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1362466145 pad, agiography & angioplasty

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pad, agiography & angioplasty

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1362466145 pad, agiography & angioplasty

  1. 1. Peripheral Vascular Disease, Angiography - Angioplasty and Surgical Techniques Dr. Rajdeep Agrawal,Dr. Rajdeep Agrawal, MD,MD, DMDM Interventional Cardiologist &Interventional Cardiologist & Vascular InterventionistVascular Interventionist ,, Sir H N Hospital,MumbaiSir H N Hospital,Mumbai Breach Candy HospitalBreach Candy Hospital Cumballa Hill HospitalCumballa Hill Hospital
  2. 2. Dr. Rajdeep Agrawal Indications of Angiography in PVD  Life style limiting claudicationLife style limiting claudication  Critical ischemia / limbCritical ischemia / limb threatening ischemia (rest pain,threatening ischemia (rest pain, nocturnal pain, non healing ulcer,nocturnal pain, non healing ulcer, gangrenegangrene  Graft stenosisGraft stenosis  High surgical riskHigh surgical risk  Acute ischemia of lower limbAcute ischemia of lower limb
  3. 3. Dr. Rajdeep Agrawal Arteriogram  Remains the ‘Gold standard’ for vascularRemains the ‘Gold standard’ for vascular evaluation.evaluation.  Should be done only in patients who haveShould be done only in patients who have clinical indications for vascularclinical indications for vascular interventions (surgery or angioplasty)interventions (surgery or angioplasty)  Complications are less than 5% andComplications are less than 5% and mortality about 0.025%.mortality about 0.025%.  Patients should be well hydraded beforePatients should be well hydraded before and after angiograms, especiallyand after angiograms, especially diabetics.diabetics.
  4. 4. Dr. Rajdeep Agrawal Angioplasty -- History  Charles Dotter (1964)Charles Dotter (1964)  First angioplasty using co-axialFirst angioplasty using co-axial cathetercatheter  Andreas Gruentzig (1977)Andreas Gruentzig (1977)  First PTCA using double lumenFirst PTCA using double lumen cathetercatheter
  5. 5. Dr. Rajdeep Agrawal Percutaneous Transluminal Angioplasty (PTA) in Peripheral Vascular Disease An over view of the arterialAn over view of the arterial pathologies of the lower limbspathologies of the lower limbs and their percutaneousand their percutaneous treatmenttreatment modalitiesmodalities
  6. 6. Dr. Rajdeep Agrawal Percutaneous Transluminal Angioplasty  A non-surgical technique designed toA non-surgical technique designed to increase the lumen of the vessel &increase the lumen of the vessel & thus prevent ischemia & itsthus prevent ischemia & its complicationscomplications  MechanismMechanism Inflated balloon exertsInflated balloon exerts circumferentialcircumferential pressure on the plaquepressure on the plaque 1. Plaque splitting & disruption1. Plaque splitting & disruption 2. Stretching of the vessel wall2. Stretching of the vessel wall
  7. 7. Dr. Rajdeep Agrawal Rutherford – Becker classification of PVD GradGrad ee CategorCategor yy SymptomsSymptoms OO OO NoneNone II 11 Mild claudicationsMild claudications II 22 Moderate claudicationsModerate claudications II 33 Severe (life style limiting)Severe (life style limiting) claudicationsclaudications IIII 44 Rest painRest pain IIIIII 55 Nonhealing ulcers focalNonhealing ulcers focal gangrenegangrene IIIIII 66 Major tissue lossMajor tissue loss
  8. 8. Dr. Rajdeep Agrawal Rutherford – Becker classification of PVDRutherford – Becker classification of PVD Ankle Brachial Index -Ankle Brachial Index - > 0.90 – No significant obstructive> 0.90 – No significant obstructive diseasedisease 0.50 to 0.90 – Claudications (Grade I)0.50 to 0.90 – Claudications (Grade I) <0.50 – Limb threatening ischemia<0.50 – Limb threatening ischemia (Grade II or III)(Grade II or III)
  9. 9. Dr. Rajdeep Agrawal Ideal settings for PTA LesionsLesions CharacteristicsCharacteristics PatientPatient CharacteristicsCharacteristics ShortShort Non diabeticNon diabetic ConcentricConcentric ClaudicationClaudication Non calcifiedNon calcified SolitarySolitary Non occlusiveNon occlusive Large vesselLarge vessel Continuous run offContinuous run off
  10. 10. Dr. Rajdeep Agrawal Percutaneous Transluminal Angioplasty (PTA) in Peripheral Vascular Disease Modalities will include –Modalities will include – Angioplasty,Angioplasty, Stents,Stents, Lasers,Lasers, Rotablaters,Rotablaters, And ThrombolysisAnd Thrombolysis
  11. 11. Dr. Rajdeep Agrawal Percutaneous Transluminal Angioplasty (PTA) in Peripheral Vascular Disease Modalities will be treated together or separatelyModalities will be treated together or separately in the territories commonly affected byin the territories commonly affected by vascular diseasevascular disease Acute arterial obstruction will be treated as aAcute arterial obstruction will be treated as a separate issue, where multimodal treatmentsseparate issue, where multimodal treatments may come togethermay come together
  12. 12. Dr. Rajdeep Agrawal Lower Limb Ischemia - Vascular involvement in Diabetic  Aorto illiac relatively spared.Aorto illiac relatively spared.  Most of the diseases involvesMost of the diseases involves infrainguinal arteries (femoral - popliteal -infrainguinal arteries (femoral - popliteal - tibial)tibial)  About 60% have involvement of plantarAbout 60% have involvement of plantar arch and digital arteries.arch and digital arteries.  About 80% have microangiopathyAbout 80% have microangiopathy Does not adversely affect the outcome ofDoes not adversely affect the outcome of vascular reconstructionvascular reconstruction..
  13. 13. Dr. Rajdeep Agrawal Angiography -- Technique  ApproachApproach  Femoral / BrachialFemoral / Brachial  Vascular accessVascular access using Seldinger’susing Seldinger’s techniquetechnique  Material / HardwareMaterial / Hardware  0.035 guide wire0.035 guide wire  Renal catheter, Simmon’s cathRenal catheter, Simmon’s cath
  14. 14. Dr. Rajdeep Agrawal Seldinger needle & guide wire for introducing an arterial catheter
  15. 15. Dr. Rajdeep Agrawal  Arterial OcclusionArterial Occlusion just above thejust above the knee causingknee causing claudication of theclaudication of the calf; goodcalf; good collateralcollateral circulationcirculation
  16. 16. Dr. Rajdeep Agrawal Balloon Catheter for PTA
  17. 17. Dr. Rajdeep Agrawal Contraindications to percutaneous revascularization PTA C/I - Medically unstablePTA C/I - Medically unstable (Absolute) - Stenosis adjacent to aneurysm(Absolute) - Stenosis adjacent to aneurysm or near an ulcerated plaqueor near an ulcerated plaque (Relative) - (Unfavourable anatomy)(Relative) - (Unfavourable anatomy) Long segment & multi-focalLong segment & multi-focal stenosisstenosis Long segment OcclusionsLong segment Occlusions (thrombolysis)(thrombolysis)
  18. 18. Dr. Rajdeep Agrawal PTA Contra-indicationsPTA Contra-indications (Relative) - If large vessel at ankle is available(Relative) - If large vessel at ankle is available for bypassfor bypass - Heavy eccentric calcification- Heavy eccentric calcification - Lesion in essential collateral vessel- Lesion in essential collateral vessel - Stenosis with thrombus- Stenosis with thrombus Percutaneous revascularization
  19. 19. Dr. Rajdeep Agrawal Post PTA recurrence are seldom worse thanPost PTA recurrence are seldom worse than before, does not interfere with the originalbefore, does not interfere with the original planned surgery.planned surgery. In 25% Femoro - popliteal PTFE Graft,In 25% Femoro - popliteal PTFE Graft, Popliteal gets occluded when bypassPopliteal gets occluded when bypass closescloses Adar etalAdar etal Percutaneous revascularization
  20. 20. Dr. Rajdeep Agrawal THROMBOLYSISTHROMBOLYSIS is an alternateis an alternate attemptable modality of treatment inattemptable modality of treatment in PVDPVD Safe if cases are selected properlySafe if cases are selected properly Cannot be used in all cases.Cannot be used in all cases. Various methods are used to administerVarious methods are used to administer thrombolysisthrombolysis Acute ischemia of lower limb is one areaAcute ischemia of lower limb is one area Percutaneous revascularization
  21. 21. Dr. Rajdeep Agrawal Intra-arterial ThrombolysisIntra-arterial Thrombolysis Restores blood flowRestores blood flow Identifies underlying lesionIdentifies underlying lesion Thrombotic or embolic occlusionThrombotic or embolic occlusion Native artery or bypass graftNative artery or bypass graft Percutaneous revascularization
  22. 22. Dr. Rajdeep Agrawal THROMBOLYSIS - CONTRAINDICATIONSTHROMBOLYSIS - CONTRAINDICATIONS Absolute -Absolute - Active internal bleedingActive internal bleeding Irreversible limb ischaemiaIrreversible limb ischaemia Recent stroke, craniotomyRecent stroke, craniotomy Mobile L-V thrombusMobile L-V thrombus Percutaneous revascularization
  23. 23. Dr. Rajdeep Agrawal THROMBOLYSIS CONTRAINDICATIONSTHROMBOLYSIS CONTRAINDICATIONS Relative - H/o GI bleedRelative - H/o GI bleed - Recent major- Recent major surgery/CPR/Traumasurgery/CPR/Trauma - Diastolic BP- Diastolic BP >>125 mm125 mm - DM – Proliferative Retinopathy- DM – Proliferative Retinopathy - Sub acute bacterial endocarditis- Sub acute bacterial endocarditis - Coagulopathy- Coagulopathy - Post partum state- Post partum state Percutaneous revascularization
  24. 24. Dr. Rajdeep Agrawal Stents: Contra indicationsStents: Contra indications -- Diffuse aortic diseaseDiffuse aortic disease -- Extravasation of contrast after PTAExtravasation of contrast after PTA -- Non compliant lesion on angioplastyNon compliant lesion on angioplasty -- Diffuse iliac diseaseDiffuse iliac disease -- Aortic tortuosity & aneurysmAortic tortuosity & aneurysm -- Diffuse long segment small caliber externalDiffuse long segment small caliber external iliac or femoral arteryiliac or femoral artery Percutaneous revascularization
  25. 25. Dr. Rajdeep Agrawal Stent Complications (10%)Stent Complications (10%) - Almost all are minorAlmost all are minor - Puncture site injuryPuncture site injury - Distal embolizationDistal embolization - Stent dislodgementStent dislodgement - Pseudo anemysm formationPseudo anemysm formation - Vessel ruptureVessel rupture Percutaneous revascularization
  26. 26. Dr. Rajdeep Agrawal Percutaneous Transluminal Angioplasty (PTA) in Peripheral Vascular Disease AORTO – ILIAC PercutaneousAORTO – ILIAC Percutaneous Transluminal AngioplastyTransluminal Angioplasty -- Optimizes inflow for bypassOptimizes inflow for bypass - Excellent patient tolerance- Excellent patient tolerance -- Short recovery periodShort recovery period -- No worsening of vascular status – if failsNo worsening of vascular status – if fails
  27. 27. Dr. Rajdeep Agrawal AORTIC OCCLUSSIONSAORTIC OCCLUSSIONS - Relatively uncommonRelatively uncommon - Younger population who smokeYounger population who smoke - Claudication and impotencyClaudication and impotency - Risk of propagation of clot to renalRisk of propagation of clot to renal and mesenteric arteryand mesenteric artery Percutaneous revascularization
  28. 28. Dr. Rajdeep Agrawal ABDOMINAL AORTIC STENOSISABDOMINAL AORTIC STENOSIS - Isolated - relatively uncommonIsolated - relatively uncommon - More frequent in women with hypoplasticMore frequent in women with hypoplastic aortasaortas - PTA and Stent can be tried and are useful ifPTA and Stent can be tried and are useful if the lesions are amenablethe lesions are amenable - Otherwise Grafts can be placedOtherwise Grafts can be placed - Even thrombolysis could be attempted withEven thrombolysis could be attempted with angioplastyangioplasty - Large thick atherosclerotic lesions could beLarge thick atherosclerotic lesions could be commoncommon Percutaneous revascularization
  29. 29. Dr. Rajdeep Agrawal Percutaneous revascularization AORTO – ILIAC STENTINGAORTO – ILIAC STENTING Indications - Residual stenosis > 30% afterIndications - Residual stenosis > 30% after percutaneous revascularizationpercutaneous revascularization Or if a gradient >10mm persistsOr if a gradient >10mm persists DissectionDissection Highly eccentric stenosisHighly eccentric stenosis Recurrent Stenosis post PTARecurrent Stenosis post PTA Iliac artery occlusionIliac artery occlusion
  30. 30. Dr. Rajdeep Agrawal ILIAC ARTERY STENOSISILIAC ARTERY STENOSIS PTAPTA - PTA with/without stentPTA with/without stent - Focal, uncalufied sterosis <5 cm longFocal, uncalufied sterosis <5 cm long - Eccentric or calufied sterosis < 3cm longEccentric or calufied sterosis < 3cm long Long segment (Long segment (>>10cm)10cm) respond less favorablyrespond less favorably STENTSSTENTS - Residual pressure gradient (<5mmHg) orResidual pressure gradient (<5mmHg) or residual stenosis(>30%)residual stenosis(>30%) - Flow limiting dissection flapFlow limiting dissection flap - Restenosis (acute or subaiute)Restenosis (acute or subaiute) Percutaneous revascularization
  31. 31. Dr. Rajdeep Agrawal ILIAC ARTERY OCCLUSIONSILIAC ARTERY OCCLUSIONS - Bilateral – Surgery treatmentBilateral – Surgery treatment - Primary stent placementPrimary stent placement - PTA followed by stentPTA followed by stent - Thrombolysis followed by stentThrombolysis followed by stent Percutaneous revascularization
  32. 32. Dr. Rajdeep Agrawal INTERNAL ILIAC STEONSISINTERNAL ILIAC STEONSIS - Isolated buttock claudicationIsolated buttock claudication - ImpotenceImpotence - PTA is the choicePTA is the choice Percutaneous revascularization
  33. 33. Dr. Rajdeep Agrawal CFA STENOSISCFA STENOSIS - Isolated is uncommon without history of injuryIsolated is uncommon without history of injury (eg. Catheterization)(eg. Catheterization) - Endarterectomy – choice simple, LA andEndarterectomy – choice simple, LA and conscious sedationsconscious sedations - Durable than PTADurable than PTA Percutaneous revascularization
  34. 34. Dr. Rajdeep Agrawal Ext. Iliac Artery stenosis - before, after dilatation, after stent
  35. 35. Dr. Rajdeep Agrawal Femoro poplitealFemoro popliteal - Lesion 3 times commoner than iliac- Lesion 3 times commoner than iliac - Occlusions 3 times commoner than- Occlusions 3 times commoner than stenosisstenosis - 80% of the stenosis- 80% of the stenosis areare <<10cm10cm - 20% occlussions- 20% occlussions << 10cm10cm Percutaneous revascularization
  36. 36. Dr. Rajdeep Agrawal Femoro poplitealFemoro popliteal - 10 cm upper limit to select cases- 10 cm upper limit to select cases - Stents disappointing beyond that- Stents disappointing beyond that length of stenosislength of stenosis - Covered (PTFF) grafts have a promise- Covered (PTFF) grafts have a promise - Over 5 years 15-20% new Femoro- Over 5 years 15-20% new Femoro popliteal occlussions developpopliteal occlussions develop Percutaneous revascularization
  37. 37. Dr. Rajdeep Agrawal Narrowed superficial femoral artery before & after dilatation
  38. 38. Dr. Rajdeep Agrawal Femoropopliteal stenosis:Femoropopliteal stenosis: - PTA is less durable than bypass.PTA is less durable than bypass. - Bypass 5 year patency rate is about 80%Bypass 5 year patency rate is about 80% -- Complication of PTA is 10%, surgical repairComplication of PTA is 10%, surgical repair required in 2% casesrequired in 2% cases Percutaneous revascularization
  39. 39. Dr. Rajdeep Agrawal Femoropopliteal stenosisFemoropopliteal stenosis -- Stents useful in proximal Superficial FemoralStents useful in proximal Superficial Femoral ArteryArtery -- Stents – restenosis in distal SFA or poplitealStents – restenosis in distal SFA or popliteal artery due to extrinsic compressions (eg.artery due to extrinsic compressions (eg. Addutor canal) is possibleAddutor canal) is possible -- Long term consequences of placing flexibleLong term consequences of placing flexible stents across joints is unknown.stents across joints is unknown. Percutaneous revascularization
  40. 40. Dr. Rajdeep Agrawal Femoropopliteal occlussions:Femoropopliteal occlussions: - Long segment or complete SFA occlusionsLong segment or complete SFA occlusions does not respond well to any widelydoes not respond well to any widely available endovascular techniqueavailable endovascular technique - Amplatz thrombectomy catheter – excellentAmplatz thrombectomy catheter – excellent technical access, but long term patency istechnical access, but long term patency is modest or unknownmodest or unknown - Covered stents - results disappointingCovered stents - results disappointing - Endovascular stent grafts show mostEndovascular stent grafts show most promisepromise Percutaneous revascularization
  41. 41. Dr. Rajdeep Agrawal Femoropopliteal occlusions:Femoropopliteal occlusions: - PTA is effective for short solitary occlusions,PTA is effective for short solitary occlusions, < 10cm long, not involving SFA origins or< 10cm long, not involving SFA origins or distal popliteal arterydistal popliteal artery and tenders occlusions <3cm longand tenders occlusions <3cm long - Focal occlussions (<2 to 3cm)Focal occlussions (<2 to 3cm) PTA alonePTA alone - Long occlussions – Thrombolysis prior to PTALong occlussions – Thrombolysis prior to PTA Percutaneous revascularization
  42. 42. Dr. Rajdeep Agrawal Femoropopliteal occlusions:Femoropopliteal occlusions: - Upper SFA occlusions – stent if PTA is sub-Upper SFA occlusions – stent if PTA is sub- optimaloptimal - PTA long term patency rates may bePTA long term patency rates may be substantially less than clinical patency ratessubstantially less than clinical patency rates - Technical failure almost always results fromTechnical failure almost always results from inability to cross the lesion with guide wire.inability to cross the lesion with guide wire. Percutaneous revascularization
  43. 43. Dr. Rajdeep Agrawal Infra-popliteal revascularization -Infra-popliteal revascularization - IndicationsIndications Absence of pedal pulses – minimal orAbsence of pedal pulses – minimal or asymptomaticasymptomatic If collaterals are not well developed orIf collaterals are not well developed or limitation of activity resultslimitation of activity results Focal lesionsFocal lesions Limited in diffuse disease,Limited in diffuse disease, If short term patency is desired sufficient toIf short term patency is desired sufficient to heal superficial ulcerations or amputationheal superficial ulcerations or amputation sitessites Percutaneous revascularization
  44. 44. Dr. Rajdeep Agrawal Infra popliteal revascularization –Infra popliteal revascularization – Early results - Not impressiveEarly results - Not impressive Manipulations - Easier with DSAManipulations - Easier with DSA & road mapping& road mapping Increased popularity - Safe & SuccessfulIncreased popularity - Safe & Successful Decision with surgeonDecision with surgeon Inflow lesions Treatment firstInflow lesions Treatment first Percutaneous revascularization
  45. 45. Dr. Rajdeep Agrawal Tibial Artery Obstructions:Tibial Artery Obstructions: –– Infra popliteal PTA is almost always performed forInfra popliteal PTA is almost always performed for limb salvagelimb salvage - Short term patency may be sufficient to allow healingShort term patency may be sufficient to allow healing of an ischemic ulcer or amputation site or to avoidof an ischemic ulcer or amputation site or to avoid amputationamputation - PTA is not particularly effective if run-off vessels arePTA is not particularly effective if run-off vessels are not visualized. Liberal Heparin use must to maintainnot visualized. Liberal Heparin use must to maintain patencypatency Percutaneous revascularization
  46. 46. Dr. Rajdeep Agrawal STENTS RESULTSSTENTS RESULTS -- Technical success rate – 90-100%Technical success rate – 90-100% -- Cumulative 5 year vessel patency – 94%Cumulative 5 year vessel patency – 94% -- Clinical success – 93%Clinical success – 93% -- (PTA 65% & 70%)(PTA 65% & 70%) Percutaneous revascularization
  47. 47. Dr. Rajdeep Agrawal Infra-popliteal revascularizationInfra-popliteal revascularization IndicationsIndications -- Limb threatening IshcemiaLimb threatening Ishcemia (Disabling claudication, Rest pain, Ulcer, Gangrene)(Disabling claudication, Rest pain, Ulcer, Gangrene) -- ABI < 0.5 Ischemic rest pain or ankle pressure <60ABI < 0.5 Ischemic rest pain or ankle pressure <60 mm, with or without a non healing ulcermm, with or without a non healing ulcer -- DM – ABI not useful - calcificationDM – ABI not useful - calcification Percutaneous revascularization
  48. 48. Dr. Rajdeep Agrawal Stent  An expandable metallic helicalAn expandable metallic helical device which is permanentlydevice which is permanently implanted in the arteryimplanted in the artery ..  MechanismMechanism  The prosthesis acts as aThe prosthesis acts as a scaffold to hold the artery openscaffold to hold the artery open  Prevents recoil of the vesselPrevents recoil of the vessel  Reduces RestenosisReduces Restenosis
  49. 49. Dr. Rajdeep Agrawal Newer Techniques Of Angioplasty  AtherectomyAtherectomy  DirectionalDirectional  Percutaneous RotationalPercutaneous Rotational  TECTEC  LASERLASER  StentStent
  50. 50. Dr. Rajdeep Agrawal Directional Atherectomy  It excises the atheromatousIt excises the atheromatous plaque material into very fineplaque material into very fine slices which can be retrievedslices which can be retrieved outside bodyoutside body
  51. 51. Dr. Rajdeep Agrawal Percutaneous Rotational Atherectomy (Rotablator)
  52. 52. Dr. Rajdeep Agrawal LASER  A LASER produces an intenseA LASER produces an intense beam of light in uniformbeam of light in uniform wavelength that can be preciselywavelength that can be precisely focused to deliver high energyfocused to deliver high energy levels to a small arealevels to a small area  It converts solid plaque to gasIt converts solid plaque to gas which is soluble in bloodwhich is soluble in blood
  53. 53. Dr. Rajdeep Agrawal Stent Complications (5-10%)Stent Complications (5-10%) Groin hematomaGroin hematoma Pseudo AneurysmPseudo Aneurysm Embolization of thrombusEmbolization of thrombus Acute stent thrombosisAcute stent thrombosis DissectionDissection Vessel perforationVessel perforation Percutaneous revascularization
  54. 54. Dr. Rajdeep Agrawal IDDM – Reduce insulinIDDM – Reduce insulin First caseFirst case 5% Dextrose, Blood sugar,5% Dextrose, Blood sugar, Insulin (1-3 units/ hr) or more for higherInsulin (1-3 units/ hr) or more for higher blood glucose levelsblood glucose levels No protamine zinc insulin should be usedNo protamine zinc insulin should be used Protamine antagonizes the heparinProtamine antagonizes the heparin anticoagulationanticoagulation Hybration to prevent aute tubular necrosisHybration to prevent aute tubular necrosis Percutaneous revascularization
  55. 55. Dr. Rajdeep Agrawal Cost effectiveness of PTA compared toCost effectiveness of PTA compared to surgical reconstructionsurgical reconstruction PTA - Bypass - 53% in Disabling ClaudicationPTA - Bypass - 53% in Disabling Claudication 75% in critical ischemia75% in critical ischemia A cost effective analysis demonstrated that performingA cost effective analysis demonstrated that performing PTA as a initial procedure is more desirablePTA as a initial procedure is more desirable technically feasible cases and reserving bypasstechnically feasible cases and reserving bypass surgery for those PTS in whom PTA fails, or recurssurgery for those PTS in whom PTA fails, or recurs would save more lives, limbs and money.would save more lives, limbs and money. Percutaneous revascularization
  56. 56. Dr. Rajdeep Agrawal Cost effectiveness of PTA compared toCost effectiveness of PTA compared to surgical reconstructionsurgical reconstruction In technically feasible cases PTA would be theIn technically feasible cases PTA would be the preferred optionpreferred option Reserve bypass surgery for those PTAs inReserve bypass surgery for those PTAs in whom it fails, or recurswhom it fails, or recurs It would save more lives, limbs and money.It would save more lives, limbs and money. Percutaneous revascularization
  57. 57. Dr. Rajdeep Agrawal Complications:Complications: Vasospasm - Nifedipine start well beforeVasospasm - Nifedipine start well before procedureprocedure - Intra-arterial Nitroglycerins,- Intra-arterial Nitroglycerins, in the vessel to be treated –in the vessel to be treated – (100 to 200 mg) before(100 to 200 mg) before dilationdilation Flow limiting dissection flap – Employ StentFlow limiting dissection flap – Employ Stent Percutaneous revascularization
  58. 58. Dr. Rajdeep Agrawal Complications:Complications: Post PTA occlusion –Post PTA occlusion – Repeat PTA & thrombolytic therapyRepeat PTA & thrombolytic therapy OR Repeat PTA – StentOR Repeat PTA – Stent Arterial rupture – Reinflation of baloon acrossArterial rupture – Reinflation of baloon across rupturerupture ,, followed by surgical repairfollowed by surgical repair Percutaneous revascularization
  59. 59. Dr. Rajdeep Agrawal Medical Therapy Exercise programExercise program Risk factor modificationsRisk factor modifications
  60. 60. Dr. Rajdeep Agrawal Results of percutaneous therapy Site &Site & DiseaseDisease Of arterialOf arterial stenosisstenosis TherapTherap yy SuccessSuccess % of% of TechnicTechnic 1 year1 year patencypatency (%)(%) 3 year3 year patencpatenc y (%)y (%) AbdominalAbdominal AortaAorta PTAPTA 9595 ?? ?? IliacIliac PTAPTA 9595 8080 7070 IliacIliac StentStent 9595 9090 8585 Iliac occlusionIliac occlusion StentStent 8080 7070 6565 Two year limb salvage of 60 to 80%Two year limb salvage of 60 to 80%
  61. 61. Dr. Rajdeep Agrawal Results of percutaneous therapy Site & DiseaseSite & Disease Of arterialOf arterial stenosis /stenosis / occlusionocclusion TherapyTherapy SuccesSucces s % ofs % of TechnicTechnic OneOne yearyear patencypatency (%)(%) ThreeThree yearyear patencypatency (%)(%) ProximalProximal femoralfemoral StentStent 9595 8585 7575 FemoroFemoro poplitealpopliteal OcclusionOcclusion Lysis,Lysis, PTAPTA 8080 5050 4040 Tibial stenosisTibial stenosis PTAPTA 9090 -- -- Two year limb salvage of 60 to 80%Two year limb salvage of 60 to 80%
  62. 62. Dr. Rajdeep Agrawal Aorto-iliac Occlusions:Aorto-iliac Occlusions: Aorto bifemoral bypassAorto bifemoral bypass - Extra anatomic- Extra anatomic - Endarterctomy- Endarterctomy - 5 year patency - 85 to 95%- 5 year patency - 85 to 95% Surgical revascularization - 1
  63. 63. Dr. Rajdeep Agrawal Infra – inguinal occlusions:Infra – inguinal occlusions: - Autologous veins or PTFE grafts are usedAutologous veins or PTFE grafts are used PTEF above Hunter’s canal for SFAPTEF above Hunter’s canal for SFA - Saphenous Vein – below knee, for tibial or peronealSaphenous Vein – below knee, for tibial or peroneal occlusionocclusion - 5 yr patency – 60% - above5 yr patency – 60% - above - Below knee – 3 yr patency and limb salvage 58 toBelow knee – 3 yr patency and limb salvage 58 to 92% respectively92% respectively Surgical revascularization - 1
  64. 64. Dr. Rajdeep Agrawal AORTIC OCCLUSSIONSAORTIC OCCLUSSIONS - Aorto bifemoral graft with endarterectomyAorto bifemoral graft with endarterectomy axillo bifemoral graft or thorarofemoral graftaxillo bifemoral graft or thorarofemoral graft - Re-construction with endovascular stent graftRe-construction with endovascular stent graft is feasible – long term results unknownis feasible – long term results unknown Surgical revascularization - 2
  65. 65. Dr. Rajdeep Agrawal Lower Limb Ischemia - Approach to Therapy Direct arterial reconstruction.Direct arterial reconstruction.  EndarterectomyEndarterectomy  Vascular bypassVascular bypass  Endovascular (minimally invasive)Endovascular (minimally invasive) interventionintervention  Lumbar sympathectomyLumbar sympathectomy
  66. 66. Dr. Rajdeep Agrawal Lower Limb Ischemia - Results of Direct Reconstruction  Aorto illiac reconstruction - early graft patency ofAorto illiac reconstruction - early graft patency of about 98%, operative mortality 3%:5years graftabout 98%, operative mortality 3%:5years graft patency of 85-90%.patency of 85-90%.  Femoro popliteal bypass - early graft patency ofFemoro popliteal bypass - early graft patency of over 90%, with mortality of 2-5% : 5 year patencyover 90%, with mortality of 2-5% : 5 year patency of about 75%.of about 75%.  Infrapopliteal/ paramalleolar bypass - earlyInfrapopliteal/ paramalleolar bypass - early patency of about 90% with 2% mortality. 5 yearpatency of about 90% with 2% mortality. 5 year patency of 55%patency of 55% LIMB SALVAGE about 90%LIMB SALVAGE about 90%
  67. 67. Dr. Rajdeep Agrawal OPERATIONS Depends on the site of occlusion andDepends on the site of occlusion and the physical state of the patientthe physical state of the patient..
  68. 68. Dr. Rajdeep Agrawal Aorto-iliac occlusion  Limited involvement : Iliac EndartectomyLimited involvement : Iliac Endartectomy  Marked involvement : Aorto-femoral bypassMarked involvement : Aorto-femoral bypass Aorto-iliac occlusion patient unable to undergoAorto-iliac occlusion patient unable to undergo surgerysurgery;;  1 iliac artery involved : femoro-femoral or ileo-1 iliac artery involved : femoro-femoral or ileo- femoral bypassfemoral bypass  Both iliac arteries involved : Axillo-bifemoralBoth iliac arteries involved : Axillo-bifemoral bypassbypass
  69. 69. Dr. Rajdeep Agrawal  AtheroscleroticAtherosclerotic narrowing ofnarrowing of aortic bifurcationaortic bifurcation  AortobifemoralAortobifemoral graft to bypassgraft to bypass stenosisstenosis
  70. 70. Dr. Rajdeep Agrawal Femoral & Profunda Femoris Occlusion  If conservative measures not suitable,If conservative measures not suitable, PTA may be possiblePTA may be possible  For more severe disease, angioplastyFor more severe disease, angioplasty or bypass maybe usedor bypass maybe used  Femoropopliteal bypass graft is theFemoropopliteal bypass graft is the most usual operationmost usual operation  Saphenous vein graft gives the bestSaphenous vein graft gives the best resultsresults
  71. 71. Dr. Rajdeep Agrawal  SuperficialSuperficial femoral arteryfemoral artery occlusion withocclusion with profunda femorisprofunda femoris stenosis providingstenosis providing poor collateralpoor collateral circulationcirculation  FemoropoplitealFemoropopliteal graft used tograft used to bypass thebypass the occluded areaoccluded area
  72. 72. Dr. Rajdeep Agrawal Occlusion below popliteal  Bypass to tibial vessels, even down toBypass to tibial vessels, even down to the ankle can be met with reasonablethe ankle can be met with reasonable success.success.  Most successful is with long saphenousMost successful is with long saphenous vein in thevein in the in situin situ fashion.fashion.  If saphenous not available, can useIf saphenous not available, can use PTFE (Polytetrafluoroethylene) graft.PTFE (Polytetrafluoroethylene) graft.
  73. 73. Dr. Rajdeep Agrawal PROSTHETIC MATERIALS  Aortoiliac bypass - DacronAortoiliac bypass - Dacron  Femoropopliteal - Autogenous veinsFemoropopliteal - Autogenous veins (Long saphenous best)(Long saphenous best) If not available - PTFE orIf not available - PTFE or glutaraldehyde-tanned, Dacronglutaraldehyde-tanned, Dacron supported, human umbilical veinsupported, human umbilical vein  Profundoplasty - Vein/PTFE/DacronProfundoplasty - Vein/PTFE/Dacron
  74. 74. Dr. Rajdeep Agrawal Treatment of A/C Occlusion  Embolectomy - Using Fogarty’s catheter ->Embolectomy - Using Fogarty’s catheter -> Catheter passed beyond emblous, balloonCatheter passed beyond emblous, balloon inflated & pulled back till blood comesinflated & pulled back till blood comes  Direct Embolectomy - Artery exposed,Direct Embolectomy - Artery exposed, transverse incision, clot removed.transverse incision, clot removed.  Intra-arterial Thrombolysis - TPA preferred.Intra-arterial Thrombolysis - TPA preferred. Arteriography done and a catheter embeddedArteriography done and a catheter embedded in clot - Thrombolytic agent infused overin clot - Thrombolytic agent infused over several hrsseveral hrs
  75. 75. Dr. Rajdeep Agrawal Surgical Embolectomy  Relatively simple procedureRelatively simple procedure  Done under LA, small incision in theDone under LA, small incision in the groin, using Fogarty’s cath.groin, using Fogarty’s cath.  ProblemsProblems 1. Blind procedure, can be traumatic1. Blind procedure, can be traumatic 2. Not successful in 10 – 30% cases2. Not successful in 10 – 30% cases 3. Inefficient in multistenosed artery3. Inefficient in multistenosed artery 4. Complete removal of thrombus4. Complete removal of thrombus difficult in leg arteriesdifficult in leg arteries
  76. 76. Dr. Rajdeep Agrawal Post PTA MX  Antiplatelet agentsAntiplatelet agents  LMW Heparin X 7 – 10 DLMW Heparin X 7 – 10 D  IV / oral TrentalIV / oral Trental  StatinsStatins  Aggressive control of riskAggressive control of risk factorsfactors
  77. 77. Dr. Rajdeep Agrawal Conclusion  In Diabetic foot, PVD contributes toIn Diabetic foot, PVD contributes to amputation by impeding the delivery ofamputation by impeding the delivery of antibiotics, Oxygen, nutrients & byantibiotics, Oxygen, nutrients & by delaying wound healing & the ability todelaying wound healing & the ability to fight infection.fight infection.  Aggressive therapy with debridement,Aggressive therapy with debridement, antibiotics,good control of Diabetes &antibiotics,good control of Diabetes & when indicated revascularisationwhen indicated revascularisation results in salvage of > 90% ofresults in salvage of > 90% of threatened limbs even in high riskthreatened limbs even in high risk patientspatients

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