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  • Access siteNeuro
  • Thromboembolism-progressive occlusion
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Most IIa or Iib ischemiaHistory of claudication
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  • It was not possible to advance the catheter distally due to tortuosity and kinking. A prograde micro-catheter was advanced to the mid posterior tibial artery.
  • There was only minimal progress of recanalization after 12, 24 and 36 hours.
  • An angiogram revealled disease of the end segment of the PTA
  • a single tibial artery in continuity with the pedal arch was demonstrated at the end and collaterals around the ankle joint
  • Access siteNeuro
  • Access siteNeuro
  • Access siteNeuro

2013session2 1 Presentation Transcript

  • 1. Popliteal aneurysm and acuteischemia :Treatment optionsENTRETIENS VASCULAIRES 2013Oren K. Steinmetz MD, FRSC(C)
  • 2. Intra-arterial thrombolysis forALI due to thrombosed poplitealaneurysm is indicated inpatients with:1) 2) 3) 4) 5)20% 20% 20%20%20%1) Grade I ischemia2) Grade IIa ischemia3) Grade IIb ischemia4) Grade III ischemia5) none of the aboveCompte à rebours6
  • 3. In my practice I have used thefollowing to treat poplitealaneurysm presenting with ALI:1. 2. 3. 4.25% 25%25%25%1. Bypass2. intra-arterial thromboloysis3. tibial angioplasty4. endovascular stent graftCompte à rebours6
  • 4. What should we do with CareyPrice ?1. 2. 3.33% 33%33%1. Don’t give up hope, he isvery talented2. Give up hope Choix Trois3. Trade him to Calgary, he ismore comfortable wearingcowboy hats anywayCompte à rebours6
  • 5. Popliteal aneurysm and acuteischemia :Treatment optionsENTRETIENS VASCULAIRES 2013Oren K. Steinmetz MD, FRSC(C)
  • 6. Disclosures none
  • 7. Popliteal Aneurysm Most common peripheral aneurysm Prevalence less than 1% 55-65 % symptomatic at presentation Swedish national registry* 15 years 32% present acute ischemia*Ravn H, Bergqvist D, Bjorck M: Nationwide study of the outcome of popliteal arteryaneurysms treated surgically. Br J Surg 94:970-977, 2007
  • 8. Robinson WP, Belkin M.Semin Vasc Surg 2009.22:17-24 .
  • 9. Popliteal aneurysm with ALIOutcomes Popliteal aneurysm ALILimb loss 20-60%VS Elective bypass for asymptomaticpopliteal aneurysm>85% 5 year patency
  • 10. VS
  • 11. Popliteal aneurysm with ALIPathophysiology Thromboembolism Occlusion of tibial runoff vessels Acute thrombosis Combination
  • 12. Popliteal aneurysm with ALIPathophysiology 90% abnormalities of tibial arteries 22%-38% single vessel runoff* Patients with grade IIa ischemia** 12/13 no tibial runoff*Lilly MP, Flinn WR, McCarthy WJ 3rd, et al: The effect of distal arterial anatomy on thesuccess of popliteal aneurysm repair. J Vasc Surg 7:653-660, 1988**Marty B, Wicky S, Ris HB, et al: Success of thrombolysis as a predictorof outcome in acute thrombosis of popliteal aneurysms. J Vasc Surg35:487-493, 2002
  • 13. Popliteal aneurysm with ALIPresentation PE Duplex CTA Intra-op angio
  • 14. Popliteal aneurysm with ALIManagementEstablish outflow vessel(s)EffectivelySafely
  • 15. Robinson WP, Belkin M.Semin Vasc Surg 2009.22:17-24 .
  • 16. Robinson WP, Belkin M.Semin Vasc Surg 2009.22:17-24 .
  • 17. Popliteal aneurysm with ALIPresentation
  • 18. Robinson WP, Belkin M.Semin Vasc Surg 2009.22:17-24 .
  • 19. Popliteal aneurysm with ALIManagementGrade IIb and III ischemiaAnticoagulationAttempt Immediate revascularization
  • 20. Popliteal aneurysm with ALIManagementGrade IIb and III ischemiaAnticoagulationIdentify outflow vessels-angiogram (angio suite or intra-op)Tibial/popliteal exploration and thrombectomy
  • 21. Popliteal aneurysm with ALIManagementGrade IIb and III ischemiaAnticoagulationBypass/medial approachInflow generally from SFAVein conduitProximal and distal ligation of aneurysm
  • 22. Popliteal aneurysm with ALIManagementGrade IIb and III ischemiaNo runoff vesselanticoagulationamputation
  • 23. Robinson WP, Belkin M.Semin Vasc Surg 2009.22:17-24 .
  • 24. Popliteal aneurysm with ALIManagementGrade I and IIa ischemiaAnticoagulationAngiography via contralateral femoraloutflow vesselsVSno outflow vessels
  • 25. Popliteal aneurysm with ALIManagementGrade I and IIa ischemiaAngio- good runoff1) bypass2) endovascular
  • 26. Popliteal aneurysm with ALIManagementGrade I and IIa ischemiaAngio- no visible runoff1) thrombolysis2) popliteal/tibial exploration
  • 27. Popliteal aneurysm with ALIManagementThrombolysis Contraindications Absolute1. Established cerebrovascular event (including transient ischemic attacks within last 2 mo)2. Active bleeding diathesis3. Recent gastrointestinal bleeding (<10 d)4. Neurosurgery (intracranial, spinal) within last 3 mo5. Intracranial trauma within last 3 mo Relative major1. Cardiopulmonary resuscitation within last 10 d2. Major nonvascular surgery or trauma within last 10 d3. Uncontrolled hypertension: >180 mm Hg systolic or >110 mm Hg diastolic4. Puncture of noncompressible vessel5. Intracranial tumor6. Recent eye surgery Minor1. Hepatic failure, particularly those with coagulopathy2. Bacterial endocarditis3. Pregnancy4. Diabetic hemorrhagic retinopathy
  • 28. Popliteal aneurysm with ALIManagementThrombolysis ContraindicationsAbsolute1. Established cerebrovascular event (including transientischemic attacks within last 2 mo)2. Active bleeding diathesis3. Recent gastrointestinal bleeding (<10 d)4. Neurosurgery (intracranial, spinal) within last 3 mo5. Intracranial trauma within last 3 mo
  • 29. Popliteal aneurysm with ALIManagementGrade I and IIa ischemiaThrombolysis-catheter positioned in thrombus-rTPA 5-10mg bolus-0.5-1.0 mg/hour
  • 30. Popliteal aneurysm with ALIManagementGrade I and IIa ischemiaThrombolysis-monitoring-access site-neuro status-heparin aPTT 60 sec-repeat imaging 6-12 hours-24 - 48 hours
  • 31. Popliteal aneurysm with ALIManagementThrombolysis Complications Intracranial hemorrhage: 0 - 2.5% Major bleeding requiring transfusion orsurgery: 1 - 20% Compartment syndrome: 1 - 10% Distal embolization: 1 - 5% Failure - up to 33%
  • 32. Popliteal aneurysm with ALIManagementGrade I and IIa ischemiaAngio- runoff re-established1) bypass2) endovascular
  • 33. Case
  • 34. 2.7 Fr microcatheter in BKpoplitealr-TPA infusion: 5 mgbolus, followed by infusion of0.5 mg/ hourPatient was admitted to ICUContinuous anticoagulationwith heparin for a goal ofAPTT~ 60 sec
  • 35. 12 hours
  • 36. 24 hours
  • 37. 36 hours
  • 38. Popliteal aneurysm with ALIOutcomes-preoperativethrombolysisRobinson WP, Belkin M. Semin Vasc Surg 2009, 22:17-24 .
  • 39. VS
  • 40. VS
  • 41. Popliteal aneurysm with ALIManagementGrade I and IIa ischemiaThrombolysis – gives no patent runoff vesseloptions:1)tibial exploration and thrombectomy2) endovascular PTA3) anticoagulation
  • 42. A Case 82 male2 day cold and painful left foot PMH: HTN, Renal transplantation Grade IIa limb ischemia
  • 43. A Case – Diagnostic angiogramPTA
  • 44. A Case - Thrombolysis 2.7 Fr microcatheter in proximal PTA r-TPA infusion: 0.5 mg/ hour Patient was admitted to ICU Continuous anticoagulation withheparin for a goal of APTT~ 60 sec
  • 45. 12h 24h 36h
  • 46. A Case No significant clinical improvement Failure to open a single tibial artery in continuitywith the pedal arch Thrombolysis was terminated No autologous vein available
  • 47. Endovascular treatment of a PAA 0.035-inch Amplatzsuper-stiff wire 2 - 8x150 mmViabahn stentgrafts Post-dilated with a8x100 mm balloon
  • 48. Endovascular treatment of a PAA the distal third of PTAwas crossed using a0.018’’ V-18 Control wireand Quick Cross supportcatheter
  • 49. Endovascular treatment of a PAA0.014’’ Miracle 3 wireto the plantar arterysupported by theQuick Cross supportcatheter
  • 50. Endovascular treatment of a PAA Dilation was repeated with a 3x100 mm Savvy balloon (prolonged, highpressure dilations)
  • 51. Endovascular treatment of a PAAPTAPlantararteryTPtrunk
  • 52. Another Case-59 yo male-Grade II ? III ischemia-Airlift to Mexico City-Thrombolysis establishes peroneal runoff
  • 53. Another Case
  • 54. Another Case
  • 55. Popliteal aneurysm with ALIOutcomes-stent graftSaratzis et al. Perspectives in Vascular Surgery and Endovascular Therapy 2010.22(4) 245.
  • 56. Popliteal aneurysm with ALIManagementEndovascular stent graftLimited outcome dataElderlyMedically unfit for bypassNo autologous conduit
  • 57. From Tielliu et al.JVS, 51(6), 2010, 1413-1418.
  • 58. From Tielliu et al.JVS, 51(6), 2010, 1413-1418.
  • 59. From Tielliu et al.JVS, 51(6), 2010, 1413-1418. Overlap zones 93% Adductor tubercle73% Younger patients Not related topatency
  • 60. Popliteal aneurysm with ALIManagementTreatment choice depends on Grade ofischemiaPriority to establish outflowIntra-arterial thrombolysisGrade I and IIa ischemiaBypass with autologous graft
  • 61. Popliteal aneurysm with ALIManagementEndovascular stent graftLimited outcome dataElderlymedically unfit for bypassNo autologous conduit
  • 62. Robinson WP, Belkin M.Semin Vasc Surg 2009.22:17-24 .
  • 63. What should we do with CareyPrice ?1) Don’t give up hope,he is very talented2) Give up hope3) Trade him to Calgary,he is more comfortable wearingcowboy hats anyways