27/02/2018

1

Wondzorg bij arteriëlewonden

Prof Dr Randon C , MD , PhD

Dienst Thoracale en Vasculaire Heelkunde

UZ Gent

1

27/02/2018 Indeling

�Claudicatio intermittens of etalage benen (pijn bij stappen)

�Acute kritische lidmaat ischemie (koud been )

�Chronische kritische lidmaat ischemie (rustpijn , nachtelijke pijn , evt ulcus / necrose) (> 14d)

Bedreigd been

2

Classificatie volgens Fontaine

� Stadium 1: asymptomatisch

� Stadium 2A: milde claudicatio (>250M)

� Stadium 2B: ernstige claudicatio (<250M)

� Stadium 3: ischemische rustpijn , nachtelijke pijn

� Stadium 4: ulceratie of gangreen Chron KLI

• CLI= critical limb ischemia of kritische lidmaat ischemie

Classificatie volgens Rutherford

4

27/02/2018

2

2 tot 3% mannen en 1 tot 2% vrouwen > 60j (in werkelijkheid X4)

1 op 4 patienten operatie noodzakelijk

< 10% mineure amputatie bij KLI

1 à 2 % majeure amputatie (diabetes 21%) bij KLI

30% coronair lijden

15 à 25% cerebraal lijden

1 op 3 ptn dood binnen 5 j (vasculaire of niet vasculaire oorzaak)

Epidemiologie

5

Epidemiologie

�na 10 jaar : 95% amputatie bij patiënten met ulcera of gangreen (Fontaine graad IV)

60% overlijden bij patiënten met rustpijn (Fontaine graad III)

6

Niveau claudicatio

� Thv de voet : occlusie thv a poplitea of lager

� Thv de kuit : occlusie/ stenose a fem superficialis

� Thv de dij : occlusie/stenose a fem comm of art iliaca externa

� Thv de bil (gluteaal) : occlusie/stenose a iliaca comm , aorta

Erectiele dysfunctie door stenosen/occlusies van beide art iliaca interna

Sensiebele dysfunctie !!!! (diabetische neuropathie)

7

�Chronische wonde

�Probleem angiogenese in wondheling

Arterieel ulcus

8

27/02/2018

3

Oorzaak niet genezen van arterieel ulcus

� Macro angiopathie = large - vessel disease

� Micro angiopathie = small - vessel disease

� Mönckebergse sclerosis = media calcificatie (diabetes)

Oorzaken arterieel ulcus

�Perifeer vaatlijden (atherosclerose)

�Vasculitis (Buerger)

�Diabetes mellitus

�Renaal falen

�Hoge RR (Martorell ulcus)

�Arterieel trauma

�Embolisatie / trombose

10

27/02/2018

12

27/02/2018

4

Risicofactoren

� Man

� 60-70j

� Roker

� Hypercholesterolemie

� Arteriële hypertensie

� Ischemisch harlijden , nierinsufficiëntie

� Diabetes mellitus

� TIA of CVA

� Obesitas

� Familiaal

� Verschillende vaatingrepen

� Hematologisch (hypercoagulabiliteit , homocysteine , …)

Anamnese

Symptomatologie = pijn !!!!!!!!!!!!!!!!!!!!!

�Aard pijn (bij stappen / in rust)

�Ernst en loopafstand

�Duur symptomen , evolutie

�Relatie met inspanning

�Lokalisatie letsels / pijn (niveau)

15

Claudicatio klachten

�Verminderde afstand wandelen

�Moeheid

�Been uit bed hangen

�Nachtelijke pijn

�Pulsaties

�ABI

16

27/02/2018

5

Arterieel ulcus

�Punched out beeld

�Goed afgelijnde wondranden

�Geen bloeding wondbodem

�Weinig tot geen exsudaat

�Pijnlijk

�Diep (fascia , bot)

�Droge huid

�Kalknagels

�Haargroei ↘

17

Veneus ulcus

18

19 20

27/02/2018

6

21

Classificatie arteriële wonde : Wifi

22

Arterieel ulcus : onderzoeken

�Pulsaties

�Enkel-arm index (vaak niet comprimeerbare distale vaten)

�Test van Buerger

�Capillaire refill

�Duplex

�Angio : CT , MR , Klassiek , CO2

23

Palpatie

24

27/02/2018

7

Buerger: test

25

Capillaire vultest

= capillaire refill: het opnieuw vullen met bloed van leeg gedrukte haarvaten

26

Doppler-onderzoek + enkel-arm index

�! niet comprimeerbaar omwille van verkalkte vaten bij diabetici

�Aanwezigheid van dopplersignalen # afwezigheid stenosen

27 28

27/02/2018

8

29 30

31

Afwezige pulsaties

Arteriële duplex aanvragen

32

27/02/2018

9

Technische onderzoekingen

� Arteriële duplex (echo + doppler)

� Angiografie

� conventionele contrast angio

� MRI angio met gadolinium (ambulant)

� CO2 angio zo slechte nierfunctie

� CT angio

Behandeling

Ischemische wonde of gangreen

�1e keuze : vaatheelkunde

�TIME IS TISSUE

�Behandeling van risicofactoren

Nooit arterieel ulcus debrideren alvorens oorzaak behandeld is

35

Medische therapie

� Rookstop

� Behandeling arteriële hypertensie

� Behandeling hypercholesterolemie (statines)Stabilisatie plaque

↓ cardiovasculaire mortaliteit

� Dieet

� Staptherapie

� Behandeling diabetes

� Plaatjesremmers (aspirine , clopidogrel)↑ patency

↓ hart en cerebrovasculair problemen

27/02/2018

10

38

Welke revascularisatie?

39

Behandeling

�Doel: herstel van de directe bloedvoorziening naar de voet

Endovasculaire

behandeling

1ste keuze , minimaal invasief

Chirurgische

behandeling

Bypass met eigen VSM of

donorsafena

40

27/02/2018

11

Endovasculaire therapie

� PTA of percutane transluminele angioplastie

� Verwijden van het lumen door ruptuur van de plaque met dilatatie ballon

� Gebruik contrast

� Minimaal invasief

� Evt stent

� Evt thrombolyse

Welke revascularisatie?

43

Endovasculair vs open chirurgie

Three-Year Outcomes of Surgical Versus Endovascular Revascularization for

Critical Limb Ischemia: The SPINACH Study (Surgical Reconstruction Versus

Peripheral Intervention in Patients With Critical Limb Ischemia)

The 3-year amputation-free survival was not different between surgical

reconstruction and EVT in the overall CLI population. The subsequent interaction

analysis suggested that there would be a subgroup more suited for surgical

reconstruction and another benefiting more from EVT

44 Circ Cardiovasc Interv. 2017 Dec;10(12

27/02/2018

12

Endovasculair vs open chirurgie

�Endovascular tibial intervention is associated with poorer primary patency but similar secondary patency and wound healing rates compared with the “gold standard” of surgical bypass to a pedal target. In patients with tibial arterial disease, endovascular intervention should be considered a lower risk alternative to pedal bypass that provides similar clinical outcomes.

45 46

Femoropopliteale bypass

47 48

•Published2016inJournal of the American College of Cardiology

27/02/2018

13

Gecombineerde revascularisatie en vrije flap transfer

49 50

� Geintroduceerd in 1987 door Taylor en Palmer

� 3 dimensionale vasculaire regios bevloeid door bepaalde art en vene

≠ dermatomen

� Veel gebruikt in plastische heelkunde voor flappen

� Recentelijk geintroduceerd in de vaatheelkunde voor heling van diabetische

ulcera

Angiosomen

51

Angiosomen

A tib post

A tib ant

52

27/02/2018

14

Angiosoom concept

53 54

55

Pedale access (Tami techniek)

56

27/02/2018

15

Meta-analysen angiosoom concept

�Betere wondheling met rechtstreekse revascularisatie zowel bij open als bijendovasculaire procedures

�Betere limb salvage rates bij rechtstreekse revascularisatie maar niet significant

�Geen verschil in mortaliteit of re-interventie ratio

�Probleem : wondes vaak in verschillende angiosomen

57

Indien geen vasculaire behandeling mogelijk (12m FU)

�Mortaliteit 22% (CI12%-33%)

�Majeure amputatie 22% (CI, 2%-42%)

�Wonde toename 35% (CI, 10%-62%)

�21%?

58

J Vasc Surg 2015;62:1642-51

Risico factoren “niet genezen” arteriële ulcera

�Glycemie ontregeling

�Perifere neuropathie

�Roken

�Voetafwijkingen

�Callus of eelt

�Vaatlijden

�Voorgeschiedenis wonde

�Amputatie

�Visus afwijkingen

�Nierlijden (vnl dialyse)

59

60

Despite the increase in revascularizations, of the roughly 500 to 1000

new cases of critical limb ischemia (CLI) per million population per

year in industrialized countries, an estimated 20% to 40% are not

suitable for arterial reconstruction or have failed revascularization

27/02/2018

16

Prostin?

�We found high-quality evidence showing that prostanoids have no effect on the incidence of total amputations when compared against placebo. Moderate-quality evidence showed small beneficial effects of prostanoids for rest-pain relief and ulcer healing when compared with placebo. Additionally, moderate-quality evidence showed a greater incidence of adverse effects with the use of prostanoids, and low-quality evidence suggests that prostanoids have no effect on cardiovascular mortality when compared with placebo. None of the included studies reported quality of life measurements. The balance between benefits and harms associated with use of prostanoids in patients with critical limb ischaemia with no chance of reconstructive intervention is uncertain; therefore careful assessment of therapeutic alternatives should be considered. Main reasons for downgrading the quality of evidence were high risk of attrition bias and imprecision of effect estimates.

61

Cochrane Database Syst Rev. 2018 Jan 10;1:CD006544. doi: 10.1002/14651858.CD006544.pub3. [Epub ahead of print]

Prostanoids for critical limb ischaemia.

Vietto V1, Franco JV, Saenz V, Cytryn D, Chas J, Ciapponi A

Lokale wondzorg bij arteriële ulcera

�Chlorhexidine-impregnated dressings�Effective in reducing vascular and epidural catheter bacterial colonization (evidence Level A)

�Use is associated with fewer adverse effects on wound healing (evidence Level C)

�Iodine: Available as povidine-iodine and second generation dextranomer and cadexomer�Reduces bacterial load, decreases infection rates and promotes healing (evidence Level C)

�Antibiotics are indicated in cases of overt wound infection where the classical signs of infection are evident (evidence Level C).

62Indian Dermatol Online J. 2014 Jul-Sep; 5(3): 400–407

Lokale wondzorg bij arteriële ulcera

�Bacteriological swabbing is unnecessary unless there is evidence of clinical infections such as inflammation, redness, cellulitis, increased pain, purulent exudates, rapid deterioration of the ulcer, pyrexia, and foul odor (evidence Level B)

�Cleaning of an ulcer is recommended using simple irrigation with either normal saline compresses or plain tap water (evidence Level E)

�Dressing technique should be clean and aimed at preventing cross-infection (evidence Level E).

�Surgical debridement is most appropriate in wounds with large amounts of necrosis and eschar, but must be undertaken by specialist.

63

Lokale wondzorg bij arteriële ulcera :dressings

�Chronic ulcer management requires the use of the wound dressings that provide the optimal “moist” environment. Dressing should be simple, low or nonadherent, low cost and acceptable to the patient (evidence Level A)

�No single dressing material is favored (evidence Level C).

�Use of granulocyte macrophage colony-stimulating factor

�The topical and peri-lesional injections of granulocyte macrophage colony-stimulating factor (GM-CSF) promotes healing of leg ulcers and is safe (evidence Level B).

64

27/02/2018

17

Lokale wondzorg bij arteriële ulcera

�Compression therapy�Recommendations are for graduated, multi-layered high compression system with adequate

padding should be the first line of treatment for uncomplicated venous leg ulcers with ABPI ≥0.8 in all settings (evidence Level A).

�Washing for about 10 min twice a day is optimal. Water just above body temperature is most desirable, and more natural the emollient soap, more supportive it is of the epidermis (evidence Level E)

Indian Dermatol Online J. 2014 Jul-Sep; 5(3): 400–40765

Cochrane 2015: Dressings and topical agents for arterial leg ulcers

�Besluit:�One trial met the inclusion criteria, which was a small trial that compared 2% ketanserin

ointment in polyethylene glycol (PEG) with vehicle alone (PEG) control, changed twice a day in 40 participants with arterial leg ulcers.

�The overall quality of the evidence was low with a single small included study which showed inadequate reporting of the results and had too short a follow-up time (eight weeks) to be able to capture sufficient healing events to allow comparisons to be made. In addition, the study was of low methodological quality.

66

Tissue Infection Moisture EdgeHydrogel Purilon®

Intrasitegel®

Flamigel

Autolytic debridement Rehydration Granulation

Sugar pasta Flower sugar +

Isobetadine demicum®

Osmotic debridement Antibacterial Absorption Granulation

Epithelialization

Honey Activon®

L-Mesitran®

Osmotic debridement Antibacterial Absorption Granulation

Epithelialization

Collagenase ointment Iruxol®

Novuxol®

Enzymatic debridement

Foam dressing Biatain®

Mepilex®

Absorption protective

Granulation

Epithelialization

Hydrofiber Aquacel®

Exufiber®

Absorption Granulation

Epithelialization

Silver dressing Aquacel Ag®

Mepilex Ag®

Biatain Ag®

Antibacterial moisturizing

Absorption

Silver alginate pasta Askina Calgitrol® Antibacterial Rehydration Granulation

Epithelialization

Hydrogel with alginate Flaminal hydro®

Flaminal forte®

Enzymatic debridement Limited antibacterial: biofilm

Absorption

Granulation

Epithelialization

Alginates Kaltostat®

Biatain alginaat®

Absorption Granulation

Epithelialization

Povidone-iodine Isobetadinegel®

Braunoltulle ®

Antibacterial Granulation

67 68

27/02/2018

18

69 70