CLIGLOBALThe Official Publication of the Critical Limb Ischemia Global Society Treating CLI During COVID-19 Webinar Presented by CLI Global Society Board Members LI Global Society President, Dr. Dr. van den Berg and other panelists Barry Katzen, from Miami, recently reported an anecdotal increase in ampu- Cmoderated an interactive panel dis- tation over the last weeks due to patients cussion with all nine Board Members of not seeking treatment for revasculariza- the CLI Global Society. Their discussion tion in a timely manner out of fear of on treating critical limb ischemia during contracting the COVID-19 virus. The COVID-19 was attended by 350 individu- panelists discussed how they would have als globally from five continents. proceeded with patient treatment at their Dr. Jos van den Berg started off the dis- respective institutions. cussion with a case of a patient who had Dr. Andrew Holden, from New presented to his institution in Lugano, Zealand, shared that his institution does Switzerland one day prior. A 70-year-old have the ability to test. However, such male with a history of diabetes, obesity, a case with no history of travel, known and CLI presented with ulceration of the exposure, and respiratory symptoms left forefoot with ischemia. His symptoms would be revascularized without testing had been present for several weeks but he and standard personal protective equip- had been avoiding a visit to the hospi- ment (PPE) would be utilized for staff tal outpatient clinic due to fear of the and the patient would be masked. With COVID-19 virus infection. The patient the presence of a fever, they would test did present with a fever, but no known and wait 6 hours for results prior to re- exposure or respiratory symptoms. The vascularization. Professor Thomas Zeller, fever was assumed to be attributed to from Germany, said his institution would the infected wound. The patient did have take an approach similar to the one Dr. sensory deficit. Following a negative Holden described. COVID-19 test the patient was revascu- Dr. Robert Lookstein, from New York larized immediately. CT angiography was City, reported that his institution would waived due to a GFR of 27. Continued on page 16 CLI in Europe: Are There Lessons to Be Learned? Jos C. van den Berg, MD, PhD Ospedale Regionale di Lugano, sede Civico, Lugano; University of Bern, Switzerland; Board Member, CLI Global Society CLI IS UNDERDIAGNOSED, disease. A more alarming statistic is that prevalence by 25%.7 Given these factors, it Classification Categories 4, 5, and 6, re- UNDERTREATED, AND DEADLY more than 50% of amputations occur can be estimated that between 1 million spectively.8 When an individual first re- Critical limb ischemia (CLI) is an un- without any prior vascular intervention and 3 million Americans have CLI.1 ceives a diagnosis of CLI, the mortality derdiagnosed and undertreated deadly in the year prior.4 Adding to the poor prognosis after di- risk is 24% over 1 year and 60% over 5 disease that requires proper diagnos- Efforts to estimate the true prevalence agnosis of CLI, patients with this disease years.9 Fewer diseases connote a higher tic imaging and increased awareness. of CLI in population studies are challeng- remain underserved with regard to diag- mortality rate. Among 22 different types Between 2000 and 2010, the world’s ing because the CLI diagnosis is clinically nostic evaluation, medical therapy, and of malignancy, only six have a 5-year population increased by 12.6%, and the established by a constellation of lower ex- utilization of revascularization.1 mortality rate higher than that of CLI.10 prevalence of peripheral arterial disease tremity features, including ischemic rest A study by the CLI Global Society (PAD) has increased twice as much over pain and non-healing ischemic wounds or NATURAL HISTORY OF CLI showed that mortality rates at 4 years this period.1 In the United States (US) gangrene, and requires the objective mea- A recent publication by Conte et al differed by Rutherford Class presen- and the European Union (EU), more surement of ankle or toe pressures. Few in the Journal of Vascular Surgery shows tation with 41% (Rutherford 4), 55% than 3.8 million patients suffer from CLI2 prior population-based studies have used that 12-month outcomes of patients (Rutherford 5), and 68% (Rutherford 6), and this number is expected to increase such symptom- and examination-based diagnosed with CLI are poor with a whereas major amputation rates at 4 years by 23% over the next 10 years.3 These clinical criteria to define CLI incidence 22% mortality rate and a 22% amputa- were 6% (Rutherford 4), 9% (Rutherford alarming statistics can be attributed to an or prevalence.5,6 Validation studies sug- tion rate. Amputation rates at 4 years as 5), and 30% (Rutherford 6).9 Overall, the explosion in the diagnosis of diabetes and gest that use of administrative codes for stratified by Rutherford classification are high incidence of CLI in combination decreasing mortality from cardiovascular CLI diagnosis may underestimate the true 12.1%, 35.3%, and 67.3% for Rutherford Continued on page 14 June 2020 DOWNGRADE THE LESION. UPGRADE THE OUTCOME. HawkOne™ Directional Atherectomy System Remove plaque and improve patency with directional atherectomy. From routine to complex cases, the HawkOne™ directional atherectomy system sets the stage for optimal DCB performance. The HawkOne™ system removes plaque, restoring blood flow and increasing the luminal surface area available for drug delivery. Pre-treatment Post Post HawkOne™ IN.PACT™ Admiral™ Directional Drug-Coated Balloon Atherectomy Images courtesy of Syed Hussain, MD, Christie Clinic, Vein and Vascular Care Center To learn more visit Medtronic.com/hawkone Indications, contraindications, warnings and instructions for use can be found in the product labeling supplied with each device. CAUTION: Federal (USA) law restricts this device to sale by or on the order of a physician. Medtronic directional atherectomy products are contraindicated for use in patients with in-stent restenosis. Aortic | Peripheral | endoVenous Orders UC201903644EN © 2019 Medtronic. All 3033 Campus Drive, N550 Tel: +1.763.514.8510 rights reserved. Medtronic, Medtronic logo Plymouth, MN 55441 Toll free: +1.800.716.6700 and Further, Together are trademarks of USA Fax: +1.877.697.4841 Medtronic. All other brands are trademarks Email: [email protected] of a Medtronic company. 02/19 24-hour Technical Support Toll free: +1.800.328.2518 CardioVascular LifeLine Customer Support medtronic.com/hawkoneGlobal Tel: +1.763.526.7890 Toll free: +1.877.526.7890 CLIGLOBAL 3 Treatment of Calcified Common and EDITORIAL J.A. MUSTAPHA, MD, FACC, FSCAI Clinical Editor Deep Femoral Arteries Advanced Cardiac & Vascular Centers for Amputation Prevention Grand Rapids, MI Michael S. Lee, MD, FACC, FSCAI Clinical Associate Professor of Medicine UCLA Medical Center, Los Angeles, California Michigan State University COM, East Lansing, MI ercutaneous vascular interven- Carson McGarrity, Publisher Carmen Heaney, Executive Editor tion (PVI) is a safe and effec- Rebecca Kapur, Managing Editor tive treatment option for symp- P Percutaneous vascular intervention of the Vic Geanopulos, Creative Director tomatic peripheral artery disease. The Elizabeth Vasil, Graphic Production ideal treatment strategy for common Manager femoral artery (CFA) disease is contro- deep femoral artery is uncommonly performed versial. Common femoral endarterecto- EDITORIAL CORRESPONDENCE: my (CFE) has been considered the stan- because angiographic complications may lead Laurie Gustafson, Executive Editor dard of care for over half a century given HMP / [email protected] to critical limb ischemia if it is the last remaining 70 East Swedesford Road, Suite 100 that the CFA is easily accessible surgical- Malvern, PA ly, technically feasible, and provides du- rable patency.1 However, CFE may not conduit to the lower limb. be a good option in some patients, es- SCIENTIFIC ADVISORY BOARD pecially if they have multiple comorbid- ities or are elderly.2 A large registry from GEORGE ADAMS, MD the National Surgical Quality Improve- territory to treat with PVI. Compared follow-up, there were no differences in Garner, NC ment Program database reported a 30- with CFE, PVI also provides the abil- sustained clinical improvement and the VICKIE R. DRIVER, DPM, MS day morbidity and mortality rate of 15%, ity to revascularize other vascular beds rates of primary patency, target lesion Boston, MA including a mortality rate of 3.4%.2 Sur- including the iliac and superficial femo- revascularization, and target extremity gery is also associated with infection and ral arteries. PVI of the CFA can be per- revascularization. LAWRENCE GARCIA, MD Boston, MA paresthesia. Furthermore, CFA disease formed via the radial or brachial artery There are several aspects of the CFA is commonly accompanied by involve- because of the proximal location of the which increase the technical complex- PHILIP P. GOODNEY, MD ment of the iliac or superficial femoral CFA, which decreases the risk of vascu- ity of PVI. Osteoid metaplasia, a mature Lebanon, NH arteries which are not revascularizable lar access complications and bleeding. In bone structure, was commonly observed ANDREW HOLDEN, MD during CFE. PVI represents an alterna- the TECCO trial, the stent group pro- in CFA disease.4 Severe calcification of Auckland, New Zealand tive for patients who do not want sur- vided lower rates of 30-day morbidity the CFA decreases the acute procedural