Use of Vascular plugs in cardiovascular medicine

1. VASCULAR PLUGS: CURRENT USE
SHORT SEMINAR
Satyam Rajvanshi

2. INTRODUCTION

3. • Embolization is defined as the "therapeutic
introduction of various substances into the
circulation to occlude vessels, either to arrest or
prevent active hemorrhage; to devitalize a structure,
tumor, or organ by occluding its blood supply; or to
reduce blood flow to an arteriovenous
malformation."
Stedman T. Stedman's Medical Dictionary. 27th ed. Lippincott Williams & Wilkins. 2000.

4. • Endovascular embolization, or embolotherapy, is
performed by interventional cardiologists or
interventional radiologists

5. Embolization therapeutic goals:
• An adjunctive goal (preoperative, adjunct to
chemotherapy or radiation therapy)
• A curative goal (aneurysms, arteriovenous fistulae
[AVFs], arteriovenous malformations [AVMs], and
traumatic bleeding)

6. Medical conditions treated by using embolotherapy can
be grouped as follows:
• Vascular anomalies (eg, AVM, AVF, venous
malformation [VM], lymphatic malformation [LM],
and hemangioma)
• Hemorrhage (eg, pseudoaneurysms, GI tract, pelvic,
posttraumatic, epistaxis, and hemoptysis bleeding)
• Other conditions (eg, tumors, varicoceles, organ
ablation, BPF)

7. EMBOLIZATION MATERIALS AND
SUBSTANCES

8. • Permanent vessel occlusion
– Particulate material
• Polyvinyl alcohol
• Gelatin-acrylic microspheres
– Sclerosing agents
• Alcohols
– Glue
• Cyanoacrylate
• Sodium Tetradecyl Sulfate
– Metallic
• Coils
• Vascular Plugs
• Temporary occlusion
– Gelfoam

9. VASCULAR PLUGS

10. VASCULAR PLUG
• Self-expandable devices made of nitinol wire
mesh (or other material) which can be
cylinderized into a sheath and deployed
precisely at embolization targets

11. Vascular plug vs. Coil
• Speed: Reduction in procedure times
• Radiation Exposure: Reduction in radiation times
• Cost-effectiveness: Reduction in procedural costs
– specially in large vessels
• Efficiency: Reduction in materials used,
uncommon recanalisation or persistent flow,
device embolisation rare
• Precision: Recapturable and redeployable for
precise placement

12. • Amplatzer vascular plugs
• Cera vascular plugs
• Medusa vascular plug
• Microvascular plug

13. AMPLATZER VASCULAR PLUG
• Manufactured by St. Jude Medical (USA)
• First approved by USFDA on May 3, 2004, for
peripheral vascular embolizations
• 1st study reporting successful use of the AVP was
published in 2004
Hijazi ZM (2004) New device for percutaneous closure of aortopulmonary collaterals.
Catheter Cardiovasc Interv 63(4): 482–485

14. • Designed as a permanent occluding flexible
cylindrical device derived as a modification of the
family of Amplatz septal occluders and Amplatzer
Duct Occluder
• Excellent alternative to coils or detachable balloons
in the embolization of medium to large vessels with
high flow - otherwise require multiple coils

15. • All AVP models - 2 basic components: a vascular plug
and a delivery wire
• Plugs built with nitinol braids, self-expanding
radiopaque platinum marker bands at both ends
that allow for high visibility under fluoroscopy
Stainless-steel screw on one of the platinum
marker bands attaches to a delivery cable
• Ability to recapture and reposition the device as
needed
• After satisfactory positioning, counterclockwise
rotation of connecting cable releases device

17. • Single model has evolved into 4 models
• For use in various types of anatomy,
hemodynamics, and lesion entities
• AVP I and II – USFDA approved 2004, 2007
• AVP III – 2008 CE marked but not available in
US
• AVP 4 – USFDA approved 2012

18. AVP or AVP I
Single lobar plug
Guide 5-8 Fr
Sheath 4-6 Fr
Diameter 4-16 mm
Increments 2 mm
Length 7-8 mm
Lesion with short landing
zone requiring high
radial force to secure
AVP

19. Select a device with a diameter approximately 30-50% larger
than the vessel diameter at the occlusion site

23. AVP II
Multi (6)-layered Tri-lobar
plug with increased
length
Guide 5-9 Fr
Sheath 4-7 Fr
Diameter 3-22 mm
Increments 2 mm
Length 6-18 mm
Rapid occlusion
Used when Variable landing
zone – can be shortened
by compression
Minimises migration and
recanalization

24. Select a device with a diameter approximately 30-50% larger
than the vessel diameter at the occlusion site

25. Large Left Segmental Pulmonary Artery Pseudoaneurysm

26. AVP 4
Multi (4)-layered Bi-lobar
plug with small profile,
more flexible delivery
wire
Simple delivery - 0.038”
guidewire compatible
diagnostic catheter
(Guide/Sheath not
required)
Diameter 4-8 mm
Increments 1 mm
Length 10-13.5 mm
Small, tortuous vessel
Rapid occlusion

27. Select a device with a diameter approximately 30-50% larger
than the vessel diameter at the occlusion site

28. AVP 4 completely occluding coronary fistula originating from
proximal RCA draining into the right upper lung field

29. AVP III
Oblong plug with 2
extended rims
Guide 6-9 Fr
Sheath 4-7 Fr
Diameter 4-14 mm (Long Axis)
Increments 2 mm (Long Axis)
Length 2-5 mm (Short Axis)
Fastest occlusion of all AVPs
Enhanced stability in high
flow states
Niche device for suitable
anatomy
Like ASD occluder stretched sideways!

30. Amplatzer Vascular Plug III 12/5 device implant in aortic position. A: in systole, the device does not interfere
with the prosthesis. B: in diastole, the device does interfere with the prosthesis. C: an Amplatzer Duct
Occluder 12/10 device implant that does not interfere in systole. D: or in diastole

31. CERA VASCULAR PLUG SYSTEM
• Manufactured by Lifetech Scientific Corp., China
• Single lobe device coated with Titanium Nitride –
prevent thrombosis and improves endothelialisation
• PTFE coated – shorter occlusion time

32. Single lobed, PTFE covered
Guide 4-9 Fr
Diameter 4-24 mm
Increments 2 mm
Length 7-14 mm
Rapid occlusion due to PTFE

33. MEDUSA VASCULAR PLUG
• Manufactured by Endoshape, USA
• USFDA approved in Nov,2013
• Constructed from multiple 0.018” polymer coils
• Highly trackable in tortuous anatomy

34. MEDUSA VASCULAR PLUG
• Manufactured by Endoshape, USA
• USFDA approved in Nov,2013
• Constructed from multiple 0.018” polymer coils
• Highly trackable in tortuous anatomy
• Better Imaging - Minimal metal content reduces
artifacts; follow up can be with a CT/MRI versus an
angiogram

37. MICROVASCULAR PLUG
• Manufactured originally by Covidien, USA
• Covidien later bought by Medtronic, USA
• MVP plug - The first plug deliverable through a
micro catheter
• Enables super-selective embolization of distal
vessels
• PTFE coated Nitinol design – rapid occlusion

38. • Length 12 mm
• Diameter 5.3 mm and 6.5 mm
• 3 mm MVP™ plug: recommended delivery through .021"
micro catheter2
• 5 mm MVP™ plug: recommended delivery through .027"
micro catheter

39. APPLICATIONS

41. VASCULAR
• ARTERIAL: Parent artery occlusion
– Internal iliac
– Carotid
– Vertebral
– Renal
– Gastroduodenal
– Aberrant right subclavian artery
– Popliteal artery aneurysm
– Hepatic artery pseudoaneurysm
– Hepatic cavernous hemangioma

42. VASCULAR
• VENOUS
– Portal Vein –Preoperative embolization of tumor
side portal vein stimulates contralateral liver
lobular hypertrophy - improves resection rate
– Gastric varix in conjunction with a TIPS
– Varicocele embolization for infertility
– Ovarian vein embolization for female pelvic
congestion syndrome
– Saphenous vein graft aneurysm
– Large inferior vena cava aneurysm

43. ABNORMAL VASCULAR CONNECTIONS
• CONGENITAL
– Pulmonary AVMs; renal AVMs; Hepatic AVMs
– PDA
– PDV – intrahepatic portosystemic shunt
– Splenorenal shunt
– Spontaneous mesocaval shunt in SMA
– Scimitar vein to left atrium
– Congenital coronary artery fistula

44. ABNORMAL VASCULAR CONNECTIONS
• ACQUIRED
– HD-AVF
– TIPS
– Blalock-Taussig shunt
– Traumatic arteriovenous fistula

45. CARDIAC
• Paravalvular leak closure
– Mechanical MV/AV
– TAVI
• PDA
• LAA

46. MICROVASCULAR PLUGS
• Hepatic artery skeletonisation – before
radioembolisation/chemoembolisation of tumor
• Gastroduodenal artery - during radioembolization
• Recanalized pulmonary arteriovenous
malformation previously coil embolised
• Splenic artery hemorrhage secondary to tumoral
erosion
• Lower gastrointestinal hemorrhage
• Temporary vessel occlusion by undeployed MVP
plug - Whenever only temporary occlusion of a
critical vessel is desired - during complex vascular
procedures; or Radio/chemo embolisation

47. NON-VASCULAR
• EXTRA VASCULAR
– Bronchopleural fistula!
– Vesicovaginal fistula!
– Intraperitoneal bile leak!

48. CONCLUSION
• Vascular plugs as occlusion devices are valuable in
managing a wide variety of disease processes
• Easy to use, can be precisely deployed in the target
vessel, high resistance to migration, low recanalization
rate
• Vessel size, high-flow status, and coagulopathy can
prolong the occlusion time. The addition of coils,
gelfoams as an adjunct can achieve rapid and reliable
occlusion with minimal cost
• Continued evolution in product design has improved
occlusion properties and decreased device profile –
alongwith interventionalist’s innovative usage – has
truly widened the spectrum of clinical indications for
these versatile devices

49. CARDIOLOGY IS NOTHING BUT
‘JUGAAD’ WITH EXPERTISE
- Dr. Ranjeet Nath