2. Plugs
• self-expanding devices made of nitinol wire mesh which can be
cylinderlized into a sheath and realise gets back there shape for
stoppage of flow
3. Misnomer
Through vascular is used for plugging abnormal congenital or acquired
vascular connections but is also used for sometimes intracardiac
plugging (off-label)
4. Types
1. Amplatzer vascular plugs (AVP) [St. Jude Medical, Inc.; Minnesota,
USA] :I to IV for small and medium size vascular communications.
• Cera™[Lifetech Scientific Corp., China]: A single lobe device coated
with Titanium Nitride (TiN) to prevent thrombosis and improves
endothelialisation. PTFE occludes vessel faster
• Cardiac plugs for the closure of left atrial appendage and Paravalvular
leak : The Amplatzer cardiac plug-2 (ACP 2)
• Micro plugs(3 mm and 5 mm sizes that enables super-selective
embolization of distal vessels)
5. First approved AVP
AVP was approved by the US FDA in May 2004 for peripheral vascular
embolizations.
6. AVP I
• Made of finely braided Nitinol wire
• A single-layer mesh
• A single-lobe
• High radial force
• Short landing zone
• Choosing the appropriate length
and diameter of the device is very
critical as there are no rims on
either side
• Longer time for complete occlusion
7. AVP II
• Introduced in 2007.
• More occlusive
• Finer and more densely woven nitinol
braided in two or 3 layers
• A central lobe and 2 discs on each side
• The multi-layered, multi-segmented
design reduces the time to occlusion and
offers full cross-sectional vessel coverage
• Lower migration and recanalization
chances
• The multi-layered mesh lobes create six
occlusive planes, which enable faster
vessel occlusion
8. AVP III
• High flow
• Oblong cross-sectional shape made
of multiple Nitinol mesh layers and
has extended rims
• Fastest occlusion
• Device rims extending beyond
device body enables full wall
apposition
• Stability
• in high-flow vessels
• Fits elliptical shaped vascular
structures
9. AVP IV
• best and smaller profile
• Delivered through a 5F
diagnostic catheters(0.038)
• No need for catheter exchange
• distal vasculature/ tortuous and
angulated structures
• Multi-layered,double-lobed
design also enables rapid
embolization
• Size of up to 8mm.
10.
11.
12. How to implant
• Groin or jugular approach
• Sheath at Groin or Jugular route
• Diagnostic catheter
• A good quality angiogram
• Delivery catheters or sheath
• Retrieval and reposition
• Confirmation
13. Diagnostic catheter
Judkin's right coronary, Picard or Conard catheter is used to hook the
vessel and cross the site of interest using a J tipped Terumo wire
(Terumo Medical Corporation, Somerset, NJ, USA). An exchange length
Terumo or ordinary guidewire is advanced and is parked distally
14. Delivery /guide catheter of sheath
• Judkin's right (JR) guide catheter (Cordis Corporation, Miami, FL, USA)
5-7F for most of the plug delivery
• Other catheters : Multipurpose (MP),Amplatzer duct occluder (ADO)
delivery sheath (St Jude Inc,MN, USA), Cook delivery sheaths (Cook,
Bloomington, USA),carotid shudder sheath, renal guide, Amplatzer
left (AL) and Amplatzer right (AR) guide catheters
15. Delivering
• Like ASD/VSD/PDA devices
• Confirmation of successful deployment by a repeat angiogram after 5-
10minuts
• A little larger device is better
• Retrieval and preimplantation is possible in these devices
17. Advantages
• medium to large vessels with high flow
• One plug substitutes for multiple coils
• Cost effective
• Lower profile ,so easy delivery, less trauma
• Radio opacity good for visualisation
• Some plugs can be even delivered by using diagnostic angiograghic
catheters
18. Technical issues
• Technical success:92-100%
• Residual flow: higher flow, large vessel size and coagulopathy are
predictors of residual flow
• Recanalization:0.4%
• Device migration and embolization
• Reconfiguration
20. Dedicated to Ex-President And Missile Man
Of India on his death on Monday 27-2015
APJ Abdul Kalam had said once,
“Don’t declare holiday on my
death, instead work an extra day,
if you love me.”
