Endovascular Prep Basic
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My presentation on endovascular workshop in Manado during Annual Meeting of Indonesian Cardiothoracic & Vascular Associations
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Endovascular Prep Basic
- 1. Basic principles &Basic principles & preparation of peripheralpreparation of peripheral interventionsinterventions Dicky A.Wartono ,MDDicky A.Wartono ,MD Consultant Cardiac & Vascular SurgeonConsultant Cardiac & Vascular Surgeon 20142014
- 2. WHY SO IMPORTANT? • PAD is often present in patients with established CAD • PAD may be the first and/or only manifestation of atherothrombosis in several pts • Peripheral complications during PCI or other cardiac interventions are not rare
- 3. A GLOBAL MANAGEMENT APPROACH IS A MUST
- 4. Before the Battle • Be prepared (for the worst) • Be carefull (misleading journals & articles) • Be well trained surgeon
- 5. Before the Battle • Endovascular setting is Surgical setting • Blood – OR team – Fasting – Consent – Surgical field preparation. • Radiation knowledge • Access problem = BIG problems
- 6. TAKE CARE AT PREPPING
- 7. ALWAYS BEGIN YOUR TRAINING AND YOUR SINGLE PROCEDURE WITH A GOOD QUALITY ANGIO
- 8. IMAGING WITH DSA IS A MUST FOR ALL VESSELS < 5.0 MM
- 9. Garcia et al, Catheter Cardiovasc Interv 2009;74:27-36 COMMON ACCESS SITES FORCOMMON ACCESS SITES FOR PERIPHERAL=FOR CORONARYPERIPHERAL=FOR CORONARY
- 10. Garcia et al, Catheter Cardiovasc Interv 2009;74:27-36 LESS COMMON ACCESS SITESLESS COMMON ACCESS SITES FOR PERIPHERAL≠FORFOR PERIPHERAL≠FOR CORONARYCORONARY
- 11. Vascular Access sites Retrograde Common Femoral Artery Access •Common access site used for peripheral diagnostic angiography and intervention •Prevent injury to the less diseased extremity
- 12. Vascular access sites •Contralateral femoral retrograde access : •Internal iliac stenoses are best treated from a contralateral approach •SFA,PFA- lesions located within the CFA/involve SFA/PFA ostium – •Proximity to arterial puncture site, Bifurcation anatomy of CFA •Also allows treatment B/L disease with a single arterial puncture
- 14. Vascular Access site Antegrade Common Femoral Artery Access: •Required for infrainguinal proced •Approx 3cm CFA lies betw ligament & FA bifurcation •Inorder to access CFA, skin entry- prox to ing ligm •Access too close to F bifurc – inadeq working room to selectively cath SFA
- 15. DEVICE SIZES AND FEATURESDEVICE SIZES AND FEATURES • Sheaths (3-9 Fr) • Shuttle sheaths (30-90 cm) • Guidewires (0.014”, 0.018”, 0.035”) • Balloons (1.25-15.0 mm) • Stents (balloon-, self-expandable) • Filters • Thrombectomy catheters (4-6 Fr)
- 17. LOWER-LIMB INTERVENTIONS: TASC II 2007 vs. TASC 2000
- 18. Modified TASC Morphological Classification of Femoral-Popliteal Lesions •A. Endovascular treatment of choice: • Single <3-cm stenosis (unilateral/bilateral) •B. Endovascular more often used: • Single 3- to 5-cm stenosis • Heavily calcified stenoses ≤3 cm • Multiple lesions each ≤3 cm (stenoses or occlusions) • Single or multiple lesions, in the absence of continuous tibial runoff, to improve inflow for infrageniculate bypass •C. Endovascular if possible: • Single stenosis or occlusion 5 to 10 cm • Multiple stenoses or occlusion, each 3 to 5 cm •D. Surgery preferred, endovascular considered on case-by-case basis: • Complete occlusion of CFA or SFA or popliteal and proximal crural arteries Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007; 45: S5–S67 SFA and Popliteal Artery Disease
- 19. IMPORTANCE OF SUBINTIMAL ANGIOPLASTY FOR LOWER-LIMB PTA
- 20. BTK PTA: TOOLS OF THE TRADE Biondi-Zoccai et al, J Endovasc Ther 2009
- 23. CAROTID ARTERY STENOSIS McDonald et al, Stroke 2009
- 24. TAKE HOME MESSAGES • Peripheral intervention skills must be mastered by all endovascular surgeon for bail-out indications • Motivated endovascular surgeons can pursue further improvements by focusing on district-specific indications, anatomy, and devices • Team work
- 25. Question ??
Editor's Notes
- emonstrated no difference at 1 year for angioplasty or surgery There was no difference in limb salvage or patient survival at 5 years.. But patency etc Darah daftar puasa konsul inform consent sio cukur… psiapa op lengkap dg graft Akses.. Open or puncture DM, renal failure, koagulopathy, tua(CV, kalsifikasi) Complication.. To outcome
- Medical therapy, intervention, and surgery have been compared in several trials in symptomatic patients with femoral-popliteal disease. A meta-analysis that compared PTA with exercise therapy in patients with intermittent claudication reported similar quality-of-life outcomes at 3 and 6 months but also found that functional capacity (ABI) improved more with endovascular therapy than with exercise.49 Cost-effectiveness and quality-of-life outcomes favor the performance of percutaneous therapy whenever feasible as a more effective treatment than exercise alone.50 A matched-cohort study of 526 patients with intermittent claudication found significant advantages for a revascularization strategy (surgery or PTA) compared with medical therapy.51 Revascularization was more effective than medical therapy for improvement in physical function, bodily pain, and walking distance. Patients with the greatest improvement in their ABI results had the best clinical improvement, which indicates that the degree of revascularization was related to a successful outcome. If the 5-year patency rate is estimated to be ≥30%, the authors concluded that percutaneous therapies would be superior to surgery.52 Clinical success in patients with SFA lesions depends on a durable, long-lasting procedure. Multiple clinical trials in small numbers of patients had previously failed to show any advantage for stents compared with PTA (Table 4).1 A meta-analysis did, however, demonstrate better patency at 3 years for stents than for PTA in the most severely affected patients, those with occlusions and CLI.53 A recent randomized controlled trial demonstrated a better outcome for primary SFA stent placement than a strategy of provisional stent placement. Not only was restenosis significantly lower in the stent group at 6 and 12 months, but there was also better functional improvement (ABI) and walking distance in the primary stent group (Figure 7).54 An interesting observation was that stent fractures, which have been associated with restenosis in SFA lesions,55 were only reported in 2% of the stents (Dynalink/Absolute, Abbott Vascular) used in this trial. There are differences regarding stent fracture among SFA stents that are presumably related to their composition and architecture. A recently published series found fracture rates of 28% for the SMART stent (Cordis), 19% for the Wallstent (Boston Scientific), and 2% for the Dynalink/Absolute stent (Abbott Vascular).56 The issue of stent fracture is a complex one, with attendant restenosis being greater in the fracture territory and the length of lesion/presence of multiple overlapping stents also being an apparent contributing factor