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Interventional radiology should be the initial course of management in diabetic PVD

This debate explores the effectiveness of interventional radiology as the first line of management in diabetic peripheral vascular disease (PVD), discussing advantages, limb factors, patient factors, and vascular evaluation. Are angioplasty procedures a valid and efficient alternative to surgery? Let's find out.

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Interventional radiology should be the initial course of management in diabetic PVD

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  1. Interventional radiology should be the initial course of management in diabetic PVD ABCD Debate 12-11-04 Malcolm Simms opposing the motion

  2. The Motion Absurd oversimplification or Valid generalisation

  3. Just a prick

  4. Annual reconstructions for lower limb ischaemia- MS 1990-2003

  5. Annual arteriography SOH 1990-2002

  6. The shift from surgery PTA  SIA Pre Post Pre Post

  7. Advantages of angioplasty • Quick to do • Short stay • Complications ~ 20%(4) • Success ~ 80% • Repeatable • Surgery still feasible • Durability mirrors life expectancy

  8. Durability of SIA in Diabetic PVD(nb excludes initial 19% technical failure)

  9. Survival in CLI (pooled)

  10. If it’s that simple, why not cut out the (surgical) middleman?

  11. Patient Factors- • Psychological • Social/Family • Physical function • Metabolic • Nutritional • Anaesthetic status

  12. Limb Factors- • Mobility (nerves, muscles, joints) • Sensation • Sepsis (sup. & deep) • Viability • Arteries (occlusion & calcification) • Veins (sup. & deep)

  13. Limb Factors- • Mobility (nerves, muscles, joints) • Sensation • Sepsis (sup. & deep) • Viability • Arteries (occlusion & calcification) • Veins (sup. & deep)

  14. Limb Factors- • Mobility (nerves, muscles, joints) • Sensation • Sepsis (sup. & deep) • Viability • Arteries (occlusion & calcification) • Veins (sup. & deep)

  15. Limb Factors- • Mobility (nerves, muscles, joints) • Sensation • Sepsis (sup. & deep) • Viability • Arteries (occlusion & calcification) • Veins (sup. & deep)

  16. Limb Factors- • Mobility (nerves, muscles, joints) • Sensation • Sepsis (sup. & deep) • Viability • Arteries (occlusion & calcification) • Veins (sup. & deep)

  17. Limb Factors- • Mobility (nerves, muscles, joints) • Sensation • Sepsis (sup. & deep) • Viability • Arteries (occlusion & calcification) • Veins (sup. & deep)

  18. Vascular evaluation pre-angio • Clinical- pulses/perfusion/skin • Venous reflux/ulcers • ABPI (?) • Pole test • Doppler mapping • Pedal arch patency • Duplex imaging

  19. Vascular evaluation pre-angio • Clinical- pulses/perfusion/skin • Venous reflux/ulcers • ABPI (?) • Pole test • Doppler mapping • Pedal arch patency • Duplex imaging

  20. Vascular evaluation pre-angio • Clinical- pulses/perfusion/skin • Venous reflux/ulcers • ABPI (?) • Pole test • Doppler mapping • Pedal arch patency • Duplex imaging

  21. Vascular evaluation pre-angio • Clinical- pulses/perfusion/skin • Venous reflux/ulcers • ABPI (?) • Pole test • Doppler mapping • Pedal arch patency • Duplex imaging

  22. Vascular evaluation pre-angio • Clinical- pulses/perfusion/skin • Venous reflux/ulcers • ABPI (?) • Pole test • Doppler mapping • Pedal arch patency • Duplex imaging

  23. Vascular evaluation pre-angio • Clinical- pulses/perfusion/skin • Venous reflux/ulcers • ABPI (?) • Pole test • Doppler mapping • Pedal arch patency • Duplex imaging

  24. Vascular evaluation pre-angio • Clinical- pulses/perfusion/skin • Venous reflux/ulcers • ABPI (?) • Pole test • Doppler mapping • Pedal arch patency • Duplex imaging

  25. Current SOH practice- Angioplasty:Surgery 3:1-When to operate? 100 grafts 2000-2002 Failed angioplasty - 8 Occlusion foot - 8 Popliteal aneurysm - 5 Acute thrombosis - 3 Failure of old graft - 23 Inflow/CFA occlusion - 30 Surgery “obligatory” - 64 “optional” - 36*

  26. Current SOH practice- Angioplasty:Surgery 3:1-When to operate? 100 grafts 2000-2002 Failed angioplasty - 8 Occlusion foot - 8 Popliteal aneurysm - 5 Acute thrombosis - 3 Failure of old graft - 23 Inflow/CFA occlusion - 30 Surgery “obligatory” - 64 “optional” - 36*

  27. Current SOH practice- Angioplasty:Surgery 3:1-When to operate? 100 grafts 2000-2002 Failed angioplasty - 8 Occlusion foot - 8 Popliteal aneurysm - 5 Acute thrombosis - 3 Failure of old graft - 23 Inflow/CFA occlusion - 30 Surgery “obligatory” - 64 “optional” - 36*

  28. Current SOH practice- Angioplasty:Surgery 3:1-When to operate? 100 grafts 2000-2002 Failed angioplasty - 8 Occlusion foot - 8 Popliteal aneurysm - 5 Acute thrombosis - 3 Failure of old graft - 23 Inflow/CFA occlusion - 30 Surgery “obligatory” - 64 “optional” - 36*

  29. Current SOH practice- Angioplasty:Surgery 3:1-When to operate? 100 grafts 2000-2002 Failed angioplasty - 8 Occlusion foot - 8 Popliteal aneurysm - 5 Acute thrombosis - 3 Failure of old graft - 23 Inflow/CFA occlusion - 30 Surgery “obligatory” - 64 “optional” - 36*

  30. Current SOH practice- Angioplasty:Surgery 3:1-When to operate? 100 grafts 2000-2002 Failed angioplasty - 8 Occlusion foot - 8 Popliteal aneurysm - 5 Acute thrombosis - 3 Failure of old graft - 23 Inflow/CFA occlusion - 30 Surgery “obligatory” - 64 “optional” - 36*

  31. Current SOH practice- Angioplasty:Surgery 3:1-When to operate? 100 grafts 2000-2002 Failed angioplasty - 8 Occlusion foot - 8 Popliteal aneurysm - 5 Acute thrombosis - 3 Failure of old graft - 23 Inflow/CFA occlusion - 30 Surgery “obligatory” - 64 _______ Surgery “optional” - 36* (nb BASIL awaited)

  32. Advantages of surgery • Adapts to Anatomy • Compatible with LA • Quality perfusion • Durability

  33. Advantages of surgery • Adapts to Anatomy • Compatible with LA • Quality perfusion • Durability

  34. Advantages of surgery • Adapts to Anatomy • Compatible with LA • Quality perfusion • Durability

  35. Advantages of surgery • Adapts to Anatomy • Compatible with LA • Quality perfusion • Durability

  36. Advantages of surgery • Adapts to Anatomy • Compatible with LA • Quality perfusion • Durability

  37. Advantages of surgery • Adapts to Anatomy • Compatible with LA • Quality perfusion • Durability

  38. Advantages of surgery • Adapts to Anatomy • Compatible with LA • Quality perfusion • Durability

  39. Advantages of surgery • Adapts to Anatomy • Compatible with LA • Quality perfusion • Durability

  40. Advantages of surgery • Adapts to Anatomy • Compatible with LA • Quality perfusion • Durability (65% pat. at 1y, few late failures) Acquired snydactyly- 12y post fem-tib

  41. Reasons for surgical nihilism….. • Steep and prolonged learning curve • Operating time • Microvascular training • No margin for error • Anaesthetic morbidity • High revision rate Enthusiasm essential!

  42. Angioplasty favoured Short or single level block Limited ulcer/gangrene but Poor rehabilitation and survival prospects Surgery favoured Multi-level block Extensive necrosis but Good rehabilitation potential Multidisciplinary approach essential when therapeutic options unclear

  43. Support your local vascular surgeon-Reject the motion!

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