1362577943_PVD & DM RevascularizaR

7/27/2019 1362577943_PVD & DM RevascularizaR

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Peripheral Vascular Disease,

Angiography - Angioplasty andSurgical Techniques

Dr. Rajdeep Agrawal,MD, DM

Interventional Cardiologist &Vascular Interventionist,

Sir H N Hospital,MumbaiBreach Candy HospitalCumballa Hill Hospital


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Dr. Rajdeep Agrawal

Indications of Angiography in

PVD Life style limiting claudication

Critical ischemia / limb threateningischemia (rest pain, nocturnal pain,non healing ulcer, gangrene

Graft stenosis

High surgical riskAcute ischemia of lower limb


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Dr. Rajdeep Agrawal

Arteriogram

Remains the Gold standard for vascularevaluation.

Should be done only in patients who have

clinical indications for vascularinterventions (surgery or angioplasty)

Complications are less than 5% and

mortality about 0.025%.

Patients should be well hydraded before

and after angiograms, especially

diabetics.


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Dr. Rajdeep Agrawal

Angioplasty -- History

Charles Dotter (1964)

First angioplasty using co-axial

catheter

Andreas Gruentzig (1977)

First PTCA using double lumencatheter


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Percutaneous TransluminalAngioplasty (PTA) in Peripheral

Vascular Disease

An over view of the arterialpathologies of the lower limbs

and their percutaneoustreatment

modalities


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Dr. Rajdeep Agrawal

Percutaneous TransluminalAngioplasty

A non-surgical technique designed toincrease the lumen of the vessel & thus

prevent ischemia & its complications

Mechanism

Inflated balloon exerts circumferential

pressure on the plaque

1. Plaque splitting & disruption

2.

Stretching of the vessel wall

3. Compression of the atheroma


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Rutherford Becker classification of PVD

Grade

Category

Symptoms

O O None

I 1 Mild claudications

I 2 Moderate claudications

I 3 Severe (life style limiting)claudications

II 4 Rest pain

III 5 Nonhealing ulcers focalgangrene


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Rutherford Becker classification of PVD

Ankle Brachial Index -

> 0.90 No significant obstructive

disease

0.50 to 0.90 Claudications (Grade I)


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Ideal settings for PTA

LesionsCharacteristics

PatientCharacteristics

Short Non diabeticConcentric Claudication

Non calcified

SolitaryNon occlusive

Large vessel

Continuous run off


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Vascular Disease

Modalities will include

Angioplasty,

Stents,

Lasers,

Rotablaters,

And Thrombolysis


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Vascular Disease

Modalities will be treated together or separately

in the territories commonly affected byvascular disease

Acute arterial obstruction will be treated as a

separate issue, where multimodal treatmentsmay come together


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Lower Limb Ischemia -Vascular involvement in Diabetic

Aorto illiac relatively spared.

Most of the diseases involves

infrainguinal arteries (femoral - popliteal -tibial)

About 60% have involvement of plantar

arch and digital arteries.

About 80% have microangiopathy

Does not adversely affect the outcome of

vascular reconstruction.


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Angiography -- Technique

Approach Femoral / Brachial

Vascular accessusing Seldingerstechnique

Material / Hardware 0.035 guide wire

Renal catheter, Simmons cath


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Seldinger needle & guide wire forintroducing an arterial catheter


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Arterial Occlusionjust above theknee causing

claudication ofthe calf; goodcollateralcirculation


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Balloon Catheter for PTA


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Contraindications topercutaneous revascularization

PTA C/I - Medically unstable

(Absolute) - Stenosis adjacent to aneurysm

or near an ulcerated plaque(Relative) - (Unfavourable anatomy)

Long segment & multi-focal

stenosisLong segment Occlusions

(thrombolysis)


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PTA Contra-indications

(Relative) - If large vessel at ankle is availablefor bypass

- Heavy eccentric calcification

- Lesion in essential collateral vessel

- Stenosis with thrombus

Percutaneousrevascularization


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Dr. Rajdeep Agrawal

Post PTA recurrence are seldom worse thanbefore, does not interfere with the originalplanned surgery.

In 25% Femoro - popliteal PTFE Graft,

Popliteal gets occluded when bypass

closes

Adar etal



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THROMBOLYSIS is an alternateattemptable modality of treatment in

PVDSafe if cases are selected properly

Cannot be used in all cases.

Various methods are used to administerthrombolysis

Acute ischemia of lower limb is one area

Percutaneous revascularization


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Intra-arterial Thrombolysis

Restores blood flowIdentifies underlying lesion

Thrombotic or embolic occlusion

Native artery or bypass graft



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THROMBOLYSIS - CONTRAINDICATIONS

Absolute -Active internal bleedingIrreversible limb ischaemia

Recent stroke, craniotomy

Mobile L-V thrombus



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THROMBOLYSIS CONTRAINDICATIONS

Relative - H/o GI bleed

- Recent major surgery/CPR/Trauma

- Diastolic BP >125 mm

- DM Proliferative Retinopathy

- Sub acute bacterial endocarditis

- Coagulopathy- Post partum state



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Dr. Rajdeep Agrawal

Stents: Contra indications

- Diffuse aortic disease- Extravasation of contrast after PTA

- Non compliant lesion on angioplasty

- Diffuse iliac disease

- Aortic tortuosity & aneurysm- Diffuse long segment small caliber external

iliac or femoral artery



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Stent Complications (10%)

- Almost all are minor

- Puncture site injury- Distal embolization

- Stent dislodgement

- Pseudo anemysm formation- Vessel rupture



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Vascular DiseaseAORTO ILIAC Percutaneous

Transluminal Angioplasty

- Optimizes inflow for bypass

- Excellent patient tolerance

- Short recovery period

- No worsening of vascular status if fails


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AORTIC OCCLUSSIONS

- Relatively uncommon

- Younger population who smoke

- Claudication and impotency

- Risk of propagation of clot to renal and

mesenteric artery



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ABDOMINAL AORTIC STENOSIS

- Isolated - relatively uncommon

- More frequent in women with hypoplasticaortas

- PTA and Stent can be tried and are useful if thelesions are amenable

- Otherwise Grafts can be placed- Even thrombolysis could be attempted with

angioplasty

- Large thick atherosclerotic lesions could be

common



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AORTO ILIAC STENTING

Indications - Residual stenosis > 30% after

percutaneous revascularizationOr if a gradient >10mm persists

Dissection

Highly eccentric stenosisRecurrent Stenosis post PTA

Iliac artery occlusion


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ILIAC ARTERY STENOSISPTA

- PTA with/without stent

- Focal, uncalufied sterosis 10cm) respond less favorably

STENTS

- Residual pressure gradient (30%)

- Flow limiting dissection flap

-

Restenosis (acute or subaiute)



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ILIAC ARTERY OCCLUSIONS

- Bilateral Surgery treatment

- Primary stent placement

- PTA followed by stent

- Thrombolysis followed by stent



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INTERNAL ILIAC STEONSIS

- Isolated buttock claudication

- Impotence

- PTA is the choice



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CFA STENOSIS

- Isolated is uncommon without history ofinjury (eg. Catheterization)

- Endarterectomy choice simple, LA andconscious sedations

- Durable than PTA



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Ext. Iliac Artery stenosis - before,after dilatation, after stent


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Femoro popliteal

- Lesion 3 times commoner than iliac

- Occlusions 3 times commoner than

stenosis

- 80% of the stenosis are


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Femoro popliteal

- 10 cm upper limit to select cases

- Stents disappointing beyond thatlength of stenosis

- Covered (PTFF) grafts have a promise

- Over 5 years 15-20% new Femoropopliteal occlussions develop



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Narrowed superficial femoral arterybefore & after dilatation


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Femoropopliteal stenosis:

- PTA is less durable than bypass.- Bypass 5 year patency rate is about 80%

- Complication of PTA is 10%, surgical repair

required in 2% cases



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Femoropopliteal stenosis

-Stents useful in proximal Superficial FemoralArtery

- Stents restenosis in distal SFA or poplitealartery due to extrinsic compressions (eg.

Addutor canal) is possible- Long term consequences of placing flexible

stents across joints is unknown.



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Femoropopliteal occlussions:

- Long segment or complete SFA occlusions doesnot respond well to any widely available

endovascular technique

- Amplatz thrombectomy catheter excellenttechnical access, but long term patency ismodest or unknown

- Covered stents - results disappointing

- Endovascular stent grafts show most promise



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Femoropopliteal occlusions:- PTA is effective for short solitary occlusions,

< 10cm long, not involving SFA origins ordistal popliteal artery

and tenders occlusions


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Femoropopliteal occlusions:- Upper SFA occlusions stent if PTA is sub-

optimal

- PTA long term patency rates may besubstantially less than clinical patency rates

- Technical failure almost always results frominability to cross the lesion with guide wire.



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Infra-popliteal revascularization -Indications

Absence of pedal pulses minimal orasymptomaticIf collaterals are not well developed orlimitation of activity resultsFocal lesionsLimited in diffuse disease,If short term patency is desired sufficient toheal superficial ulcerations or amputationsites



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Infra popliteal revascularization

Early results - Not impressive

Manipulations - Easier with DSA

& road mapping

Increased popularity - Safe & Successful

Decision with surgeon

Inflow lesions Treatment first



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Tibial Artery Obstructions:

Infra popliteal PTA is almost always performed forlimb salvage

- Short term patency may be sufficient to allow healingof an ischemic ulcer or amputation site or to avoidamputation

- PTA is not particularly effective if run-off vessels arenot visualized. Liberal Heparin use must to maintainpatency



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STENTS RESULTS

- Technical success rate 90-100%- Cumulative 5 year vessel patency 94%

- Clinical success 93%

- (PTA 65% & 70%)



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Infra-popliteal revascularization

Indications

- Limb threatening Ishcemia

(Disabling claudication, Rest pain, Ulcer, Gangrene)

- ABI < 0.5 Ischemic rest pain or ankle pressure


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Stent

An expandable metallic helicaldevice which is permanentlyimplanted in the artery.

MechanismThe prosthesis acts as a scaffold

to hold the artery open

Prevents recoil of the vessel

Reduces Restenosis


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Newer Techniques OfAngioplasty

Atherectomy

Directional

Percutaneous Rotational

TEC

LASERStent


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Directional Atherectomy

It excises the atheromatous

plaque material into very fineslices which can be retrievedoutside body


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Percutaneous Rotational

Atherectomy (Rotablator)


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LASER

A LASER produces an intense beamof light in uniform wavelength that

can be precisely focused to deliverhigh energy levels to a small area

It converts solid plaque to gaswhich is soluble in blood


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Stent Complications (5-10%)

Groin hematoma

Pseudo AneurysmEmbolization of thrombus

Acute stent thrombosis

DissectionVessel perforation



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IDDM Reduce insulin

First case

5% Dextrose, Blood sugar,

Insulin (1-3 units/ hr) or more for higher

blood glucose levels

No protamine zinc insulin should be used

Protamine antagonizes the heparinanticoagulation

Hybration to prevent aute tubular necrosis



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Dr. Rajdeep Agrawal

Cost effectiveness of PTA compared tosurgical reconstruction

PTA - Bypass - 53% in Disabling Claudication

75% in critical ischemia

A cost effective analysis demonstrated that performing

PTA as a initial procedure is more desirabletechnically feasible cases and reserving bypasssurgery for those PTS in whom PTA fails, or recurswould save more lives, limbs and money.



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Dr. Rajdeep Agrawal

Cost effectiveness of PTA compared tosurgical reconstruction

In technically feasible cases PTA would be thepreferred option

Reserve bypass surgery for those PTAs in whom

it fails, or recursIt would save more lives, limbs and money.



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Complications:

Vasospasm - Nifedipine start well beforeprocedure

- Intra-arterial Nitroglycerins,in the vessel to be treated(100 to 200 mg) before dilation

Flow limiting dissection flap Employ Stent



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Complications:

Post PTA occlusion

Repeat PTA & thrombolytic therapyOR Repeat PTA Stent

Arterial rupture Reinflation of baloon across

rupture

,followed by surgical repair



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Medical Therapy

Exercise program

Risk factor modifications


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Results of percutaneous therapy

Site & DiseaseOf arterialstenosis

Therapy

Success% of

Technic

1 yearpatency

(%)

3 yearpatency (%)

AbdominalAorta

PTA 95 ? ?

Iliac PTA 95 80 70

Iliac Stent 95 90 85Iliac occlusion Stent 80 70 65

Two year limb salvage of 60 to 80%


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Results of percutaneous therapy

Site & DiseaseOf arterialstenosis /occlusion

Therapy Success% of

Technic

Oneyear

patency(%)

Threeyear

patency(%)

Proximalfemoral

Stent 95 85 75

Femoro

poplitealOcclusion

Lysis,

PTA

80 50 40

Tibial stenosis PTA 90 - -

Two year limb salvage of 60 to 80%


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Aorto-iliac Occlusions:

Aorto bifemoral bypass- Extra anatomic

- Endarterctomy

- 5 year patency - 85 to 95%

Surgical revascularization - 1


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Infra inguinal occlusions:

- Autologous veins or PTFE grafts are used

PTEF above Hunters canal for SFA

- Saphenous Vein below knee, for tibial or peronealocclusion

- 5 yr patency 60% - above

- Below knee 3 yr patency and limb salvage 58 to92% respectively



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AORTIC OCCLUSSIONS

- Aorto bifemoral graft with endarterectomyaxillo bifemoral graft or thorarofemoral graft

- Re-construction with endovascular stent graftis feasible long term results unknown


L Li b I h i


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Lower Limb Ischemia -Approach to Therapy

Direct arterial reconstruction.

Endarterectomy

Vascular bypass

Endovascular (minimally invasive)intervention

Lumbar sympathectomy

L Li b I h i


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Lower Limb Ischemia -Results of Direct Reconstruction

Aorto illiac reconstruction - early graft patency of

about 98%, operative mortality 3%:5years graft

patency of 85-90%.

Femoro popliteal bypass - early graft patency of

over 90%, with mortality of 2-5% : 5 year patency

of about 75%.

Infrapopliteal/ paramalleolar bypass - earlypatency of about 90% with 2% mortality. 5 year

patency of 55%

LIMB SALVAGE about 90%


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OPERATIONS

Depends on the site of occlusion and

the physical state of the patient.


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Aorto-iliac occlusion

Limited involvement : Iliac Endartectomy

Marked involvement : Aorto-femoral bypass

Aorto-iliac occlusion patient unable to undergosurgery;

1 iliac artery involved : femoro-femoral or

ileo-femoral bypass

Both iliac arteries involved : Axillo-bifemoralbypass


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Atheroscleroticnarrowing ofaortic bifurcation

Aortobifemoralgraft to bypassstenosis

Femoral & Profunda Femoris


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Femoral & Profunda FemorisOcclusion

If conservative measures not suitable,PTA may be possible

For more severe disease, angioplasty orbypass maybe used

Femoropopliteal bypass graft is the

most usual operation Saphenous vein graft gives the best

results


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Superficialfemoral arteryocclusion withprofunda femorisstenosis providing

poor collateralcirculation

Femoropopliteal

graft used tobypass theoccluded area


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Occlusion below popliteal

Bypass to tibial vessels, even down tothe ankle can be met with reasonable

success. Most successful is with long saphenous

vein in the in situfashion.

If saphenous not available, can usePTFE (Polytetrafluoroethylene) graft.


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PROSTHETIC MATERIALS

Aortoiliac bypass - Dacron

Femoropopliteal - Autogenous veins

(Long saphenous best)If not available - PTFE orglutaraldehyde-tanned, Dacron

supported, human umbilical vein Profundoplasty - Vein/PTFE/Dacron


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Treatment of A/C Occlusion

Embolectomy - Using Fogartys catheter ->Catheter passed beyond emblous, ballooninflated & pulled back till blood comes

Direct Embolectomy - Artery exposed,transverse incision, clot removed.

Intra-arterial Thrombolysis - TPA preferred.

Arteriography done and a catheter embeddedin clot - Thrombolytic agent infused overseveral hrs

S i l E b l t


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Surgical Embolectomy

Relatively simple procedure Done under LA, small incision in the

groin, using Fogartys cath.

Problems1. Blind procedure, can be traumatic

2. Not successful in 10 30% cases

3. Inefficient in multistenosed artery

4. Complete removal of thrombusdifficult in leg arteries


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Post PTA MX

Antiplatelet agents

LMW Heparin X 7 10 D

IV / oral Trental

Statins

Aggressive control of riskfactors


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Conclusion

In Diabetic foot, PVD contributes toamputation by impeding the delivery ofantibiotics, Oxygen, nutrients & by

delaying wound healing & the ability tofight infection.

Aggressive therapy with debridement,antibiotics,good control of Diabetes &

when indicated revascularisation resultsin salvage of > 90% of threatened limbseven in high risk patients

1362577943_PVD & DM RevascularizaR

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