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Dr. R.

Suhartono, SpB(K)V
TTL : Jakarta/ 25 Desember 1962
Alamat : Pulomas Timur II No.120. RT001/012 Kel. Kayu Putih, Kelapa Gading
Telp : 08158751962

S-1 FKUI 1982 1988


Pendidikan Dokter

S-2 Pendidikan Dokter Spesialis Ilmu Bedah Ilmu Bedah FKUI 1991 1996
FKUI
Pendidikan Trainee Divisi Vaskuler dan RSCM 1996 2000
Endovaskuler FKUI/RSCM

Staf RSU Tanjung Selor Bulungan RSU Tanjung Selor 1989 1991
Bulungan Kalimantan Timur
Staf RSU Bangkinang Pekanbaru, Riau 1997 -2000
Anggota PESBEVI (Perhimpunan okter Divisi Vaskuler dan Endovaskuler FKUI/ 2000 - sekarang
Spesialis Vaskuler dan Endovaskuler RSCM
Indonesia)
Ketua PESBEVI (Perhimpunan okter Divisi Vaskuler dan Endovaskuler FKUI/ 2010 - 2015
Spesialis Vaskuler dan Endovaskuler RSCM
Indonesia)
Staf Divisi Vaskuler RSCM Jakarta 2001 - Sekarang
Direktur operasional Ambulance Gawat 118 2000 - 2010
Darurat 118
Ketua Yayasan Ambulance Gawat Darurat 118 2010 sekarang
118
Presidium IKABI 2015-Sekarang
Vascular Problems
in DiabePc Foot
R. Suhartono
Vascular and Endovascular Surgeon
Cipto Mangunkusumo Hospital/
Faculty of Medicine University of Indonesia
Rule of 15

DiabeOc foot ulcer precipitate 85% of amputaOon

15% of diabetes paOents will have foot ulcer in lifeOme


15% of foot ulcers are followed by osteomyeliOs
15% of foot ulcers will end with foot amputaOon

Clinical Care of DiabeOc Foot, 2005


Rule of 50

50% of amputaOons are major amputaOons


50% of paOents will have 2nd amputaOons in 5y
50% of paOents will die in 5y

Clinical Care of DiabeOc Foot, 2005


DiabePc Foot
PaPents CharacterisPc

Age (61-70yo, yet in Indonesia mostly were


51-60yo)
Helpless
Lack of sanitary and medical care
MulOple drugs therapy
Financial diculOes
O^en had undergone an amputaOon
Steps to have Successful DiabePc
Foot Treatment in Your PracPce

TheoreOcal background
Epidemiological & economical background
AdaptaOon to real life situaOon
InnovaOon
The Primary Goals of
RevascularizaPon

Relieve ischemic pain


Heal (neuro)ischemic ulcers
Prevent limb loss
Improve paOent funcOon & quality of life &
prolong survival
What Kind of
RevascularizaPon?

Open or Endovascular ?
Arterial lesion based ?
Targeted ulcer related arterial lesion ?
Open or Endovascular?

The determinaOon of the best method of


revascularizaOon is based upon the balance
between risk of a specic intervenOon and the
degree and durability of the improvement
that can be expected from this intervenOon
Which vessel are frequently
involved in DiabePc Foot ?

Femoro-popliteal or SFA lesion (less common)

Below the knee 90%


Anterior Obia artery
Posterior Obia artery
Peroneal artery (this is the artery that in most
cases remains patent & the last of the three crural
artery to occlude
What do you need to expect in
BTK lesion?

2/3 of BTK lesion are occlusions


1/2 of lesion are occlusions > 10 cm
Short lesion are not represented
ContraindicaPon for
BTK intervenPon

Complete trifurcaOon occlusion


No distal run-o at pedal level
Dense calcicaOons lesion
Endovascular
Equipment & Strategy
0.018 compaOble/3-3.5F catheter; some balloon dedicated
for BTK have good crossing prole, good guide wire support
0.014 compaOble/2-3F catheter; very low crossing prole,
slightly poorer guide wire support
Long sheath
Re-entry catheter
Hydrophilic coaOng wire at 1-2mm out of the catheter
amempt to advance this set as one piece set through the
occluded segment
Use alternaOve technique if the lesion is dicult to pass
antegrade
Is there any place for
Stents in BTK?

SOll extremely rare despite good trials result

Moderate success of angioplasty result


Residual stenosis more than 30 40%
Flow limiOng dissecOon (in appropriate
angiosome vessel)
Concern for BTK intervenPon

Treatment of long segmental lesion


Limb salvage is important yet it is not equal to
angiography result
IniOally try to target appropriate angiosome

We can expect a successful DSA, but clinically is


rather hard addiOonal work and some lomery
Our Experiences
SFA Angioplasty
Our Experiences
BTK Angioplasty
Open Surgery
Femoral popliteal bypass Femoral Pbial bypass
Vascular ReconstrucPon
Open Surgery
Other Problems

Nowadays, despite progress in


revascularizaOon, we are facing new complex
problems:
Mixed diseases (DM, CHD, PAOD, renal failure,
etc)
Very old or very young paOents
LoS & Cost for DFU in UK
LoS & Cost in USA & Indonesia
USA : Length of stay in USA:
$ 9-13 billion in total 10.1 days
$ 102 - 188,645 per case
Length of stay in
Indonesia (RSCM) : Indonesia:
IDR 20 143 billion per 2013 : 8 76 days
case 2014 : 12 60 days
DiabePc Foot Ulcer (DFU) PaPents
in Cipto Mangunkusumo Hospital,
a TerPary Health Care Center
data was divided into 2 part
due to dierent government health care policy in Indonesia
July December 2013 : ASKES/GAKIN/JAMKESMAS
January June 2014 : BPJS
PaPents Demograpic
60 40 37
51 35
46 35
50 29 <40 yo
30
40 35 33 41-50 yo
25 21 51-60 yo
30 20
Male 61-70 yo
20 15 13
Female >70 yo
10 7 8
10
4 5 4
0 5
July-Dec Jan-June 0
2013(86 2014 (79 July-Dec Jan-June
pts) pts) 2013 2014
Blood Glucose Control

67
July-Dec 2013
12

Uncontroled
Controled
54
Jan-June 2014
22

0 10 20 30 40 50 60 70 80
Albumin Level

57
July-Dec 2013
25

< 3
> 3
58
Jan-June 2014
21

0 10 20 30 40 50 60 70
InfecPon in DiabePc Foot
July - December 2013 January - June 2014
6, 7%
12,
15%

80, 67,
93% 85%

Non-infected Non-infected
Wound Wound
Surgical IntervenPon
Bypass Bypass
femoro femoro Minor
Minor
femoral femoral Amput
Amput
, 1, 2% aOon,
, 2, 3% aOon, Major
Amput
16, 20%
21, aOon,
29% 6, 7%

Redebri Major
dement Amput Redebri
, 44, aOon, dement
61% 6, 8% , 57,
70% January - July 2014
July - December 2013
Endovascular IntervenPon
25

20
20

15
SFA
10 BTK
10
5
5

3
0
July-Dec 2013 (13 pts) Jan-June 2014 (25 pts)
Total IntervenOon : 38 paOents
Length of Stay
July December 2013:
Mean 35 days
Minimum 8 days, maximum 76 days

January June 2014:
Mean 30 days
Minimum 12 days, maximum 60 days
Summary

DiabeOc foot problems in Indonesia:


High infecOon incidence
Younger paOents
Poor metabolic control of blood glucose level &
albumin
Longer length of stay
Tindakan endovaskular lain
Venogra dan venoplasO
EVAR
TEVAR Thoracal Endovascular aorOc
repair
Embolisasi pada kasus avm
Stenosis vena yang dilakukan
venoplasty pasca av shunt
Pseudo aneurisma pasca trauma
Pemasangan IVC lter
Embolisasi pada trauma ginjal