E.J. Wylie Traveling Fellowship Report

2017-2018

Christopher J. Abularrage, MD
The Johns Hopkins Hospital
Baltimore, Maryland

The treatment of lower extremity peripheral arterial disease has always been a passion for me. I was first introduced to limb salvage by my mentors, Dr. Tony Sidawy and Dr. Richard Neville, while training at Georgetown University. I was immediately drawn to both the intellectual decision making, as well as the technical nature of both open and endovascular revascularizations. This passion further developed over my Vascular Surgery fellowship at The Massachusetts General Hospital.

Upon my arrival to The Johns Hopkins Hospital in 2010, lower extremity limb salvage took on a new meaning. Being in the heart of Baltimore, MD, the majority of my patients with chronic limb threatening ischemia suffered from Diabetes and socioeconomic deprivation.  Initially, fragmented and compartmentalized Diabetic foot care resulted in poor outcomes, increased lengths of hospital stay, and patient frustration at both perceived and clinically significant delays in implementation of care. We created our Multidisciplinary Diabetic Foot & Wound Service in response to this lack of continuity of care.

It was this background that led me to further explore Diabetic vascular anatomy and microcirculatory dysfunction, theories on angiosomal perfusion, and multidisciplinary models of healthcare delivery. And, it was this exploration that identified centers of excellence in Europe that I would visit as part of the E.J. Wylie Traveling Fellowship. Prior to applying for the Fellowship, I contacted specific European leaders in the field of Diabetic limb salvage and was immediately received with enthusiasm, which I knew would allow me to foster ties with those who specialized in endovascular techniques aimed at infrainguinal revascularizations, and the multidisciplinary care of patients with Diabetic foot disease.

I began my travels by visiting Dr. Romain Schockmel at the Centre Hospitalier Emile Mayrisch in Esch-sur-Alzette, Luxembourg. Dr. Schockmel was a principal investigator for the Angiosome Concept Pre-Study. During my visit, I was able to scrub with Dr. Schockmel in multiple cases for below-the-knee (BTK) revascularizations. I learned more about his antegrade approach for pedal arch alpha-loop angioplasty, including specific wire recanalization techniques. We discussed indications, risks/benefits and complications of BTK and, particularly, pedal arch recanalization. We also touched upon his thoughts regarding angiosome-directed revascularizations. Given my recent focus on direct revascularizations, we concentrated on the need for such procedures and how it relates to wound care. I was able to spend time discussing different wound care therapies and how they perform in the context of impaired microcirculation and structural pathology. We learned that, while many of the techniques that we employ are different, the overlying premise to Diabetic limb salvage is the same. Thus, everything that I learned would be applicable once I returned home.

While in Luxembourg, I also met with members of the Luxembourg Vascular Surgical Society and the German Society for Vascular Surgery and Vascular Medicine. We discussed limitations to BTK revascularizations, both anatomic and technological. We discussed advanced platforms used in Europe that are not currently available in the US, and how those technologies still do not completely address long-term patency of tibial interventions. However, these roundtables did provide insight into my current practice allowing me to already make changes to the techniques I use in BTK interventions.

From Luxembourg, I traveled to meet Dr. Vladamir Alexandrescu at the Princesse Paola Hopital located in Marche-en-Famenne, Belgium. Dr. Alexandrescu is a pioneer of the application of the angiosome concept to Diabetic limb salvage. He has also performed extensive research on techniques to evaluate post-BTK intervention changes in perfusion.

I was also able to participate in multiple BTK revascularizations with Dr. Alexandrescu. He was able to show me new techniques for interventions of chronically occluded tibial vessels. We also discussed the importance of angiosome directed revascularizations as a way to specifically improve microcirculatory dysfunction. We also discussed, at length, the varying definitions of what a "direct" revascularization can mean. He introduced me to his new idea of "wound­ directed" revascularization, taking into account collateral size and number.

While in Marche, I also participated in a Work-Shop Vasculaire which discussed the emerging idea of "Fast-Track" Diabetic foot care delivery.  While many of tenets for "Fast-Track" care are similar to the current model we use at Johns Hopkins, there were multiple advances that he taught me about that I will bring back to Baltimore and implement within our Limb Preservation Service.

I have learned many things during my traveling fellowship. I have learned new techniques and new ways to think about Diabetic vascular disease. Furthermore, the knowledge that I have gained has allowed me to transform the way that I teach our medical students, residents and vascular surgery fellows about revascularization, limb preservation and multidisciplinary care.

I cannot thank the SVS Foundation and the Research & Education Committee enough for awarding me the E.J. Wylie Traveling Fellowship and allowing me the opportunity to collaborate with these great surgeons. I truly believe that this award not only fostered collaborations that will last my entire career, but that this award will benefit me, my patients, and my SVS colleagues for years to come.