Contemporary critical limb ischemia: Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care
The burden of peripheral artery disease (PAD) and diabetes in Asia is projected to increase. Asia also has the highest incidence and prevalence of end-stage renal disease (ESRD) in the world. Therefore, most Asian patients with PAD might have diabetic PAD or ESRD-related PAD. Given these pandemic conditions, critical limb ischemia (CLI) with diabetes or ESRD, the most advanced and challenging subset of PAD, is an emerging public health issue in Asian countries. Given that diabetic and ESRD-related CLI have complex pathophysiology that involve arterial insufficiency, bacterial infection, neuropathy, and foot deformity, a coordinated approach that involves endovascular therapy and wound care is vital. Recently, there is increasing interaction among cardiologists, vascular surgeons, radiologists, orthopedic surgeons, and plastic surgeons beyond specialty and country boundaries in Asia. This article is intended to share practical Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care for CLI.
KeywordsPeripheral artery disease Interdisciplinary Collaboration Ischemia Bacterial infection Foot deformity
The beginning of collaboration between endovascular and wound care specialists in Asia
Appropriate diagnosis of critical limb ischemia (CLI) has been underappreciated. Although endovascular therapy has evolved around the world during the last decade, the endovascular community in both developed and developing Asian countries has distinct variations in clinical practice frameworks, device availability, regulations, and reimbursement. Consequently, there is a broad spectrum in maturity or dominancy of the endovascular specialty among cardiologists, vascular surgeons, and radiologists by county. In parallel with advancements in endovascular therapy, awareness of the importance of wound management still remains underdeveloped. Thus, dissemination of comprehensive approaches in different disciplines for treatment of CLI is urgently needed.
In 2010, the first meeting of the Endovascular Asia (formerly, Bay Area Endovascular Summit) took place as a grassroots forum for interaction between cardiologists, vascular surgeons, radiologists, orthopedic surgeons, plastic surgeons, vascular nurses, wound care nurses, vascular ultrasonography technologists, and clinical engineering technologists beyond national boundaries to appreciate the need for multidisciplinary practice and harmonize endovascular therapy and wound care. During Endovascular Asia 2017 in Osaka, the first Asian CLI meeting session called CLI Asia was convened on December 2, 2017, to generate Asian multidisciplinary expert consensus on the essential diagnostic and treatment strategy with participation by endovascular and wound specialists from Japan, Taiwan, South Korea, Hong Kong, India, Singapore, Thailand, and Malaysia. This article is intended to share the practical consensus statement based on the collaboration between endovascular therapy and wound care beyond specialty and country borders that reflect discussions at that meeting.
An emerging framework for critical limb ischemia in Asia
Assessment of the microcirculation and differential diagnosis
Building a multidisciplinary team for infected neuroischemic wounds
Close follow-up for timely reintervention and debridement
Regular serial evaluation of the wound and microcirculation after revascularization until complete wound healing can facilitate early identification of wound worsening and timely clinically driven reintervention and debridement. Judging from the Japanese clinical experience, SPP evaluation or a similar technique on the day after the procedure, 2–3 days later, 7 days later, 1 month later, and every month thereafter might be a reasonable routine schedule . In cases of unfavorable wound conditions (e.g., wound color, speed of granulation), temporary evaluation for severity of ischemia and infectious wound is recommended. Also, even if foot microcirculation is preserved, a couple of times of debridement or minor amputation might be needed to remove residual necrotic or infectious tissue and to control recurrence of infection in the wound until complete wound healing.
Practical endovascular strategies
Rationale for endovascular therapy
With the rapid evolution of endovascular techniques and technologies, the role of endovascular therapy for atherosclerotic CLI is expanding based on operators’ expectations of procedural success, risk of complications, patency rate, and potential of extensive reocclusion than before. Approximately, half of patients with CLI have multisegment disease with aortoiliac artery disease approximately in 20%, femoropopliteal artery disease approximately in 50%, and infrapopliteal artery disease in over 90% . Aortoiliac intervention is durable, whereas femoropopliteal intervention is developing and infrapopliteal intervention remains underdeveloped [4, 35]. Ischemic tissue loss needs much more blood flow to heal than to resolve ischemic rest pain or to prevent recurrence of tissue loss. Since complete wound healing takes 3–6 months on average, endovascular therapy with liberal clinical-driven reintervention is acceptable on a clinical basis even if patency after endovascular intervention is short lived [9, 10, 36].
Reintervention is technically straightforward in most cases, and multiple reinterventions for recurrence of critical ischemia may be carried out as required until complete wound healing [4, 9]. Although the need for multiple reinterventions is common, when frequent repeat intervention is needed in a short period, shifting treatment toward surgical options can be considered if vascular surgeons proficient with bypass surgery are available and the patient can tolerate general anesthesia and bypass surgery with a good vein conduit. Also, endovascular therapy might be a last resort with symptomatic bypass occlusion in patients undergoing primary bypass surgery  and can serve as a bridge therapy to bypass surgery after the achievement of infection control.
Although there is a tremendous advancement of procedural success of endovascular therapy, some experts might consider hybrid therapy with endovascular therapy and bypass surgery for complex lesions. In cases of common femoral artery disease involvement, hybrid therapy consisting of endovascular therapy and endarterectomy can be considered although percutaneous common femoral angioplasty might be technically feasible and durable in the short term [38, 39, 40, 41].
Establishment of one straight-line flow with infrapopliteal intervention
As many as possible strategy
Controversy over the angiosome
When to do below-the-ankle intervention
Awareness of anatomical variants for endovascular therapy
Increasing awareness of lower limb artery anatomical variations can improve patient care. Although a persistent sciatic artery is a well-recognized anatomical variant in the suprapopliteal artery segment, variants in the popliteal artery branching pattern consisting of aplasty or hypoplasty of the tibial artery, a high takeoff for the tibioperoneal artery, trifurcation, and anterior tibioperoneal trunk are also not uncommon . Given that approximately 10% of infrapopliteal arteries have variants, with the type 3A variant characterized by an aplastic posterior tibial artery and a hypertrophied peroneal artery connected to the plantar artery being the most common, differentiating occlusion from anatomical variation is a challenging task in severe infrapopliteal artery disease. When an infrapopliteal variant is observed in one extremity, there is a 28–50% probability of the same pattern on the other side. Keeping in mind the possibility of underlying infrapopliteal variations is the key to their successful identification and outcomes [62, 63, 64].
Amid a pandemic of PAD with diabetes and ESRD in Asia, endovascular therapy represents a paradigm shift in the treatment of CLI. However, from a clinical perspective, a comprehensive patient-oriented approach, rather than a one-size-fits-all approach, is the key to clinical success. Therefore, harmonization of revascularization and wound management into a coordinated multidisciplinary approach that goes beyond a specialty-based framework is vital for the treatment of CLI.
This article was supported in part by Endovascular Asia, a nonprofit physician education and research meeting.
Compliance with ethical standards
Conflict of interest
Osami Kawarada reports honorarium for lectures and advisory board fees from Boston Scientific Corporation, honorarium for lectures and research grants from Terumo, and a consultancy fee from Medtronic. Hsuan-Li Huang reports honorarium for lectures from Boston Scientific and Medtronic. Testuya Nakama reports honorarium for lectures from Abbott Vascular, Boston Scientific, and Medtronic and consulting fee from Boston Scientific and Century Medical Inc. Naoki Fujimura reports consulting fee from W.L. Gore and Associates. Bryan Ping-Yen Yan reports honorarium for lectures from Boston Scientific Corporation, Cook Medical, and Medtronic, research grants from Medtronic and Boston Scientific Corporation, and consultancy fee from Medtronic and Cook Medical. Robbie K George reports honorariums for/consultancy agreements with Medtronic Corporation, Bard Corporation, Cook Medical, and Abbot Vascular. Kan Zen, Shinobu Aayabe, Donghoon Choi, Su Hong Kim, Jiyoun Kim, Taku Kato, Yoshinori Tsubakimoto, Shigeo Ichihashi, Akihiro Higashimori, Masahiko Fujihara, Tomoyasu Sato, Skyi Yin-Chun Pang, Chumpol Wongwanit, Yew Pung Leong, Benjamin Chua, Yoshiaki Yokoi, Hisashi Motomura, and Hideaki Obara report no conflict of interest.
- 21.Suzuki K. How to diagnose peripheral arterial disease. Podiatry Today. 2007;4:54–65.Google Scholar
- 28.Kawarada O. Nonatherosclerotic peripheral artery disease. In: Yokoi Y, editor. Angiography and endovascular therapy for peripheral artery disease. London: InTech; 2017. p. 127–50.Google Scholar
- 32.Mills JL, Conte MS, Armstrong DG, Society for Vascular Surgery Lower Extremity Guidelines Committee, et al. The Society for vascular surgery lower extremity threatened limb classification system: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2014;59:220–34.CrossRefPubMedGoogle Scholar
- 33.Ayabe S. Strategy for diabetic foot wound management in Japan: AID concept. The 3rd conference of Association of Diabetic Foot Surgeons; Venice. 2017.Google Scholar
- 34.Snyder RJ, Kirsner RS, Warriner RA 3rd, et al. Consensus recommendations on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes. Ostomy Wound Manag. 2010;56(4 Suppl):S1–24.Google Scholar
- 38.Bonvini RF, Rastan A, Sixt S, Noory E, Schwarz T, Frank U, Roffi M, Dorsaz PA, Schwarzwälder U, Bürgelin K, Macharzina R, Zeller T. Endovascular treatment of common femoral artery disease: medium-term outcomes of 360 consecutive procedures. J Am Coll Cardiol. 2011;58:792–8.CrossRefPubMedGoogle Scholar
- 44.Ichihashi S, Sato T, Iwakoshi S, et al. Technique of percutaneous direct needle puncture of calcified plaque in the superficial femoral artery or tibial artery to facilitate balloon catheter passage and balloon dilation of calcified lesions. J Vasc Interv Radiol. 2014;25:784–8.CrossRefPubMedGoogle Scholar
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