Treatment of Long Lesions and Femoropopliteal CTO
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This document discusses treatment options for long lesions and chronic total occlusions in vascular surgery. It begins by defining lesion lengths and then discusses various endovascular options for recanalization of long lesions and chronic total occlusions, including intraluminal recanalization, subintimal recanalization, re-entry catheters, and retrograde access techniques. It reviews data on outcomes for different stent and balloon options. It concludes that for non-calcified long lesions and chronic total occlusions in the femoropopliteal segment, an intraluminal approach is preferred initially, with subintimal or retrograde options if needed, and that drug-coated balloons or vascular mimetic stents can provide
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Treatment of Long Lesions and Femoropopliteal CTO
- 1. Hospital Felício Rocho Cirurgia Vascular Treatment Options for Long Lesions and Chronic Total Occlusions Daniel Mendes Pinto Vascular Surgery Hospital Felício Rocho – Belo Horizonte – MG Agosto - 2016 Hospital Felício Rocho Cirurgia Vascular
- 2. Hospital Felício Rocho Cirurgia Vascular JACC 2015:931-41 Lesion length • Focal: ≤ 1 cm • Short: > 1 and < 5 • Intermediate: ≥ 5 and < 15 cm • Long: ≥ 15 cm
- 3. Hospital Felício Rocho Cirurgia Vascular Bypass surgery: an option for long lesions and CTO
- 4. Hospital Felício Rocho Cirurgia Vascular Chronic Total Occlusions and Long Lesions Recent data push to endovascular solution •Good results of last generation nitinol stents •Patency rates of DCB •DES
- 5. Hospital Felício Rocho Cirurgia Vascular The most difficult step...
- 6. Hospital Felício Rocho Cirurgia Vascular 1. Intraluminal recanalization • Technical success: 50 – 62% • Less colateral damage • Theoretical risk of embolization • 0,035” hidrophilic wires • More recent approach: 0,018” stiff body • Support catheters (Elitecross, CXI, Quickcross) Schmidt JEVT 2012 RCSI-SMJ 2011;4(1):39
- 7. Hospital Felício Rocho Cirurgia Vascular Intraluminal crossing devices •Blunt microdissection • Success rate: 60 – 75% •Rotational • Success rate: 70 – 87% • Distal embolization Cordis FrontRunner Liang GZ. Internat J Cardiol 2013;165:423
- 8. Hospital Felício Rocho Cirurgia Vascular 2. Subintimal recanalization • High technical sucess rates: 80% • False lumen free of endothelium and atheroma: less hiperplasia • More “suitable space” for stents • Caution: bifurcation areas (commom femoral), distal popliteal, trifurcation • Keep in mind surgical options RCSI-SMJ 2011;4(1):39 Met R. Cardiovasc Intervent Radiol 2008
- 9. Hospital Felício Rocho Cirurgia Vascular Re-entry into the true lumen Small loop Suport catheter Angled catheters New wires Bern JR4 IM
- 10. Hospital Felício Rocho Cirurgia Vascular Parallel guidewires First wire – subintimal Second wire – Intraluminal
- 11. Hospital Felício Rocho Cirurgia Vascular Parallel antegrade guidewires
- 12. Hospital Felício Rocho Cirurgia Vascular 3. Re-entry catheters Outback LTD ® •Locate •Tune •Deploy Ocke PER. J Res Development 2015
- 13. Hospital Felício Rocho Cirurgia Vascular Outback LTD ® Wilkins LR. Tech Vasc Interv Radiol 2016 •Success with re-entry catheters: • 65 – 100% •Pooled complication rate: 4% Kitrou P. J Endovasc Ther 2015;22(4):538 Gandini R. Catheter Cardiovasc Interv 2014;82(3):485
- 14. Hospital Felício Rocho Cirurgia Vascular 4. Retrograde Access Distal SFA Popliteal Tibials – leg Tibials - foot
- 15. Hospital Felício Rocho Cirurgia Vascular Distal SFA / Popliteal •Supine position •US guided or fluoro guided •18G needle •0,018” or 0,035” wire •4F, 5F sheath or support with balloon Distal SFA Popliteal
- 16. Hospital Felício Rocho Cirurgia Vascular Retrograde access – distal SFA Schmidt JEVT 2012
- 17. Hospital Felício Rocho Cirurgia Vascular Tibial - lower leg / foot Tibials – leg Easy US-guided puncture Sheathless Foot: fluoroscopy guided
- 18. Hospital Felício Rocho Cirurgia Vascular Guidelines of Management of Patients with Peripheral Arterial Disease •AHA/ACCF JACC 2005 •TASC II. JVS 2007 •Update Guideline AHA 2011 •AHA/ACCF Circulation 2013 •SVS Guidelines 2015. Practice for atherosclerotic occlusive disease of the lower extremities. Ballon angioplasty Bail-out stents
- 19. Hospital Felício Rocho Cirurgia Vascular Review data – femoropopliteal segment J Vasc Surg 2014;59:1123-33
- 20. Hospital Felício Rocho Cirurgia Vascular Katsanos et al. J Vasc Surg 2014: 1123
- 21. Hospital Felício Rocho Cirurgia Vascular Katsanos et al. J Vasc Surg 2014
- 22. Hospital Felício Rocho Cirurgia Vascular Long lesions and CTO Scaffolding is advisable! •Long term patency with 3rd generation nitinol stents • > 3 year: 30 – 60% Zeller, Curr Cardiol Rep 2015 •2-year - 4th generation stents • 84% freedom from TLR Walker, NCVH 2015
- 23. Hospital Felício Rocho Cirurgia Vascular Femoro-popliteal stents Elgiloy Nitinol Helical nitinol
- 24. Hospital Felício Rocho Cirurgia Vascular Femoro-popliteal stents Vascular Mimetic Implants • Fully connected nitinol • Conform the vessel wall Smart Flex Supera
- 25. Hospital Felício Rocho Cirurgia Vascular Femoro-popliteal lesions 0 10 20 30 40 50 60 70 80 90 100 1 year primary patency DEFINITIVE-LE Aterectomia pp 75% lesões: 8,1 cm RESILIENT Lifestent pp 81,3% lesões: 6,2 cm DURABILITY II Protegé pp 77,2% lesões: 8,9 cm STRIDES Drug eluting stent pp 68% lesões: 9,0 cm STRIDES Drug eluting stent pp 68% lesões: 9,0 cm IMPACT Drug coated balloon pp 83,7% lesões: 8,4 cm LEVANT I Drug coated balloon pp 67% lesões: 8,1 cm Vascular Mimetic Stent pp 84,1% lesões: 8 cm Vascular Mimetic Stent pp 81% Lesões > 15 cm Atherectomy Bare nitinol stents Drug Eluting Stents Drug Coated Balloons 4th generation nitinol stents
- 26. Hospital Felício Rocho Cirurgia Vascular Conclusion Long lesions / CTO Femoropopliteal Non-calcified: • Intraluminal first • Subintimal if failed • Re-entry devices if avaiable • Retrograde access Drug Coated Ballon Spot stenting Vascular Mimetic Stents Severe calcified: • Subintimal • Re-entry devices if avaiable • Retrograde access Vascular Mimetic Stents Bare Nitinol Stents
- 27. Hospital Felício Rocho Cirurgia Vascular OBRIGADO! • Disponível em: slideshare.net • daniel@vascularbh.com.br • 31 99161.8318