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Board Review Vascular

Advances in the State-of-the-Art Endovascular Therapy in Lower Limbs - What the Podiatrist Must Know!

Paramjit Chopra, MD

Paramjit Chopra, MD discusses how a collaborative effort between vascular surgeons and podiatrists will better serve their combined patient population. Dr Chopra focuses on advances in endovascular surgery and how it relates to podiatric medicine.

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Goals and Objectives
  1. Understand recent advances in endovascular surgery
  2. Identify signs/symptoms of peripheral vascular disease
  3. Understand how angiosomes are used to better treat PAD
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    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

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    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Paramjit Chopra, MD

    Director, Midwest Institute of Minimally Invasive Therapies
    Associate Professor, RUSH University
    Chicago, IL

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  • Lecture Transcript
  • So with that said, I’d like to introduce our first speaker of this morning. Our first speaker is also a new speaker for our presents’ faculty family. We felt we needed to expand our course offerings in vascular surgery and endovascular surgery more than what we had done before for multiple reasons since this is such a large part of what we do and face everyday. So, we’re very pleased to have Dr. Romi Chopra join us who is going to talk about advances and state of the art endovascular therapy in lower limbs and what podiatrists must know because many of us get into trouble and have great concerns over in PAD in the lower extremities. Dr. Chopra actually trained down the street from India. I used to be at Deaconess for many, many years. He trained at the Brigham and Women’s Hospital, his residency and fellowship in Harvard Medical School. He’s now an associate professor at Ross University in his own institute MIT and I’m just going to call out many MIT, licensure from Boston anyway. Let’s welcome Dr. Chopra to this day. Thank you.

    Dr. Romi Chopra: Good morning. Usually they put me on after lunch when everybody is just about ready to fall asleep. I’m really great I’m the first speaker. Thanks to Dr. Freiberg and Dr. Shore and everybody else who present. I work a lot with podiatrist and just to give you an example a couple of days ago, I got a friend to call, actually last week Monday from one of the podiatrist and he had done some hallux surgery two or three days ago and women called over the weekend saying her toe is black. Family is freaking out, everybody is upset. He’s seized on the office first thing in the morning and the foot doesn’t look good. He goes, “I don’t what happened? What’s going on here?” There’s an underlying vascular problem, he calls me, we see her and next day, we’re doing some endovascular intervention. I have that life case to show you and she’s got a pulse in the foot now and all she might lose is a little tissue at the distal phalanx. PADs are very silent disease and it’s a lot of this case symptomatic. The second way I look at this is we both have a foot fetish, everybody agree with that? We all love feet, we all love legs and without blood supply, the leg can’t be alive. Endovascular specialist and podiatrist working together is a great team. In my daily practice, at least two of my locations, we co-partner with podiatrist. I’m opening a third one in a podiatrist ambulatory surgery center where I’m going to do endovascular work one day a week or two days a week. The common ground here is that we both love legs and feet. We fix the plumbing, I give this example to patients all the time if the plumbing behind the wall is damaged and no matter how much you fix the wall, there’s going to be issues. The teamwork together is really what makes it happen. The institute that I’ve formed about 14 years ago is called the Midwest Institute for Minimally Invasive Therapies where multiple physicians, multiple locations and all focuses on the community, still maintain academic affiliation but we try to bring or state of the art to the community and specially working with the podiatrist. It’s a human condition that we all want to preserve life and make it better. Nobody wants to lose a body part. I’ve had patient saying I’ll go to migrate with all my body parts intact. We want to prevent amputations and amputation prevention has become a key point for where this partnership starts. The primary problem on the line is atherosclerosis. When we do surgeries and plumbing, it’s like pipes rusting. We’re not dealing with the underlying disease, we are focusing on the plumbing and the question really is how do I open the blood flow to the leg? Keep it open as long as possible and prevent it from blocking again. What you may not be aware as podiatrist is the underlying cause is atherosclerosis. I guarantee you, everybody in this room has some form of it right now. The question is how does it manifest, once that we pay most attention are to the heart and the brain, but the end in mind is we want to want good viable limbs and we want to keep this open. Now lot of advances had come along. Traditional teaching has been you don’t treat claudicants, or you only have to do procedures when it’s critical limb ischemia. Not so any more. The treatment options have become so much better and you’ll see some of this. I can do peripheral artery work from a radial artery stick now. The patient that I’ve describe to you, one of them, I got it from the left radial artery, fix the SFA.

    [05:03] She was up and walking within five minutes of the procedure and gone home the same day. Worst is an open fem-pop bypass as she’d be in the hospital few days later, all the honesties issues, et cetera. We can cross occlusions. You’ll see that again on the case I’ll show you which have been occluded for years with different tools. We can modify the compliance of the artery by doing different kinds of atherectomy. I can do an endoluminal fem-pop bypass with endografts. I can puncture the dorsalis pedis artery. I routinely do pedal interventions now. We follow all these patients very aggressively, there’s small risk of disease. It is not uncommon for me now routinely to be in the pedal arteries and in the pedal arch and opening those vessels up. I have 1 millimeter balloons all the way out to whatever length, of 500 millimeter wires that I can get through from the radial artery all the way down into the foot. People think that PAD is a benign condition. Actually symptomatic PAD ten-year mortality survival is only 25 percent. If you get diagnosed today with large vessel peripheral artery disease, your chance of survival is only 25% at the end of ten years and that comes from either a heart attack or a stroke that may come from that. The surprising part of this is that 50%, it’s not surprising but the hidden secret here is that 50% of PAD is asymptomatic. Only 15% is typical where they have typical claudication and a majority of them coming with heaviness or something else in atypical pain and only 1% or 2% will show up with the wound or critical limb ischemia. One of the messages to my podiatry friend is expand your horizon, touch the foot, you don’t feel a pulse, don’t see hair, and you are not sure, get the vascular exam and get it accessed. Critical limb ischemia is 1% to 2% of the whole game and usually it’s late. By that time, they’ve got rest pain, the wound is not healing. There may be associated venous issues, we’ll talk about that this afternoon. When you look at that stage, it’s sometimes a little too late but when you look at the population of patients who’ve had critical limb ischemia or something else, 50 plus percent of these patients have had an underlying PAD that was ignored and that showed up too late. The second part of this, the pandemic, I do stuff all around the world, go to India, go to the Middle East, 10% or more of the population is diabetic and that’s happening here too. Diabetic arteriopathy actually is very silent on top of that, the neuropathy, the patient doesn’t feel much and all of a sudden they had the edge of a precipice. In there is calcium. You do a plane X-ray of the foot, you see calcium. Alarm bell should ring in your mind and say I need to send this patient for an evaluation because they’re may be PAD. We don’t always see the calcium on the X-rays well or the angiogram and we treat it so we have ways of getting rid of the calcium and the different tools that go in to get rid of that and then keep that vessel open. The second thing after that is the microcirculation is at risk. Next, renal failure, vasospastic disease and smoking and tobacco use. These all add to it so we catch those early and make sure that plumbing is open. Ultimately, what we are looking for is skin perfusion. We don’t just look at the ankle brachial index because the calcified pipe is a led pipe. Would do you know pressure in there? You can’t, the pipe is too hard. Ankle brachial indices are not sufficient. What I really do now and we’ve expanded this is we measure the perfusion pressure in the foot. If the perfusion pressure is less than 30 millimeters a mercury, it tells us that that tissue will not heal and that wound will not heal so we intervene with the goal if improving the perfusion. The next concept that’s important is angiosomes. Dermatomes, plastic surgeons, note as well where they know if they’re going to take a flap, the blood flow to that area should be good. We focus on angiosomes and test for the angiosome. If you have a wound on the lateral side of the foot and the heel, I know it’s the perineal artery feeding that area, I must open the perineal. If it’s on the dorsum of the foot, anterior tibial artery. If it’s the planter aspect which a lot of the wounds are and going up to the tips of the toes, I’m looking at the posterior tibial artery. We focus on the angiosomes, look at the pressure in each one of these different areas and intervene and we call the skin perfusion pressure test and we do this both pre and post. Important aspect is if you see calcium, ankle brachial index is not good enough, skin perfusion is important if you want the tissue to heal.

    [10:05] Pedal occlusions in the foot are very, very common especially in diabetics. That’s something you want to keep at the back of your mind just before you take them to surgery. Sometimes even if you feel a pulse, they may have some problems in their distal circulation especially in diabetics. If you feel the toes, the cool, you see that there’s less hair on top of the skin and their sensation is mildly decreased, think of PAD and most importantly is you send them in time, those tissues. We want to make sure we don’t get them to the point that they’re looking at an amputation and testing early for PAD is important. What do you test for? Diabetics? More than ten years especially, insulin dependent, send them for a quick check. More than 60 years of age. Anybody who’s more than 50 but has been either using tobacco or smoking and if they have any atypical pain that you can explain with muscular skeletal or they talk of typical claudication. You want to get those evaluated. If in ulcer is present then we look at the angiosome that’s feeding it. We treat the angiosome, we follow and monitor of that angiosome to make sure it doesn’t come back. That we do in our office for those of you interested, this can even be set up in your office. There are some financial possibilities with that as well and there are companies that allowed that. We do angiosome targeted interventions now. What you need to do is in your communities around the country, find an endovascular specialist in and around your space, we’ll partner you. Your outcomes go up, they do well. As a vascular specialist, I get referred a lot of patients who will have atypical pain and I diagnosed plantar fasciitis all the time. They’ve got problems with their toes and I send them to a podiatrist. That’s become a huge referral source for them. New technologies in terms of stents mimicking, we call the mimetic stents. We look at endovascular grafts, drug coated balloon stents, these are all the techniques just as you have yours in your world that have started to come in to keep these vessels open. We have now stents that mimic the way the SFA goes. You’ll some of this as I show you the life case and prevent these stents from getting crust. Here’s an example of how intense the calcium can be in the artery and if you don’t put the right kind of stent, it’ll get crust especially when they’ll squawk. Chronic occlusions, we can open these from just about any point in the body, radial, femoral, popliteal stick, pedal stick, dorsalis pedis, posterior tibial and peroneal artery. There’s almost no vessel that we can get to. Here’s the case, could you play that video? Okay. It’s the lady I was talking about. We do the angiogram, the aorta is open, common femoral is occluded. You can see that occlusion right there. We get through that. This was a under an hour procedure, conscious sedation. We’re doing an atherectomy where you’re spinning down that calcium. It’s decent enough result but look at the SFA, the one in the middle is completely occluded. After three vessels in the foot, only two are open. This foot is obviously ischemic but the doc didn’t know it. He went ahead and did the surgery, now the toes are black. I’m getting through that long occlusion. This probably was occluded for several years and lady was a smoker. I’m trying to get through that artery. You can see I’m digging through but I can’t really get through it from above, 80% of the times I get through. It’s all plumbing and I’m trying to dig my way though there. I’m like okay, this is not working for me from above, what can I do? I have other tools that allow me. This is a needle that’s in the catheter that’s allowing me to put my way. I can’t get through. I punctured the popliteal artery. Patient on the side, punctured the popliteal artery and going up from the popliteal artery. Now, literally doing endoluminal fem-pop bypass and I’m actually going all the way up and connecting with the catheter in the femoral artery. I’ve actually think of two little spaghetti straws next to each other and I’m putting a wire from it from one into the other and got a railroad from one side of artery to the popliteal artery. Over that now, I’m going to do an angioplasty. Atherectomy first to get rid of the calcium, then I got a long 30-centimeter balloon that I’m going to get through. Here’s that wire going into the catheter so that’s a 1 millimeter diameter catheter and I’ve got a wire in there and now I’m doing an angioplasty with that. The angioplasty is like a bulldozer, I’m pushing all the plaque aside, all the calcium.

    [15:02] Once I’ve done that, now I need to keep it open. If I leave it, it’ll shut down within a few days. Now I’m going to start deploying stents and we have the stents now that allow us to mimic the shape of the superficial femoral artery. So that superficial femoral artery, as we bend our knees and our legs, does all kinds of different things. There’s torsion, there’s flexion and stents can fracture. So these stents now have 0% fracture rates. It’s 80% patented at three years. As long as you keep this open, I have a patient at 12 years, his SFA is still open. We survey them every three months with the podiatrist. If there’s any foot problem, because they come for toes and everything else, I’ve keep an eye on them for the vasculature. You can see that metal stent. You will see, if you remember how the artery was very thin and narrow, look at the flow now as it’s flying through including the common femoral. This was all done under local anesthesia and mild sedition. Patient’s got a 2 plus pulse in the foot. I had this patient walk out in one hour, end of the day, patient went home. This would have been a long surgery just a few years ago. Now, we also have closure devices where I can put a stitch in the artery through a catheter. The left common femoral punctured, if you’ve heard a people having angiograms, they press on it for eight hours and do all that stuff. There’s a stitch that we put right through the catheter. It’s literally a 2.0 Prolene suture that you tie right up the artery. Patient gets up and walks in one hour so that’s where endovascular is today. This was a patient I see within 24 hours I’ve got a two plus pulse in the foot, now we’ll keep on surveillance. We have data to show that these are staying patent at five years, 80% plus of them and then we monitor them but we also make sure that diabetes is under control, et cetera. Quickly show you former cases, at least images here as you can see the dorsalis pedis artery has a stenosis. ABI was good, 0.96 but it’s not accurate of course because of calcification and then this is after intervention in the dorsalis pedis because imagine operating on those toes but not getting enough blood and now the SPP is 91, earlier, it was 42. You can see the progression of how that wound healed and it didn’t have to do an amputation. Same here if you see a diabetic smoker hypertension, ABI seems good, 0.83, it should be getting 83% blood supply. It’s only 32 and any surgery on that foot would be a problem. We’re able to go down all the way angioplasty, all those, the SPP goes up to 65. That means the skin pressure is 65 millimeters of mercury, perfusing the skin, that was the wound before. Now, that’s wound and that’s the toe later. It makes your job ten times easier as to how you handle it. Obviously, you’re not going to be doing the vascular interventions, we’re not go into all those and fine details but if there any questions, I’ll happily take them. We have a couple more minutes. Thank you so much for your attention.