RFT LFT albumin Pt INR RBS HbA1c lipide profile ECG ECHO
ABI and Duplex or CTA as needed
Risk factor controll
Pain controll
Started BMT
Revasculraization according to anatomy
Q2.
No need for other image duplex is better in infrapop
Q3.
Teatment option endo
Q3. I wait for autoamputate with close monitoring because the gangrene is dry