2013session2 1

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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

    1. 1. Popliteal aneurysm and acuteischemia :Treatment optionsENTRETIENS VASCULAIRES 2013Oren K. Steinmetz MD, FRSC(C)
    2. 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. 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. 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. 5. Popliteal aneurysm and acuteischemia :Treatment optionsENTRETIENS VASCULAIRES 2013Oren K. Steinmetz MD, FRSC(C)
    6. 6. Disclosures none
    7. 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. 8. Robinson WP, Belkin M.Semin Vasc Surg 2009.22:17-24 .
    9. 9. Popliteal aneurysm with ALIOutcomes Popliteal aneurysm ALILimb loss 20-60%VS Elective bypass for asymptomaticpopliteal aneurysm>85% 5 year patency
    10. 10. VS
    11. 11. Popliteal aneurysm with ALIPathophysiology Thromboembolism Occlusion of tibial runoff vessels Acute thrombosis Combination
    12. 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. 13. Popliteal aneurysm with ALIPresentation PE Duplex CTA Intra-op angio
    14. 14. Popliteal aneurysm with ALIManagementEstablish outflow vessel(s)EffectivelySafely
    15. 15. Robinson WP, Belkin M.Semin Vasc Surg 2009.22:17-24 .
    16. 16. Robinson WP, Belkin M.Semin Vasc Surg 2009.22:17-24 .
    17. 17. Popliteal aneurysm with ALIPresentation
    18. 18. Robinson WP, Belkin M.Semin Vasc Surg 2009.22:17-24 .
    19. 19. Popliteal aneurysm with ALIManagementGrade IIb and III ischemiaAnticoagulationAttempt Immediate revascularization
    20. 20. Popliteal aneurysm with ALIManagementGrade IIb and III ischemiaAnticoagulationIdentify outflow vessels-angiogram (angio suite or intra-op)Tibial/popliteal exploration and thrombectomy
    21. 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. 22. Popliteal aneurysm with ALIManagementGrade IIb and III ischemiaNo runoff vesselanticoagulationamputation
    23. 23. Robinson WP, Belkin M.Semin Vasc Surg 2009.22:17-24 .
    24. 24. Popliteal aneurysm with ALIManagementGrade I and IIa ischemiaAnticoagulationAngiography via contralateral femoraloutflow vesselsVSno outflow vessels
    25. 25. Popliteal aneurysm with ALIManagementGrade I and IIa ischemiaAngio- good runoff1) bypass2) endovascular
    26. 26. Popliteal aneurysm with ALIManagementGrade I and IIa ischemiaAngio- no visible runoff1) thrombolysis2) popliteal/tibial exploration
    27. 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. 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. 29. Popliteal aneurysm with ALIManagementGrade I and IIa ischemiaThrombolysis-catheter positioned in thrombus-rTPA 5-10mg bolus-0.5-1.0 mg/hour
    30. 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. 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. 32. Popliteal aneurysm with ALIManagementGrade I and IIa ischemiaAngio- runoff re-established1) bypass2) endovascular
    33. 33. Case
    34. 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. 35. 12 hours
    36. 36. 24 hours
    37. 37. 36 hours
    38. 38. Popliteal aneurysm with ALIOutcomes-preoperativethrombolysisRobinson WP, Belkin M. Semin Vasc Surg 2009, 22:17-24 .
    39. 39. VS
    40. 40. VS
    41. 41. Popliteal aneurysm with ALIManagementGrade I and IIa ischemiaThrombolysis – gives no patent runoff vesseloptions:1)tibial exploration and thrombectomy2) endovascular PTA3) anticoagulation
    42. 42. A Case 82 male2 day cold and painful left foot PMH: HTN, Renal transplantation Grade IIa limb ischemia
    43. 43. A Case – Diagnostic angiogramPTA
    44. 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. 45. 12h 24h 36h
    46. 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. 47. Endovascular treatment of a PAA 0.035-inch Amplatzsuper-stiff wire 2 - 8x150 mmViabahn stentgrafts Post-dilated with a8x100 mm balloon
    48. 48. Endovascular treatment of a PAA the distal third of PTAwas crossed using a0.018’’ V-18 Control wireand Quick Cross supportcatheter
    49. 49. Endovascular treatment of a PAA0.014’’ Miracle 3 wireto the plantar arterysupported by theQuick Cross supportcatheter
    50. 50. Endovascular treatment of a PAA Dilation was repeated with a 3x100 mm Savvy balloon (prolonged, highpressure dilations)
    51. 51. Endovascular treatment of a PAAPTAPlantararteryTPtrunk
    52. 52. Another Case-59 yo male-Grade II ? III ischemia-Airlift to Mexico City-Thrombolysis establishes peroneal runoff
    53. 53. Another Case
    54. 54. Another Case
    55. 55. Popliteal aneurysm with ALIOutcomes-stent graftSaratzis et al. Perspectives in Vascular Surgery and Endovascular Therapy 2010.22(4) 245.
    56. 56. Popliteal aneurysm with ALIManagementEndovascular stent graftLimited outcome dataElderlyMedically unfit for bypassNo autologous conduit
    57. 57. From Tielliu et al.JVS, 51(6), 2010, 1413-1418.
    58. 58. From Tielliu et al.JVS, 51(6), 2010, 1413-1418.
    59. 59. From Tielliu et al.JVS, 51(6), 2010, 1413-1418. Overlap zones 93% Adductor tubercle73% Younger patients Not related topatency
    60. 60. Popliteal aneurysm with ALIManagementTreatment choice depends on Grade ofischemiaPriority to establish outflowIntra-arterial thrombolysisGrade I and IIa ischemiaBypass with autologous graft
    61. 61. Popliteal aneurysm with ALIManagementEndovascular stent graftLimited outcome dataElderlymedically unfit for bypassNo autologous conduit
    62. 62. Robinson WP, Belkin M.Semin Vasc Surg 2009.22:17-24 .
    63. 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

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