The Current State of Critical Limb...
Transcript of The Current State of Critical Limb...
![Page 1: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/1.jpg)
Endovascular Treatment versus Open Surgical Bypass: What Is the “BEST”
Revascularization Option?
Matthew Menard, MD
Brigham and Women’s Hospital
![Page 2: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/2.jpg)
DISCLOSURE
Matthew Mell, MD
• No relevant financial relationship reported
![Page 3: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/3.jpg)
Revascularization Options
• Open Vascular Surgery
• Endovascular Therapy
• Hybrid procedures
![Page 4: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/4.jpg)
![Page 5: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/5.jpg)
J Vasc Surg 2015; 62:965-73
27 centers
![Page 6: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/6.jpg)
J Vasc Surg 2015; 62:965-73
Initial revascularization for CLI
- Critisch Registry: 45% bypass
- Recent VQI Data: 40% bypass
(N= 38,470)
![Page 7: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/7.jpg)
![Page 8: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/8.jpg)
Relevant questions
• Is Endovascular-first a valid strategy?
– For All Comers?
• What about surgery-first?
![Page 9: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/9.jpg)
Amputation free survival Overall survival
Primary bypass
AFS and OS worse after secondary bypass for failed PBA
Outcomes after primary bypass and
secondary bypass after failed PBA in BASIL-1
Primary bypass
Secondary bypass Secondary bypass
P = 0.04 P = 0.06
D20%D17%
![Page 10: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/10.jpg)
Eur J Vasc Endovasc Surg (2019) 57, 382e391
![Page 11: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/11.jpg)
30-Day Amputation & Graft Occlusion
![Page 12: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/12.jpg)
Primary Patency & Secondary Patency
![Page 13: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/13.jpg)
Data is compelling
• There is no free lunch!
• Emboli
• Thrombosis, with loss of domain
• Altered bypass targets
• Lost time – sometimes you have one chance
to get it right
• Everyone likes to think they’re not that guy/gal!
• Newsflash: You’re not not that guy/gal
![Page 14: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/14.jpg)
Data is compelling
• This is not an anti-endo message
• Rather a… Use endo and open
sensibly and rationally message
![Page 15: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/15.jpg)
Goals of PAD Treatment
• Improve limb perfusion
– Restore ambulatory function
– Relieve pain
– Heal wounds
– Preserve a functional limb
– Maintain ambulatory status
Hirsch AT et al. J Am Coll Cardiol 2006;47:1239-131 Conte MS and Farber A. BJS 2015;102:1007-1009
![Page 16: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/16.jpg)
General mantra
Old, frail, surgical high risk → Endo
Young, healthy, good vein → Open
![Page 17: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/17.jpg)
Relevant Domains
Anatomy
LimbPatient
![Page 18: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/18.jpg)
Patient Factors
• Ambulatory Status
• Age, comorbidities
• Estimated life expectancy
• Prior vascular interventions
Risk Stratification Models
![Page 19: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/19.jpg)
WFVS
Risk stratification tools
![Page 20: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/20.jpg)
PIII risk category predicts survival
Causey MW et al J Vasc Surg 2016; 63:1563-73.c
![Page 21: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/21.jpg)
Limb Factors
Rutherford →
![Page 23: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/23.jpg)
Society for Vascular Surgery Lower Extremity Threatened Limb Classification: WIfI Index
• Wound: extent and depth• Ischemia: perfusion/flow• Foot Infection: presence and extent
![Page 24: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/24.jpg)
SVS Lower Extremity Threatened Limb Classification - WIfI Index
• Wound: extent and depth
• Ischemia: perfusion/flow
• foot Infection: presence and extent
![Page 25: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/25.jpg)
Anatomical Factors
• Extent of occlusive disease• Location of disease• Lesion length• Size of treated artery• Degree of calcification• Quality of runoff• Quality of target• Availability of good vein• Angiosome
Anatomic Classification Schemas
![Page 26: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/26.jpg)
TASC
![Page 27: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/27.jpg)
WFVS
Global Vascular Guideline for the
Management of Chronic Limb-Threatening
Ischemia
Michael S. Conte MD, Andrew W. Bradbury MBA, MD, FRCS
Philippe Kolh MD, PhD (Co-Editors)
![Page 28: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/28.jpg)
GLASS*: Assumptions and Approach
WFVS
• Focus on Infrainguinal Disease (SFA origin to foot)
• Clinician defines the primary Target Artery Path (TAP)
• Femoro-popliteal (FP) and Infra-popliteal (IP) segments separately graded (0-4), then combined into Three GLASS Stages for the limb (I-III)
• Infra-malleolar (pedal) disease graded; used as a modifier only
• Calcification graded as Severe or not; simplified system
• *Global Limb Anatomic Staging System
![Page 29: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/29.jpg)
Vascular Bypass
Vascular Bypass
➢ Traditional, “gold standard” treatment➢ Excellent, durable results➢ Long follow up periods available
➢ Invasive➢ Significant morbidity➢ Blood loss➢ Wound complications➢ Technically demanding
![Page 30: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/30.jpg)
“It’s all about the vein”
![Page 31: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/31.jpg)
Schanzer AS et al J Vasc Surg 2007;46:1180-90
Influence of Vein Quality
![Page 32: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/32.jpg)
5-year
Primary
Graft
Patency
5-year
Secondary
Graft
Patency
5-year
Limb
Salvage
Taylor et al.(JVS 1990)
80% 84% 90%
Shah et al.(Ann Surg 1995)
72% 81% 95%
Greater Saphenous Vein
![Page 33: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/33.jpg)
Endovascular Modalities
![Page 34: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/34.jpg)
Endovascular Treatment Options for PAD
➢ Plain Balloon Angioplasty (PTA)➢ Stenting➢ Atherectomy➢ Laser assisted PTA➢ Brachytherapy➢ Stent grafts➢ Drug eluting stents➢ Drug coated balloons➢ Bioabsorbable stents➢ Lithoplasty➢ ………
![Page 35: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/35.jpg)
![Page 36: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/36.jpg)
![Page 37: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/37.jpg)
Benefits of Endovascular Therapy
➢ Minimally invasive➢ No incisions!
➢ No general anesthesia
➢ No hospitalization➢ Can be done in office setting!
➢ Financial incentives
➢ Reduced morbidity
➢ Reduced mortality
![Page 38: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/38.jpg)
SFA-Popliteal DCB Trials6-month Late Lumen Loss in SFA-Popliteal DEB Trials
J Lammer LINC 2014
![Page 39: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/39.jpg)
64.1%
83.4%
10 Patency: Provisional Zilver PTX vs. BMS
Dake MD, et al. Circulation. 2016;133:1472-1483.
72.4%
![Page 40: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/40.jpg)
Three-Year Outcomes; The SPINACH Study
Lida et al., 2017, Circ Cardiovasc Interv. 2017 Dec; 10(12): e005531.
•3-year amputation-free survival was not different between surgical reconstruction and endovascular
therapy in the overall CLI population.
![Page 41: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/41.jpg)
CRITISCH REGISTRY
Bisdas et al. J Vasc Surg 2015 Oct;62(4):965-973
➢ 27 Sites
➢ 1200 patients
Study Design
![Page 42: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/42.jpg)
Amputation-free survivalMatched populations
Bypass:72%
Endo:75%
Statistical significantnon-inferiority of endovascular
versus bypass surgery(at 2.5% level of significance)
Bisdas et al. JACC Cardiovasc Interv 2016
![Page 43: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/43.jpg)
• “Durability of ..(endovascular revascularization)… decreases with greater lesion length, occlusion rather than stenosis, presence of multiple and diffuse lesions, (and) poor quality runoff...”
Circulation 2017
![Page 44: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/44.jpg)
Scenarios when I favor surgical bypass
• TASC C and D
• Prior endo failure • “Bad actors”
• Really need good, sustained flow!•Rest pain
•Heel ulcer
• Lots of tissue loss
![Page 45: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/45.jpg)
Scenarios when I might favor endovascular
• Prohibitive groin
• Obese leg
• Extensive venous disease
• Redo bypass scenario – really don’t want to operate (e.g. densely scarred targets)
• Truly no vein (i.e. you actually looked!)
![Page 46: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/46.jpg)
Health Care Spending as Share of GDP, 1980-2013
![Page 47: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/47.jpg)
Which FIRST Revascularization
Option in CLI Has the BEST Value?
VS
Bypass
Surgery
(LEB)
Endovascular
Therapy (Endo)
![Page 48: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/48.jpg)
Enrollment Update – May 22, 2019
▪ 1,716 subjects randomized (82%)
![Page 49: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/49.jpg)
Case Presentation
• 86 y.o. F with debilitating BL rest pain
• CABG: 2/2017
![Page 50: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/50.jpg)
Case Presentation
• PE:•Slightly diminished femoral pulses•Non-palpable BL popliteal, distal pulses
• ABIs: .31/.35
• TBIs: 0/0
![Page 51: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/51.jpg)
![Page 52: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/52.jpg)
![Page 53: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/53.jpg)
![Page 54: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/54.jpg)
![Page 55: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/55.jpg)
![Page 56: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/56.jpg)
Conclusions
• Open surgical bypass and endovascular therapy are COMPLIMENTARY modalities.
• Learn to do both really well
![Page 57: The Current State of Critical Limb Ischemiapnec-seattle.org/.../uploads/2019/05/2-PNEC-Open-vs-Endo-2019-Me… · Matthew Menard, MD Brigham and Women’s Hospital. DISCLOSURE Matthew](https://reader034.fdocuments.net/reader034/viewer/2022050213/5f5f947b4162f04fb029040b/html5/thumbnails/57.jpg)
Robert Linton, M.D
• “Do the right thing”
• “Do it right”