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Basic endovascular surgery
This document provides an overview of basic endovascular surgery techniques and interventions. It discusses the history and development of endovascular therapies from crude early techniques to modern devices. It describes common instruments used including needles, wires, catheters, sheaths, balloons, stents and stent grafts. It also summarizes access techniques, contrast agents, guidewire anatomy and construction, dilators, sheaths and catheters. The document discusses indications for endovascular interventions and various applications in treating conditions like abdominal aortic aneurysms, iliac, renal and carotid artery disease. It presents some future directions including gene identification and cell therapies.
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Basic endovascular surgery
- 1. Dr Imran JavedMBBS, FCPS Surgery. Ex-International Fellow Arizona Heart Institute / Hospital, Phoenix, AZ, USA. Ex-Senior Registrar Cardiovascular Surgery Allama Iqbal Medical College/ Jinnah Hospital Lahore, Pakistan. Basic Endovascular Surgery
- 2. Basic Endovascular Surgery BasicsInstruments •Needles •Wires •Catheters •Sheaths
- 3. Basic Endovascular Surgery •Balloons • Stents • Stent Grafts • Filters • Thrombolytics • Closure Devices • IVUS Common Interventions
- 4. Endoluminal Therapy OffersLess Invasive Approaches, Thereby Justifying Intervention at Earlier Stages in the Symptom/Disease Complex
- 5. Classical Surgical Indicationsto Treat Intermittent Claudication Are Obsolete in Many Cases Endoluminal Treatment Has Liberalized Indications For Intervention
- 6. Origin of Endovascular Therapies Crude… withonly large shafted balloons, inflexible wires, etc.
- 7. Indications for InterventionalTherapy Have Forever Changed
- 8. This is the21st Century!!!
- 9. We Are APeople On The Move... Modern Treatment Methods Must Accommodate Our Life Style
- 10. Intermittent Claudication • Absenceof pain at rest • Commencement of pain, tension weakness after walking has begun; intensification of condition until walking becomes impossible • Disappearance of symptoms after a period of rest
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- 12. Interventional Treatment Should Be ReservedFor The Most Symptomatic Patients” William R. Hiatt, M.D. from Perler & Becker 1998
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- 15. The Atherocath Turnedout to be a Good Biopsy Instrument But… Believe it or not, a new generation is forthcoming
- 16. Single Most Important Breakthrough! ThePalmaz Stent for Iliacs
- 17. The Palmaz Shatz Stentfor Coronaries A Second Most Important Breakthrough!
- 18. Overnight, Endoluminal Approaches Became the Standard of Practicein Many Arterial Distributions
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- 25. The Achilles heel ofangioplasty, including stenting: Restenosis and In-stent Restenosis
- 26. New stent designshave decreased profile for delivery, increased flexibility, and provided numerous alternatives in sizing -- but all of these failed to solve the restenosis problem
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- 28. Heparin Coated Stents Conclusion: No angiographicor clinically related benefit
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- 30. Naturally occurring antibiotic coated stent. Sirolimus Conclusion: 210 daytrial, 120 pts, Coronary 0 InStent Restenosis 24 month trail, 45 pts, Coronary 0 InStent Restenosis Cordis Velocity Stent
- 31. Balanced Effect - Healingof Stented Vessel Inhibition of Restenosis The ideal drug has higher potency for smooth muscle cells (SMCs) and lower potency for endothelial cells (ECs). Benefit/Risk Relation
- 32. Investigations are extending into the peripheral circulation MobilePeripheral Radiation Trial Sponsored by: Novoste Radiation to Treat Instent Restenosis
- 33. 9 Years post-percutaneousdeployment of endoluminal graft
- 34. THE SILVER HAWKSYSTEM
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- 37. And Cool Laser(Spectranetics) has Returned Laser Therapy Only
- 38. Beyond Occlusive Disease EndovascularAttack on Aneurysms
- 39. • The currentstandard procedure, endoaneurysmorraphy with intraluminal graft placement was popularized by Creech, DeBakey and associates Abdominal Aortic Aneurysms
- 41. • Parodi JC,Palmaz JC, Barone, MD – Transfemoral intraluminal graft implantation for abdominal aortic aneurysms Ann. Vasc. Surgery, 1991, Nov. Endovascular Stent Grafting of Abdominal Aortic Aneurysms
- 42. Commercially Available AAAEndografts 2002 Excluder Gore 2005 PowerLink Endologix 2003 Zenith Cook 1999 AneuRx Medtronic April 15, 2008
- 43. If you hadthis 6cm infrarenal AAA, would you prefer a 30cm xyphoid to pubis slice, accompanied by perforations into veins, arteries and other vital structures with needles, tubes, sheaths, conduits, urinary catheter, etc?
- 44. • Completion angiogramshows aneurysm exclusion • Groins repaired • Follow-up CTA reveals thrombosis of AAA sac
- 45. Endoluminal Grafts (ELG’s) toCorrect Aneurysmal Disease
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- 47. Current Conclusions: Excellent resultswhen indications are appropriate
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- 50. The Aptus System •Venture backed start-up • Graft with fixation applied via staples • Smaller delivery system • Locking modular limbs • Unsupported body
- 51. ELGs have multipleadvantages and when applied properly, results are equal or superior to classical procedure Current Conclusions:
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- 53. Fenestrated and Branched Endografts: CourtesyDavid Hartley The Next Frontier
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- 56. Great Vessel Transpositionfor Antegrade Delivery of the TAG Endoprosthesis in the Proximal Aortic Arch Edward B. Diethrich, MD; Marwan Ghazoul, MD; Grayson H. Wheatley III, MD; Jeffrey B. Alpern, DO; Julio A. Rodriguez-Lopez, MD; and Venkatesh Ramaiah, MD Department of Cardiovascular and Endovascular Surgery Arizona Heart Institute and Hospital, Phoenix, Arizona, USA J. Endovas Therapy 2005 Surgical graft for debranching Endoluminal graft exclusion
- 58. The Future IsNow!
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- 61. Do or WillCerebral Protection Devices Make a Difference in CAS?
- 62. Refocusing Attention on CongestiveHeart Failure Major cause for hospital admission Multiple Approaches
- 63. -Medical -Surgical “patch”, cup,etc Multiple Approaches Refocusing Attention on Congestive Heart Failure
- 64. But where is allof this leading us?
- 65. Shortly the EntireHuman Genome Will be Available for Treatment Selection Risk Assessment Prognosis
- 66. Can you imaginethe power of gene identification for the care of patients in the future?
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- 68. Basic Endovascular Surgery ANATOMY 1.Femoral 2. Brachial 3. Radial 4. Axillary 5. Popliteal
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- 71. Basic Endovascular Techniques CONTRASTMEDIA 1. Ionic 2. Nonionic
- 72. Basic Endovascular Surgery CONTRASTMEDIA Contrast Agents Anion Cation Ionic Agents Renografin Diatrizoate Sodium, meglumine, or Angiovist mixture of both salts Hypaque Conray Iothalamate Meglumine, sodium, or both Low Osmolar Agents Iohexol (Omnipaque) Nonionic dimer Iopamidol (Isovue) Nonionic dimer Ioxaglate (Hexabrix) Ioxaglate Meglumine and sodium
- 73. Access Related Accessories •Steering/Torque devices • Needles 18/21 GA • Stopcocks
- 74. Basic Endovascular Surgery DiameterMaximum Guidewire Common Needles (gauge) Diameter (in.) Length Seldinger 18 0.038 2 ¾ inch 19 0.025 20 0.021 21 0.018 Potts 18 0.038 2 ¾ inch 20 0.021 Amplatz (with 5 Fr Teflon 18 18-gauge 2 ½ inch sheath over cannula) 20 sheath accepts 0.038 Butterfly 19 0.028 Various venipuncture 21 0.021 Jelco IV (with Teflon sheath) 18 0.035 Various 20 0.025 NEEDLES
- 75. Basic Endovascular Surgery DiameterMaximum Guidewire Common Needles (gauge) Diameter (in.) Length Syringe Needles 18 0.025 Various 20 0.021 21 0.018 Percutaneous Transhepatic 22 (black hub) 0.018 20 cm Cholangiography 23 (green hub) Sheath Needle 16G sheath 0.038 24 cm (19-gauge stylet) NEEDLES
- 76. Basic Endovascular Surgery ACCESS 1.Femoral 2. Brachial 3. Axillary 4. Popliteal 5. Radial
- 77. Basic Endovascular Surgery ACCESS 1.Retrograde 2. Antegrade
- 79. Basic Endovascular Surgery ACCESS 1.Single Puncture 2. Double Puncture
- 80. Guidewire Anatomy & Construction •Composite construction • Materials – Stainless Steel – Nitinol – Jacketed Composite • Tapered grinds
- 81. • Core • StainlessSteel – Used for support – Stiffness varies based on taper / diameter of core • Nitinol – Used for it’s flexibility, memory and kink resistance • Tip • Platinum / Gold – Provides radiopacity – Atraumatic – Ribbon formed for shaping tip Core Material
- 82. • Core • StainlessSteel – Used for support – Stiffness varies based on taper / diameter of core • Nitinol – Used for it’s flexibility, memory and kink resistance • Tip • Platinum / Gold – Provides radiopacity – Atraumatic – Ribbon formed for shaping tip Core Material
- 83. • Core • StainlessSteel – Used for support – Stiffness varies based on taper / diameter of core • Nitinol – Used for it’s flexibility, memory and kink resistance • Tip • Platinum / Gold – Provides radiopacity – Atraumatic – Ribbon formed for shaping tip Core Material
- 84. Grind & TipPerformance • Stiff • Intermediate • Floppy
- 85. Variable Tip Grinds& Visibility
- 86. Variable Grinds &Tip Stiffness
- 87. Tip Shaping • Shapeabletips • Pre-shaped tips
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- 89. Sheaths • Sheaths arehemostatic conduits inserted into the vessel. They allow passage of guidewires, catheters and interventional devices. The allows these to be passed in and out of the body without damaging the vessel and reducing the blood loss.
- 90. Sheath Construction Hemostatic Valve 3-WayStopcock Sheath Conduit Dilator (obturator)
- 91. Sheaths • Peripheral andcoronary sheaths have a universal color code • Universal color coding 4 Fr = red 5 Fr = gray 6 Fr = green 7 Fr = orange 8 Fr = blue 9 Fr = black 10 Fr = violet 11 Fr = yellow • Sheaths are measured inner diameter in french size (1fr = .33mm)
- 92. Basic Endovascular Surgery CATHETERS 1.Straight - End holed - Flush 2. Rim 3. JB2 4. IMA 5. Pig 6. Omni 7. Head Hunter 8. Simmons/VTEK 9. Cobra 2 10. Berenstein 11. Grollman
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