dr. rajdeep agrawal

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.  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. 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. 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. 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. 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. 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. Newer Techniques Of
Angioplasty
 Atherectomy
 Directional
 Percutaneous Rotational
 LASER
 Stent : Nitinol, DES , Biodegradable
 Cutting balloon
 Cryoplasty

9. Directional Atherectomy
 It excises the
atheromatous plaque
material into very
fine slices which can
be retrieved outside
body

10. Rotablator
Differential cutting
Grinds plaque into into fine particles

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. 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. Stents
Wallstent
(stainless steel)
Smart stent(Nitinol

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. 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. 75/M Post CABG, Severe LV Dysfunction,Renal Insuff.
LT.Great Toe Gangrene

19. Post Balloon Dilation SFA

20. Post Balloon Dilation Result

21. 60/M IHD, LV Dysfunction

22. Balloon Dilatation Of Bilat. Iliacs

24. 65 /M , Rt. Great toe +4th toe gangrene

27. 70/M , HT/IHD

29. Post Balloon- Thrombus Formation

30. Post Thrombolysis Result

31. REVASCULARIZE: HOW ?
EVERY PROCEDURE
IS “GOOD” IF:
EFFECTIVE
AT LOW RISK

32. 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

33. 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

34. 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 )

35. 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

36. 75/F Instent Restenosis

37. Post Balloon –Distal Run OFF

38. Advantages Of Angioplasty cont..
5. Option of Sx always remains in the
event of failure of angioplasty.
6. Less cost

39. 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)

40. 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

41. 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.

42. THANK YOU