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Assoc. Prof. Vinko Vidjak, MD, PhD , Medical School Zagreb

Annual Meeting of the TSIR, Antalya , 11-13 March 2016. Importance of forming Centers for diabetic foot. Assoc. Prof. Vinko Vidjak, MD, PhD , Medical School Zagreb Clinical Department for Diagnostic and Interventional Radiology Clinical Hospital Merkur Zagreb, Croatia.

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Assoc. Prof. Vinko Vidjak, MD, PhD , Medical School Zagreb

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  1. Annual Meeting of the TSIR, Antalya,11-13 March 2016. Importance of forming Centers for diabetic foot Assoc. Prof. Vinko Vidjak, MD, PhD, Medical School Zagreb Clinical Department for Diagnostic and Interventional Radiology Clinical Hospital Merkur Zagreb, Croatia

  2. Annual Meeting of the TSIR, Antalya,11-13 March 2016 • Disclosure • Speaker name: Vinko Vidjak • I have the following potential conflicts of interes to report: • consulting: Boston S • employment in industry • stockholder of a healthcare company(s) • owner of a healthcare company(s) • other(s) • I do not have any potential conflict of interest √

  3. Annual Meeting of the TSIR, Antalya,11-13 March 2016 DM is theleading cause of lower limb aputations worldwide 40% amputees die within 2 years

  4. Annual Meeting of the TSIR, Antalya,11-13 March 2016 • 315.900 adult pts in Croatia have DM (9,2%) • Annual expenditure DM treatment is 11,49%of the healthcare budget (2,5 billion HRK annually) • Average cost of treatment of 1 DM pt. / 1 year is 14.277,44 HRK • 85,72% of those costs are spent on the treatment of complications • Expected increase of DM pts (until 2030.) to 10,5% Novo Nordisk Croatia 2010 Inhabitants: 4.3 mill Complication type Cost HRK % PAD 379.266.00 14.77% Diabetic foot 155.104.00 6.04% 85.72%is spent of the treatment of complications Novo Nordisk Croatia 2010

  5. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Slavonija, Baranja andwest Srijem 891.279 ihabitants 80.214 DM patients courtesy Silvija Canecki-Varžić, dr.med

  6. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Chronic complications – CHC OsijekStructure of direct costs Izvor: Canecki-Varžić S, Miljković G. Prijedlog projekta Regionalni centar za endokrinologiju, dijabetes i bolesti metabolizma u dvorcu Batory, 2011;podaci KBC Osijek, cijene HZZO, srednja vrijednost pojedinih zahvata courtesy Silvija Canecki-Varžić, dr.med

  7. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Diabetic foot The rate of amputation in diabetic patients in the Osijek - Baranja County Amputation 9.62 / 1000 patient / 1g 9-16x higher than in the UK courtesy Silvija Canecki-Varžić, dr.med

  8. Annual Meeting of the TSIR, Antalya,11-13 March 2016 ??????? “...85% of amputation can be prevented by earlydetection & appropriate treatment”! D.Scheinart LINZ 2013

  9. Annual Meeting of the TSIR, Antalya,11-13 March 2016 - Dedicated BTK (endovascular) procedures are performed at 7 centers in Croatia - only in 5-7 with skilled physicians 1 6 !!!!!!!! • In 2008. only 3% pts referred to IR consult • IR procedure in 0,7% hospital pts • DM pts protocol not using the PtcO2 machine 1 ?? institution treats all of DM peripher. vascular complications 1

  10. Annual Meeting of the TSIR, Antalya,11-13 March 2016 MSCT angiography COLOR DUPLEX US MR angiography

  11. Annual Meeting of the TSIR, Antalya,11-13 March 2016 System of care Interdisciplinary apr. - care specialist: podiatrists, surgeons, internal medicine, physicians), invasivevascularphysicians (interventionalcardiologists, interventionalradiologists, vascularsurgenons),…

  12. Annual Meeting of the TSIR, Antalya,11-13 March 2016 IR Interventional Quarter ISSUE- 2009 Cooperationin the field of diabetic foot: EASD – EuropeanAssociationfor the Study ofDiabetes CIRSE – CardiovascularandInterventionalRadiologicalSocietyofEurope …both disciplines regarding the ability to treat DM complications …exploring possible future treatment options …guest lectures …guidelines revision …educationalprograms

  13. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Concept - DFC ItalianDiabeticFoot Care Network courtesy dr Marco Manzi

  14. Annual Meeting of the TSIR, Antalya,11-13 March 2016

  15. Annual Meeting of the TSIR, Antalya,11-13 March 2016 How to choose appropriate revascularizationtreatment for the patient with PAD ( “endo first” or “open first” ) PATIENT SELECTION • Best revascularizationoption is suggestedby TASC classification • (TransAtlantic InterSocietal Consensus on Peripheral Arterial Occlusive Disease) • 2000- TASC • 2007- TASC II • TASC revision..

  16. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Extensive Angioplasty in the treatment of ischaemic diabetic foot ulcers: clinical results of a Multicentric Study of 221 consecutive diabetic subject Faglia E. et al.: Journal of Internal Medicine 2002 Extensive Angioplasty in the Treatment of Ischemic Diabetic Foot Ulcers Multicentric trial, 191 patients with DF-ulcers and PAD • In 94,2% angioplasty of infrapopliteal arteries major amputation rate 5,2 % • Clinical follow-up mean 14 ± 7 months recurrent foot-ulcers in 7,9%

  17. Annual Meeting of the TSIR, Antalya,11-13 March 2016 PATIENT SELECTION • Interventional procedures are the first treatments proposed for most PAD patients. • PAD could be treated with endovascular interventions: • From 1998 to 2007 endovascular interventions quadrupled for CLI and doubled for claudication. • In the same period significant reduction in amputations occuredalthough patients had significantly more comorbidities.* • *Egorova NN. Et al. An analysis of the outcomes of a decade experience with lower extremity revascularisation including limb salvage, lenghts of stay and safety.J Vasc Surg. 2010. 51(4):878-85.

  18. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Minimally invasive methods of treatment Bioapsorbable stent Long term patency of below- the- knee arteries Drug eluting stents (DES) Bare stents Drug eluting ballons (DEB) Angioplasty (PTA)

  19. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Revascularization of a Specific Angiosome for Limb Salvage: Does the Target Artery Matter? Neville RF et al. Ann Vasc Surg 2009 Specific angiosome revascularization Direct revascularization (= bypass to the artery directly feeding the ischemic angiosome) of the angiosome specific to the anatomy of the nonhealing wound leads to: - A higher rate of limb salvage and healing

  20. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Angiosomes 6.day 15.day 60.day 75.day 45.day courtesy dr Marco Manzi

  21. Annual Meeting of the TSIR, Antalya,11-13 March 2016 The rate of amputation in diabetic patients in the Osijek - Baranja County Amputation 9.62 / 1000 patient / 1g 9-16x higher than in the UK • In 2008. only 3% ptsreferred to IR consult • IR procedure in 0,7% hospitalpts • DM ptsprotocolnotusingthe PtcO2 machine institution treats all of DM peripher. vascular complications Cooperationin the field of diabetic foot: EASD – EuropeanAssociationfor the Study ofDiabetes CIRSE – CardiovascularandInterventionalRadiologicalSocietyofEurope

  22. Annual Meeting of the TSIR, Antalya,11-13 March 2016 • Clinical Hospital Merkur • Educational base of the School od Medicine • WHO referral transplant center • Croatian education center for IR 2010. twohospitalsmergedandDiabeticFootClinicis formed Clinic for Metabolismdiseasesand DM Educational base oftheSchool od Medicine Croatianreferralcenter for DM WHO partner institution for DMl

  23. Annual Meeting of the TSIR, Antalya,11-13 March 2016 FormationofDiabetic Foot Clinic-DFCcovers Complications prevention Earlier diagnosis of stenotic and occluded arteries Better DM (vascular)complications treatment Reducednumber of amputations Bettermultidiscipline cooperation Reductionof treatment costs Patientinformation

  24. Annual Meeting of the TSIR, Antalya,11-13 March 2016 ClinicalHospital Merkur • General surgery • Vascularsurgery • Invasivecardiology • Non-invasive X-R diagnostics • Invasiveradiology • Physicaltherapy FormationofDiabetic Foot Clinic-DFCcovers Clinic for Metabolismdiseasesand DM DM ptspoliclinic Angioclinic Internal medicine supportin DM treatment Clinicaldepartmentwith 25 beds, 5 ofthose for DFC

  25. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Need for: regular interdisciplinary meetings to analyze complex cases and treatment strategies revascularization team: diabetologist, general surgeon, vascular surgeon, interventional radiologist reconstruction team: diabetologist, vascular surgeon, plassurgeon!, orthopaedist! meeting of regulardaily team: diabetologist, nurse, physical therapist Goals - benefit-damage ratio of each type of treatment - revascularization of at least one below-the-knee artery to the foot - reperfusion and sanation of open wounds - more important to achieve clinical reperfusion than morphological Conceptof DFC

  26. Annual Meeting of the TSIR, Antalya,11-13 March 2016 PATIENT WITH DM AND VASCULAR COMPLICATIONS CLI ASYMP.; INTER. CLAUD PULS, ABI,, TcPO2, PULS, ABI,, TcPO2, PULSE OK, ATENUATED ABI <0.9 TcPO2>50 or 30-50 ABSENT PULSE 1 ili 2 sat ABI <0.9, TcPO2<50 mmHg ABSENT PULSE, TcPO2 < 40 mmHg, ABI<0.9 ANGIO (DSA) + PTA BYPASS, distal PTA post bypass COLOR DOPPLER CLEAR FINDING INCONCLUSIVE FINDING IF REVASCULARIZATION NOT POSSIBLE TcPO2 – revascularizationindication: >50 mmHg – goodtissueperfusion, notindication 31-50 mmHg – selectiveindication, claudications, ulceration <30 mmHg – definiteindication, criticalischaemia CLI TcPO2 <30-50mmHg Bulgarian Endovascular Course 2011

  27. Annual Meeting of the TSIR, Antalya,11-13 March 2016 PATIENT WITH DM AND VASCULAR COMPLICATIONS CLI ASYMP.; INTER. CLAUD COLOR DOPPLER ANGIO (DSA) + PTA BYPASS, distal PTA post bypass CLEAR FINDING INCONCLUSIVE FINDING IF REVASCULARIZATION NOT POSSIBLE 1xyear follow-up (6 mj?) Progresion of pain, lesion and infection Stable pain and lesion MSCT or MR ANGIO Kidney function? Calcifications AMPUTATION FOLLOW-UP REVASCULARIZATION MEDICAL TREATMENT Bulgarian Endovascular Course 2011

  28. Annual Meeting of the TSIR, Antalya,11-13 March 2016 At Clinical Hospital Merkur PAD, DMeland ? IR

  29. Annual Meeting of the TSIR, Antalya,11-13 March 2016 IR Therapy - IR subspecialization mentorship - Ambulatory IR consultations • IR experience • More than 800 angio therapeutic + diagnostic procedures anually • Treatment types: PAD (pta/stent), PTA/stent on other arteries, subintim rec., transpedal ap., CAS, EVAR, BTK, reocclusive techniques (mechanical, aspiration thrombectomy, JET st,.....), cutting balloon, DEB, embolisation, TIPSS, (thrombolysis), vein procedurs, billiary, urogenital, digestive interventions, CT guided drainage,....

  30. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Minimally invasive treatment • percutaneous transluminal angioplasty ( PTA) • drug eluting balloon (DEB) • bare stent • drug eluting stent (DES), - bioabsorbing stent • subintimal angioplasty • percutaneous end/arterectomy - cryoplasty • ”cutting balloon” • thrombectomy (mech., aspir.) • transpedal approach - laser recanalization

  31. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Optimal Tibial Recanalization - Angiosome Concept Opportunity for targeted therapy

  32. Annual Meeting of the TSIR, Antalya,11-13 March 2016

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  37. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Multilevel disease

  38. Annual Meeting of the TSIR, Antalya,11-13 March 2016 CLI Patients treated at our department from May 2010 - 2013 CLI Diabetic Patients Percentage of Diabetics Follow up on 34 PATIENTS SCHEDULED FOR AMPUTATION 56 34 / 56 60%

  39. Annual Meeting of the TSIR, Antalya,11-13 March 2016 husbad

  40. Annual Meeting of the TSIR, Antalya,11-13 March 2016 State administration's blind people Headsofradiologydepartments, doctors, administrationhospital

  41. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Conclusions : Taskof Db footCenter - Promotion of interdisciplinary approach in diabetic foot treatment - One place full service providing , to the patients with DM and chronic foot impairment - Good interdisciplinary cooperation - Treatment of complications and rehabilitation with the intent of preserving integrity of the extremities

  42. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Conclusions : Taskin Db footCenter IR -primary goal of CLItreatment - ↓ number (extent) of amputations) and preserving the functional status of the leg - to be qualified for providing of significant number of different minimally invasive procedures, if it would be indicated - angiosome aimed revascularization - keeppatency long enough for the ischaemic lesion to heal and pain to regress - “multilevel” disease (AFS+BTK) - simultaneousrevascularization

  43. Annual Meeting of the TSIR, Antalya,11-13 March 2016 Thank you for your attention!

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