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Endovascular Therapy For Vascular
Insufficiency Of Lower Limbs
Dr. Rajdeep Agrawal, MD, DM
Interventional Cardiologist &
V...
 PAD is one of the commonest manifest.
of DM
 15-20% of diabetic pts have PAD
 Along with neuropathy & infection of
foo...
Goals of Revascularisation
Functional limb salvage
 Functional limb salvage & not necessarily long term vessel
patency.On...
Ante grade Straight Line flow is
generally necessary for the healing of
ischemic non-healing ulcer or gangrene.
In CLI wit...
Indications of Angioplasty in
PAD in 2006
 Life style limiting claudication
 Critical ischemia / limb threatening
ischem...
Critical Limb Ischemia
 History
 Severe claudication/Rest pain/Nocturnal pain.
 Physical Exam.
 Blanching on elevation...
Percutaneous Transluminal
Angioplasty
 A new nonsurgical technique designed
to increase the lumen of the vessel &
thus pr...
Newer Techniques Of
Angioplasty
 Atherectomy
 Directional
 Percutaneous Rotational
 LASER
 Stent : Nitinol, DES , Bio...
Directional Atherectomy
 It excises the
atheromatous plaque
material into very
fine slices which can
be retrieved outside...
Rotablator
Differential cutting
Grinds plaque into into fine particles
 A LASER produces an
intense beam of light in
uniform wavelength that
can be precisely focused to
deliver high energy lev...
Stent
 An expandable metallic spring like
device which is permanently
implanted in the artery .
 Mechanism
 The prosthe...
Stents
Wallstent
(stainless steel)
Smart stent(Nitinol
CUTTING BALLOON
 CBA involves conventional
angioplasty with microsurgical
technology in an attempt to minimize
vessel tra...
Cryoplasty
 ANGIOPLASTY SYSTEM THAT
SIMULTANEOUSLY DILATES AND COOLS THE
PLAQUES AND VESSEL WALL
 Using conventional tec...
75/M Post CABG, Severe LV Dysfunction,Renal Insuff.
LT.Great Toe Gangrene
Post Balloon Dilation SFA
Post Balloon Dilation Result
60/M IHD, LV Dysfunction
Balloon Dilatation Of Bilat. Iliacs
65 /M , Rt. Great toe +4th toe gangrene
70/M , HT/IHD
Post Balloon- Thrombus Formation
Post Thrombolysis Result
REVASCULARIZE: HOW ?
EVERY PROCEDURE
IS “GOOD” IF:
EFFECTIVE
AT LOW RISK
Meta-analysis of Angioplasty
trials for PAD (JACC V0l.46 No.6 2006)
Procedure No of
limbs
30 day
mortality
(%)
Complic
ati...
SURGERY--AORTO ILIAC
OCCLUSIVE DISEASES
TRADITIONALY TREATED WITH AORTO
FEMORAL OR AORTOBIFEMORAL GRAFT
SURGERY
 HIGHLY E...
Infrainguinal Surgical
Results (JACC V0l.46 No.6 2006)
Procedure Operative
Mortality(%)
Patency Rate
Fem- AK Popliteal vei...
Advantages Of Angioplasty
1.Minimally invasive
 Short hospital stay
 Faster recovery
2. Low risk with significantly less...
75/F Instent Restenosis
Post Balloon –Distal Run OFF
Advantages Of Angioplasty cont..
5. Option of Sx always remains in the
event of failure of angioplasty.
6. Less cost
Disadvantages Of SX
1.Significantly higher morbidity &
mortality(risk increases further in high risk cases)
2. Option of a...
Conclusion
 In Diabetic foot, PAD contributes to
amputation by impeding the delivery of
antibiotics, Oxygen, nutrients & ...
Conclusion cont…
 In the last few years, endovasc.
therapy has emerged as an equally
effective,less invasive, less risky ...
THANK YOU
1362573078 dr. rajdeep agrawal
1362573078 dr. rajdeep agrawal
1362573078 dr. rajdeep agrawal
1362573078 dr. rajdeep agrawal
1362573078 dr. rajdeep agrawal
1362573078 dr. rajdeep agrawal
1362573078 dr. rajdeep agrawal
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1362573078 dr. rajdeep agrawal

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1362573078 dr. rajdeep agrawal

  1. 1. Endovascular Therapy For Vascular Insufficiency Of Lower Limbs Dr. Rajdeep Agrawal, MD, DM Interventional Cardiologist & Vascular Interventionist, Sir H N Hospital,Mumbai Wockhardt Hospital S R Mehta & Sir Kikabhai Hosp.
  2. 2.  PAD is one of the commonest manifest. of DM  15-20% of diabetic pts have PAD  Along with neuropathy & infection of foot, it is a leading cause of amputation  Modality of Revascularisation  SX  Endovascular therapy
  3. 3. Goals of Revascularisation Functional limb salvage  Functional limb salvage & not necessarily long term vessel patency.Once the initial wound heals, even if there is recurrence ,it is clinically well tolerated. The further limb loss can be prevented with appropriate lifestyle modification, control of risk factors & proper foot care.  In pts with Diabetes with e/o tissue loss ,every attempt should be made to obtain functional limb salvage as many of these pts.are critically ill, have multisystem involvement.Loss of a limb adds markedly to their morbidity & sometimes mortality.
  4. 4. Ante grade Straight Line flow is generally necessary for the healing of ischemic non-healing ulcer or gangrene. In CLI with Diabetic foot revascularisation should generally precede surgical foot care Goal of Revascularisation
  5. 5. Indications of Angioplasty in PAD in 2006  Life style limiting claudication  Critical ischemia / limb threatening ischemia (rest pain, nocturnal pain, non healing ulcer, gangrene)  Acute ischemia of lower limb
  6. 6. Critical Limb Ischemia  History  Severe claudication/Rest pain/Nocturnal pain.  Physical Exam.  Blanching on elevation & rubor on dependency  A – B index < 0.5  Capillary filling time > 15sec.  Venous filling time > 40sec.  Non – Invasive Tests  Ankle press. < 50mmHg  Toe pressure < 30mmHg  TcO2 < 20mmHg  Duplex scan /Color Doppler
  7. 7. Percutaneous Transluminal Angioplasty  A new nonsurgical technique designed to increase the lumen of the vessel & thus prevent ischemia & its complications  Mechanism Inflated balloon exerts circumferential pressure on the plaque 1. Plaque splitting & disruption 2. Stretching of the vessel wall 3. Compression of the atheroma
  8. 8. Newer Techniques Of Angioplasty  Atherectomy  Directional  Percutaneous Rotational  LASER  Stent : Nitinol, DES , Biodegradable  Cutting balloon  Cryoplasty
  9. 9. Directional Atherectomy  It excises the atheromatous plaque material into very fine slices which can be retrieved outside body
  10. 10. Rotablator Differential cutting Grinds plaque into into fine particles
  11. 11.  A LASER produces an intense beam of light in uniform wavelength that can be precisely focused to deliver high energy levels to a small area  It converts solid plaque to gas which is soluble in blood Laser Directed Angioplasty
  12. 12. Stent  An expandable metallic spring like device which is permanently implanted in the artery .  Mechanism  The prosthesis acts as a scaffold to hold the artery open  Prevents recoil of the vessel  Reduces Restenosis
  13. 13. Stents Wallstent (stainless steel) Smart stent(Nitinol
  14. 14. CUTTING BALLOON  CBA involves conventional angioplasty with microsurgical technology in an attempt to minimize vessel trauma and injury during balloon dilation.  CB consists of microsurgical blades or atherotomes ( 3-4 in no. )mounted longitudinally on the outer surface of a non-compliant balloon. On balloon inflation, these microblades score the plaque at the lesion site & accomplish dilation at lower pressure than a conventional balloon. Also acute gain is achieved primarily via plaque compression & to a lesser extent via vessel wall expansion & hence less elastic recoil FOLDING SPRING 1cm ATHEROTOME
  15. 15. Cryoplasty  ANGIOPLASTY SYSTEM THAT SIMULTANEOUSLY DILATES AND COOLS THE PLAQUES AND VESSEL WALL  Using conventional technique, Cryoplasty balloon is filled with NO2 & dilated at 6 atm.  The plaque & vessel wall is cooled at temp. – 2 C to finally – 10C. This induces SMC apoptosis thereby inhibiting neo-intimal proliferation.
  16. 16. 75/M Post CABG, Severe LV Dysfunction,Renal Insuff. LT.Great Toe Gangrene
  17. 17. Post Balloon Dilation SFA
  18. 18. Post Balloon Dilation Result
  19. 19. 60/M IHD, LV Dysfunction
  20. 20. Balloon Dilatation Of Bilat. Iliacs
  21. 21. 65 /M , Rt. Great toe +4th toe gangrene
  22. 22. 70/M , HT/IHD
  23. 23. Post Balloon- Thrombus Formation
  24. 24. Post Thrombolysis Result
  25. 25. REVASCULARIZE: HOW ? EVERY PROCEDURE IS “GOOD” IF: EFFECTIVE AT LOW RISK
  26. 26. Meta-analysis of Angioplasty trials for PAD (JACC V0l.46 No.6 2006) Procedure No of limbs 30 day mortality (%) Complic ations (%) Technic al success (%) Primary patency (%) 1yr 3yr Iliac PTA 1473 1.0 4.3 91 74 61 Iliac stent 901 0.8 5.2 96 91 80 FEM-Pop PTA 4800 0.9 8.1 89 59 52 FEM-Pop stent 600 0.9 5.9 98 *62 43 Infrapop.PTA 1282 -- --- 93 79 74 (2yr) *Results are likely to be better with Nitinol stents
  27. 27. SURGERY--AORTO ILIAC OCCLUSIVE DISEASES TRADITIONALY TREATED WITH AORTO FEMORAL OR AORTOBIFEMORAL GRAFT SURGERY  HIGHLY EFFECTIVE PROCEDURES 88% 5 YRS  PATENCY OF AORTO BIFEM. BYPASS 75% 10 RS  BUT SUBSTANTIAL PROCEDURE RELATEDRISK FOR THE PATIENT OPERATIVE MORTALITY RATE : 3,3% MORBIDITY RATE : 8,3%  PTA LESS INVASIVE ALTERNATIVE TREATMENT
  28. 28. Infrainguinal Surgical Results (JACC V0l.46 No.6 2006) Procedure Operative Mortality(%) Patency Rate Fem- AK Popliteal vein 1.3 – 6.3 66 (5yrs ) Fem- BK Popliteal vein 1.3 – 6.3 66 (5yrs ) Fem- AK Popliteal prosth. 1.3 – 6.3 50 (5yrs ) Fem- BK Popliteal prosth. 1.3 – 6.3 33 (5yrs) Fem- Tib vein 1.3 – 6.3 60 (5yrs) Fem- Tib prosth. 1.3 – 6.3 25( 3yrs )
  29. 29. Advantages Of Angioplasty 1.Minimally invasive  Short hospital stay  Faster recovery 2. Low risk with significantly less morbidity & mortality(<0.5 –1.0 %) 3. Comparable patency rates 4. Can be performed again if recurrence occurs
  30. 30. 75/F Instent Restenosis
  31. 31. Post Balloon –Distal Run OFF
  32. 32. Advantages Of Angioplasty cont.. 5. Option of Sx always remains in the event of failure of angioplasty. 6. Less cost
  33. 33. Disadvantages Of SX 1.Significantly higher morbidity & mortality(risk increases further in high risk cases) 2. Option of angioplasty becomes difficult in the event of failure of Sx 3. Nonavailability of venous conduit in pts with bilat.varicose veins or in post CABG pts. 4. Higher cost (specially with synthetic grafts)
  34. 34. Conclusion  In Diabetic foot, PAD contributes to amputation by impeding the delivery of antibiotics, Oxygen, nutrients & by delaying wound healing & the ability to fight infection.  Aggressive therapy with debridement, antibiotics,good control of Diabetes & when indicated revascularisation results in salvage of > 90% of threatened limbs even in high risk patients
  35. 35. Conclusion cont…  In the last few years, endovasc. therapy has emerged as an equally effective,less invasive, less risky (even in high risk subset ) and overall a better initial approach to achieve revascularisation in majority of pts. Of Diabetic foot Therefore, it should be the first choice to achieve revascularisation in most of the pts. If it fails then the option of surgery should be considered.
  36. 36. THANK YOU

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