Treatment of Long Lesions and Femoropopliteal CTO
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Treatment of Long Lesions and Femoropopliteal CTO
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Treatment of Long Lesions and Femoropopliteal CTO
- 1. Hospital Felício Rocho Cirurgia Vascular Treatment Options for Long Lesions and Chronic Total Occlusions Daniel Mendes Pinto Vascular Surgery Hospital Felício Rocho – Belo Horizonte – MG Agosto - 2016 Hospital Felício Rocho Cirurgia Vascular
- 2. Hospital Felício Rocho Cirurgia Vascular JACC 2015:931-41 Lesion length • Focal: ≤ 1 cm • Short: > 1 and < 5 • Intermediate: ≥ 5 and < 15 cm • Long: ≥ 15 cm
- 3. Hospital Felício Rocho Cirurgia Vascular Bypass surgery: an option for long lesions and CTO
- 4. Hospital Felício Rocho Cirurgia Vascular Chronic Total Occlusions and Long Lesions Recent data push to endovascular solution •Good results of last generation nitinol stents •Patency rates of DCB •DES
- 5. Hospital Felício Rocho Cirurgia Vascular The most difficult step...
- 6. Hospital Felício Rocho Cirurgia Vascular 1. Intraluminal recanalization • Technical success: 50 – 62% • Less colateral damage • Theoretical risk of embolization • 0,035” hidrophilic wires • More recent approach: 0,018” stiff body • Support catheters (Elitecross, CXI, Quickcross) Schmidt JEVT 2012 RCSI-SMJ 2011;4(1):39
- 7. Hospital Felício Rocho Cirurgia Vascular Intraluminal crossing devices •Blunt microdissection • Success rate: 60 – 75% •Rotational • Success rate: 70 – 87% • Distal embolization Cordis FrontRunner Liang GZ. Internat J Cardiol 2013;165:423
- 8. Hospital Felício Rocho Cirurgia Vascular 2. Subintimal recanalization • High technical sucess rates: 80% • False lumen free of endothelium and atheroma: less hiperplasia • More “suitable space” for stents • Caution: bifurcation areas (commom femoral), distal popliteal, trifurcation • Keep in mind surgical options RCSI-SMJ 2011;4(1):39 Met R. Cardiovasc Intervent Radiol 2008
- 9. Hospital Felício Rocho Cirurgia Vascular Re-entry into the true lumen Small loop Suport catheter Angled catheters New wires Bern JR4 IM
- 10. Hospital Felício Rocho Cirurgia Vascular Parallel guidewires First wire – subintimal Second wire – Intraluminal
- 11. Hospital Felício Rocho Cirurgia Vascular Parallel antegrade guidewires
- 12. Hospital Felício Rocho Cirurgia Vascular 3. Re-entry catheters Outback LTD ® •Locate •Tune •Deploy Ocke PER. J Res Development 2015
- 13. Hospital Felício Rocho Cirurgia Vascular Outback LTD ® Wilkins LR. Tech Vasc Interv Radiol 2016 •Success with re-entry catheters: • 65 – 100% •Pooled complication rate: 4% Kitrou P. J Endovasc Ther 2015;22(4):538 Gandini R. Catheter Cardiovasc Interv 2014;82(3):485
- 14. Hospital Felício Rocho Cirurgia Vascular 4. Retrograde Access Distal SFA Popliteal Tibials – leg Tibials - foot
- 15. Hospital Felício Rocho Cirurgia Vascular Distal SFA / Popliteal •Supine position •US guided or fluoro guided •18G needle •0,018” or 0,035” wire •4F, 5F sheath or support with balloon Distal SFA Popliteal
- 16. Hospital Felício Rocho Cirurgia Vascular Retrograde access – distal SFA Schmidt JEVT 2012
- 17. Hospital Felício Rocho Cirurgia Vascular Tibial - lower leg / foot Tibials – leg Easy US-guided puncture Sheathless Foot: fluoroscopy guided
- 18. Hospital Felício Rocho Cirurgia Vascular Guidelines of Management of Patients with Peripheral Arterial Disease •AHA/ACCF JACC 2005 •TASC II. JVS 2007 •Update Guideline AHA 2011 •AHA/ACCF Circulation 2013 •SVS Guidelines 2015. Practice for atherosclerotic occlusive disease of the lower extremities. Ballon angioplasty Bail-out stents
- 19. Hospital Felício Rocho Cirurgia Vascular Review data – femoropopliteal segment J Vasc Surg 2014;59:1123-33
- 20. Hospital Felício Rocho Cirurgia Vascular Katsanos et al. J Vasc Surg 2014: 1123
- 21. Hospital Felício Rocho Cirurgia Vascular Katsanos et al. J Vasc Surg 2014
- 22. Hospital Felício Rocho Cirurgia Vascular Long lesions and CTO Scaffolding is advisable! •Long term patency with 3rd generation nitinol stents • > 3 year: 30 – 60% Zeller, Curr Cardiol Rep 2015 •2-year - 4th generation stents • 84% freedom from TLR Walker, NCVH 2015
- 23. Hospital Felício Rocho Cirurgia Vascular Femoro-popliteal stents Elgiloy Nitinol Helical nitinol
- 24. Hospital Felício Rocho Cirurgia Vascular Femoro-popliteal stents Vascular Mimetic Implants • Fully connected nitinol • Conform the vessel wall Smart Flex Supera
- 25. Hospital Felício Rocho Cirurgia Vascular Femoro-popliteal lesions 0 10 20 30 40 50 60 70 80 90 100 1 year primary patency DEFINITIVE-LE Aterectomia pp 75% lesões: 8,1 cm RESILIENT Lifestent pp 81,3% lesões: 6,2 cm DURABILITY II Protegé pp 77,2% lesões: 8,9 cm STRIDES Drug eluting stent pp 68% lesões: 9,0 cm STRIDES Drug eluting stent pp 68% lesões: 9,0 cm IMPACT Drug coated balloon pp 83,7% lesões: 8,4 cm LEVANT I Drug coated balloon pp 67% lesões: 8,1 cm Vascular Mimetic Stent pp 84,1% lesões: 8 cm Vascular Mimetic Stent pp 81% Lesões > 15 cm Atherectomy Bare nitinol stents Drug Eluting Stents Drug Coated Balloons 4th generation nitinol stents
- 26. Hospital Felício Rocho Cirurgia Vascular Conclusion Long lesions / CTO Femoropopliteal Non-calcified: • Intraluminal first • Subintimal if failed • Re-entry devices if avaiable • Retrograde access Drug Coated Ballon Spot stenting Vascular Mimetic Stents Severe calcified: • Subintimal • Re-entry devices if avaiable • Retrograde access Vascular Mimetic Stents Bare Nitinol Stents
- 27. Hospital Felício Rocho Cirurgia Vascular OBRIGADO! • Disponível em: slideshare.net • daniel@vascularbh.com.br • 31 99161.8318