Paramjit Chopra, MD will discuss how vascular surgeons can use endovascular technology to aid in the treatment and healing of podiatric patients for better patient outcomes with fewer amputations.
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Release Date: 03/16/2018 Expiration Date: 12/31/2018
Paramjit Chopra, MD
Director, Midwest Institute of Minimally Invasive Therapies
Associate Professor, RUSH University
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TAPE STARTS -- [00:00]
Harold Schoenhaus: Our next speaker is Dr. Chopra. Dr. Chopra is an interventional radiologist, associate professor of radiology at Rush University. He is chairman of two hospital radiology departments and has been the chairman of large academic radiology practice in Chicago. He also serves as director of interventional radiology at SUNY of New York. I’ve had the opportunity to know Dr. Chopra for a short period of time couple of years. He is an extremely interesting speaker. He has a great perspective of the vascular tree and how he can help with our patients and the topic is really improving outcomes in podiatric surgical patients and the endovascular therapist in podiatric surgical partnership. So please welcome, Dr. Chopra.
Dr. Paramjit Chopra: Good morning. How many of you actually work with any vascular or endovascular person right now? A few hands I see. Okay, alright. I’m going to share with you a little bit about what’s the state of the art and really another way to look at this is, how do the endovascular specialist and the podiatrist work together and actually improve outcomes? I routinely see patients in podiatrist offices, I’ve partnered with several podiatrists in the community, help enhance healing. So if you’re dealing with wounds, I’ll quickly tell you a case. I’ve got a call, it’s Monday morning, early Monday morning, actually, it’s Sunday night, a podiatrist friend total panic. So I got a call from this lady. I did some bunion work and her toe is black. I said, “Don’t worry about it. Send her to the office first thing Monday morning.” See her in the office, toe is black. It was getting black. I suspect there was some vascular thing. He had no indication that there was something going on and what the patient had with underlying vascular disease. That afternoon, we had already done endovascular work and next morning, she’s got a pulse in the foot and all she had was some debridement of the toe versus an amputation, and that kind of case really brings into perspective why partnership is important. The second most important thing is, as I always say, economics after biology always wins. And economics drive behavior. So soon it’s coming down the pike, there’ll be a bundle payment. You and I would get paid sum of money to fix the problem. I can’t keep doing vascular work in isolation forever and you won’t be able to do wound care or some podiatric work forever without the two of us talking because we’ll both lose. It’s already happening ACOs, alternative payment models, you’ve heard of MACRA, all these different terms. Bottom line is somebody is going to say, “Here’s a bucket of money, figure it out.” And that’s kind of where we’re going. It’s fair to say everybody in this room has a foot fetish. I like fetish. Yeah. I say that at every presentation I make to podiatrists. Basically, what plumbers endovascular specialist and you do the structural work and we’ll work together, and basically got good outcomes. I tell my patients this from the arteriovenous problem, if there’s not enough water going to the garden, it’s not going to grow, and if the pipes are leaking and venous problems, you can keep painting the wall and the problems are going to persist. Today, what happens is, if the vascular tree is not open, you’re not going to be able to heal the wound or solve the problem. But more importantly is where the treatment is worse than the disease. Those options are not good anymore. So you want to do it whether it’s better for us or cheaper. And in that, the endovascular options have come along the way. We’re in Chicago, we’ve been in several parts of the community, and it really ties into mankind’s mission, which is preserve life and make it better. We want to live forever if we can and want to have a great life while we’re doing it and we’re all designed to move. And I’ve had patients I’ll go to my grave intact. Nobody wants to lose a body part. And so we’ve got this passion for amputation prevention. In the last seven years, I’ve had to see only two patients go to amputation and the mortality and the morbidity on that is huge, but those patients didn’t even make it 30 days. So we work very, very hard to avoid amputations. And the problem really here is atherosclerosis and we’re focusing on plumbing. The way we look at it is the pipes are rusting. What are the questions? How do I get more blood down to the leg? How do I get pass that occlusion and how do I keep it as open as long as possible? Just last week I had a patient who’s 50 years old.
For the last 14 years, he’s been with severe clotting and he’s got all those podiatric problems, but nobody wants to touch it. He can walk from perhaps the front of the room till halfway and he stops. And he’s had a bypass. Bypass went down, now what do we do? We were able to open all of those endovascular. Within one hour, he’s got a bounding pulse in his dorsalis pedis, that’s where we are now. So we don’t need those heavy-duty surgeries anymore. The common enemy here, plaque, atherosclerosis. And in this, what we’re looking at is as plaque builds up, it will block the flow and how do we prevent that from getting the leg to be critical where the leg has to be cut off. We don’t want that. And it is very compelling. Those people who have critical limb ischemia, 25% die within one year of onset of critical limb ischemia. Of those, 25 will get an amputation, the other 25 will get an amputation. Of those who get an amputation, 40% die within two years. Bottom line, amputation is not a good thing. And I always tell my podiatrist friends, if there’s no leg, what are you going to treat? In the end, the amputation prevention is key. We want healthy viable lower limbs and we want a durable option to keep the blood flowing. I mean these all actual patients, we’ve had them now following for 14 years and more. The morbidity and mortality of atherosclerosis is very significant. If a patient walks into your office and says, “Doc, I got chest pain and every time I walk” and you know he’s got angina, you’re going to send him to the ER. When a patient walks in and says, Doc, I walk half a block and my leg hurts and I have to stop that’s intermittent claudication. The two patients have the same morbidity and mortality rates because the one with the claudication also dies from a heart attack and/or a stroke. The one thing I tell podiatrist is put your hand on the foot. If you don’t feel a strong, viable, normal limb, send him to endovascular specialist for basic evaluation. Don’t feel a pulse, send him. If you look at their foot and it doesn’t look healthy, send him before you start cutting or doing anything else because, especially with diabetes we’ll talk about that, the underlying disease is very compelling and also very silent. It will just bring up on you. The mortality of somebody with severe large vessel PAD, the fact, 10 year survival is only 25%. So, asymptomatic, it can be also very, very bad. Lot of recent advances, I’m routinely treating plantar vessels, planter arch, opening those vessels. I can get them from the radial artery, I can get them from the femoral artery, I can get them from the popliteal artery, and the peel vessels. In the old days, 80% of surgeons who are vascular surgeons now do endovascular work. Of those 80% is endovascular first. In fact, they are lamenting, the surgeons that there might not be anybody around to do open bypass anymore. Long-standing occlusions, not a problem. Long occlusions from top to bottom, not a problem, all kinds of different tools that have come into play in terms of opening up vessels. In the past, this was considered closely impossible, now, I’m routinely opening up lateral and medial plantar branches. I look at the angios. I’m aware the blood is coming from. Very aggressive follow-up, every three months they’re in my office, I check for vascular flow, make sure everything is good, measure the skin perfusion pressure because if there isn’t enough oxygen to the skin, that wound is not going to heal. You can put all the biologics you want. If there’s no oxygen there, how’s it going to heal? And the oxygen gets there by the blood. The other thing is that 50% of PAD is asymptomatic. So you have somebody who walks in the office, got podiatric problems, nothing apparent about PAD, so you got to look for some signs which we’ll talk about in a second. It can be acute or chronic. Acute is very easy to catch because all of a sudden they will prompt the screening, the leg is ischemic. It’s the chronic, it’s very silent, it’s very slowly developing, it’s where you need to catch it. When we look at patients from wound care centers, 50 plus percent have an underlying PAD and a lot of it was not recognized and that’s kind of where we have the problem. If they’re diabetic, that’s the silent killer. Ten to 20% of the world’s population is becoming diabetic. It’s a diet. All the carbs everywhere, all the sugar everywhere and that is starting to cause where we have multivessel disease, small vessel causing a arteriopathy that is silent and then all of a sudden, you’re looking at somebody with an amputation.
The third enemy there is there is calcium. You see a diabetic then go vascular. You see calcium on an x-ray, think of vascular. And it’s not going to hurt you especially if you partner with somebody in your community where they will check it and help you avoid the problem. And calcium goes very unrecognized, which is a problem even on angiograms as actually underlying x-ray. We’ve recognized calcium and with that, we’ve been able to modify the vessel and actually open vessels up and keep them open for a long time. We have intravascular ultrasound, all of this now being done in an office setting. I have one office that I share with the podiatrist that I have a vascular cath lab right in the next office, next door, and I see those patients and within a week, went from pulseless to bounding pulse in the foot. All these technologies are now available outpatient and it’s simple. It makes it better, it makes it faster, also makes it cheaper for the insurance companies. If you’re going to be part of an ACO and IPA and alternative payment model that’s where this will come into play again and you keep him out of the hospital. Diabetes, severe renal disease, vasospastic, smoking tobacco, all these cause more problems. We have started now for several years to look at the skin perfusion and what the perfusion pressure is and we look at the angiosome, which area is being provided blood by which vessel. I could have a pulse in my dorsalis pedis, but the wound could be on the posterior tibial angiosome. So that’s what we focus on and vice-verse. We can see patients who have a pulse in the posterior tibial, but they have on the anterior part of the foot a wound on the greater toe, I know I have to open the anterior tibial artery and there could be blockages there. And I’ll show you that in a second. So we measure the skin perfusion pressure to see how much oxygenation is going up to the tissue and follow it. When you look at an x-ray of the foot, you see calcium. You can’t feel a pulse, think vascular and send them out there. And sometimes even if you feel a pulse and the ABI is normal, but you have wound that’s not healing, they may have a diabetes especially pedal arch problems that we can now get a wire down there and open it up. Again, done outpatient and time is issue. The longer you wait, the worse it gets. How do you know they have PAD? Diabetic, more than 10 years, think of vascular. Most asymptomatic, so they’re not going to tell you, I have a vascular problem. Over 60 years as they get older, we start seeing, this is silent and we catch it. But if they’re smoker, especially heavy smokers, more than a pack a day, even beyond 50, you start catching them. See a wound in the leg, which you see a lot of, if they tell you I walk a short distance and I have to stop, my calf cramps up, foot cramps up or I have pain at night and it wakes me up. And anybody who you think is at risk, you want to avoid it. It’s become the standard of care and if you land up in a lawsuit situation, now this is published that have you had a vascular exam. You can do this in the office. I do vascular ultrasounds and tests in the podiatrist office. I share office space with them, their patients, they put them on my schedule. Our ultrasound tech goes in, we look at it. It’s a win-win deal for both of us and we look at how can we fix the plumbing quickly. So we want to create a viable long-term option for keeping the blood flowing and as I repeat what’s the angiosome, where’s the issue coming? This would have been a definite amputation a few years ago. With this kind of blockage, what are we going to do and here it is, it’s open. And this is just one example to show you that anterior tibial, that was the angiosome. That’s what we’re fixing. Lot of new technologies because if it’s heavy calcium, different kind of stents, I can literally do an endoluminal femoropopliteal bypass, the lasers, the tools, how do we make it cost effective and bring it into play. Bottom line, surgery is not the goal standard anymore for this. One, nobody should get an amputation without an angiogram. Two, bypass is not the first option, in fact, a very few surgeons now do bypasses. And I have not seen a single femdistal bypass in the last five years being done. It’s not the state of the art anymore and also the standard of care. And obviously, you always look at and it’s one of my all-time favorite slides is trying to escape out of prison and here’s a cesspool that is bright. So be careful what you’re digging yourself out of. As I said, we can get access from just about any site or different kind of tools that we have. We even have covered stents that allow us to do an endoluminal femoropopliteal bypass. So this is from inside a catheter, under an hour procedure.
I’ve had patients who are patent 14 years with this kind of stuff. We also have diabetic renal failure on dialysis, very heavy calcium. In the past, we could never keep them open, now we can. This is the one I was telling you about the patient who had the podiatric work and now he has a black toe. This was all silent. There’s an occlusion in the common femoral artery here. We’ve actually gone in from the other side. And we’re actually going to do a orbital atherectomy. This is a device spinning at hundred thousand RPM. It grinds down the calcium. This would have been open surgery earlier, we do an angioplasty. The whole angioplasty is occluded. That would have been a femoropopliteal bypass. At the same sitting, I’ve been able to get into the blood vessel, open that, so I’m getting the wire down. This is plumbing as its best and we’re getting through. I have to get back into the true lumen here. I pushed my way through, but I’m not connecting to the true lumen just yet. We have all devices, we all love toys. So we have devices to see how can I get into this true lumen and, remember, this is a 3.5 millimeter, 4 millimeter vessel and this device has a needle in it that I can actually poke into the lumen, but I’m not getting in. Now I get into the popliteal artery with ultrasound right there. I’m going to go backwards, go up, push a wire through that same occlusion and connect up. I have a catheter there and I get my one wire from below into that and now I’ve got kind of a wire from a floss from the right one common femoral artery, the left into the left popliteal artery and that’s what I’m doing here, connecting these two with the wire, these two dots and getting a wire across. Now I’ve got a railroad from the common femoral artery and I’m not going to go there, angioplasty that. I’ve done the atherectomy already and then what I’m actually going to do is put some stents and you’ll see how the vessel pops open. On the x-ray there, you see I got the wire in, I’ve got a catheter all the way down in the popliteal artery. Now from a patent lumen to a patent lumen, I’ve got a wire going through. I’m going to do an angioplasty here, you can see long balloons. Now we have drug-coated balloons that will help keep it open for a long time. And you can see the flow is already better, but not good enough. So I use a bigger balloon and now I’m putting these stents. And these stents mimic the artery. So they are called mimetic. As we deploy this, and the technology just keeps getting better. So what’s in the horizon is a bioabsorbable stent like this. You put in the stent, it slowly absorbs itself. Over three years, all the stent material is gone. There’s no metal anymore and what you have left is that the artery is open. The future on that is going to be bioabsorbable with drug on it. That’s going to prevent the vessel from shutting down again. Now when you see the angiogram, you will see that this whole blood vessel is now kept open with the scaffolding and that’s the flow now compared to where you had complete occlusion before. This patient as you can see has now got a patent superficial femoral artery, common femoral artery, and a three-vessel bypass to the foot. And this is the one that I described to you where the toe was blackened. All of this was silent. The patient didn’t say anything to the podiatrist that they had a vascular problem. This podiatrist now has a different office, sends me any patient he has any doubt. Don’t feel the pulse, they show up in the office and we are now checking that vascular. Then more importantly is after the procedure is done, I can put a stitch in the artery through a catheter. So within the hour, I have them walking after this whole procedure. Anticoagulation, platelet, aspirin, whatever else we can add to this and they stay open. We follow them every three months at the very least. Another lady, 75-year-old, she’s already had a left BKA. She’s not looking at a right BKA and she’s got a wound and podiatrist sent her to the vascular surgeon. The iliac is occluded. I can’t do anything. She doesn’t want to a bypass, doesn’t want an amputation. This is her angiogram. So she’s diabetic, hypertensive, already had a BKA, right great toe ulcer. I’m getting into the popliteal artery on the right, she is prone on the ultrasound, I’m getting into that artery. From here, I get a wire through and I’m getting through the blockage that’s in the common femoral and the SFA.
Opened it all the way through, you see calcium up there. Now I’m doing all of this from the popliteal artery. And then we’re doing atherectomy from there, so I’m basically spinning down that calcium. The calcium become smaller than a red cell particle and is basically washed away. Once I’ve done that and I can see I’ve got the common femoral open, but it’s still a little narrow, so I’m going to put in a stent here from the popliteal again. You can see now the common femoral is wide open. Then I got to work on the superficial femoral because I need to have straight flow going down. I’ve done the atherectomy there. It looks irregular. The bottom line with this is, I need it open for as long as the patient will live. So what technology can I use? And now you can see I’ve got some stents there and that’s what that vessel looks like. This patient is now following up with me almost the third year I believe and no amputation. She’s following up with the podiatrist. She’s diabetic, she needs foot care and she’s been following with him now for the last three years. Now if she had had an amputation, she probably wouldn’t be alive today. Same here, you can see now in the foot, this vessel occlusion and you can see here after treatment, open. These are all outpatient procedures now, done in the office, follow-up to healing. Another example, bad disease here, bad disease here, bad disease here, no flow into the foot, and you can see, you can’t do much in this foot if there’s no blood going down there. After we’ve opened that wound, healing. So this is state of the art now, this is standard of practice. If you have a patient who shows up and you’re not considering vascular, underlying vascular problems and they land up with an amputation and they sue you, you’re going to have an attorney come up to you and say, “Why didn’t you do this.” So win-win all around and coming up with a good partnership get great results, think of the plumbing, work together and it’s silent. So, team up with an endovascular specialist in your area of practice. Thank you very much indeed.
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