1362577943 pvd & dm revasculariza r

Peripheral Vascular Disease, Angiography - Angioplasty and Surgical Techniques

Dr. Rajdeep Agrawal,Dr. Rajdeep Agrawal, MD, MD, DMDM

Interventional Cardiologist Interventional Cardiologist & Vascular Interventionist& Vascular Interventionist,,

Sir H N Hospital,Mumbai Sir H N Hospital,Mumbai Breach Candy Hospital Breach Candy Hospital Cumballa Hill Hospital Cumballa Hill Hospital

Dr. Rajdeep Agrawal

Indications of Angiography in PVD

Life style limiting claudicationLife style limiting claudication Critical ischemia / limb Critical ischemia / limb

threatening ischemia (rest pain, threatening ischemia (rest pain, nocturnal pain, non healing ulcer, nocturnal pain, non healing ulcer, gangrene gangrene

Graft stenosisGraft stenosis High surgical riskHigh surgical risk Acute ischemia of lower limbAcute ischemia of lower limb

Dr. Rajdeep Agrawal

Arteriogram

Remains the ‘Gold standard’ for vascular Remains the ‘Gold standard’ for vascular evaluation.evaluation.

Should be done only in patients who have Should be done only in patients who have clinical indications for vascular interventions clinical indications for vascular interventions (surgery or angioplasty)(surgery or angioplasty)

Complications are less than 5% and mortality Complications are less than 5% and mortality about 0.025%.about 0.025%.

Patients should be well hydraded before and Patients should be well hydraded before and after angiograms, especially diabetics.after angiograms, especially diabetics.

Dr. Rajdeep Agrawal

Angioplasty -- History Charles Dotter (1964)Charles Dotter (1964)

First angioplasty using co-First angioplasty using co-axial catheteraxial catheter

Andreas Gruentzig (1977)Andreas Gruentzig (1977) First PTCA using double First PTCA using double

lumen catheterlumen catheter

Dr. Rajdeep Agrawal

Percutaneous Transluminal Angioplasty (PTA) in Peripheral

Vascular Disease

An over view of the arterial An over view of the arterial pathologies of the lower limbs pathologies of the lower limbs and their percutaneousand their percutaneous treatmenttreatmentmodalitiesmodalities

Dr. Rajdeep Agrawal

Percutaneous Transluminal Angioplasty

A non-surgical technique designed to increase A non-surgical technique designed to increase the lumen of the vessel & thus prevent ischemia the lumen of the vessel & thus prevent ischemia & its complications& its complications

MechanismMechanism Inflated balloon exerts circumferential Inflated balloon exerts circumferential pressure on the plaque pressure on the plaque 1. Plaque splitting & disruption1. Plaque splitting & disruption 2. Stretching of the vessel wall2. Stretching of the vessel wall 3. Compression of the atheroma3. Compression of the atheroma

Dr. Rajdeep Agrawal

Rutherford – Becker classification of PVD

GradGradee

CategoCategoryry

Symptoms Symptoms

OO OO NoneNoneII 11 Mild claudicationsMild claudicationsII 22 Moderate claudicationsModerate claudicationsII 33 Severe (life style limiting) Severe (life style limiting)

claudicationsclaudicationsIIII 44 Rest painRest painIIIIII 55 Nonhealing ulcers focal Nonhealing ulcers focal

gangrenegangreneIIIIII 66 Major tissue lossMajor tissue loss

Dr. Rajdeep Agrawal

Rutherford – Becker classification of PVDRutherford – Becker classification of PVD Ankle Brachial Index - Ankle Brachial Index - > 0.90 – No significant obstructive > 0.90 – No significant obstructive

diseasedisease 0.50 to 0.90 – Claudications (Grade I)0.50 to 0.90 – Claudications (Grade I) <0.50 – Limb threatening ischemia<0.50 – Limb threatening ischemia

(Grade II or III)(Grade II or III)

Dr. Rajdeep Agrawal

Ideal settings for PTALesions Lesions

CharacteristicsCharacteristicsPatient Patient

CharacteristicsCharacteristicsShort Short Non diabeticNon diabeticConcentricConcentric ClaudicationClaudicationNon calcifiedNon calcifiedSolitarySolitaryNon occlusiveNon occlusiveLarge vesselLarge vesselContinuous run offContinuous run off

Dr. Rajdeep Agrawal


Vascular Disease

Modalities will include – Modalities will include – Angioplasty, Angioplasty, Stents, Stents, Lasers, Lasers, Rotablaters, Rotablaters, And ThrombolysisAnd Thrombolysis

Dr. Rajdeep Agrawal


Vascular Disease

Modalities will be treated together or Modalities will be treated together or separately in the territories commonly separately in the territories commonly affected by vascular disease affected by vascular disease

Acute arterial obstruction will be treated Acute arterial obstruction will be treated as a separate issue, where multimodal as a separate issue, where multimodal treatments may come together treatments may come together

Dr. Rajdeep Agrawal

Lower Limb Ischemia - Vascular involvement in Diabetic

Aorto illiac relatively spared. Aorto illiac relatively spared. Most of the diseases involves Most of the diseases involves

infrainguinal arteries (femoral - popliteal - infrainguinal arteries (femoral - popliteal - tibial)tibial)

About 60% have involvement of plantar About 60% have involvement of plantar arch and digital arteries. arch and digital arteries.

About 80% have microangiopathy About 80% have microangiopathy Does not adversely affect the outcome of Does not adversely affect the outcome of

vascular reconstructionvascular reconstruction..

Dr. Rajdeep Agrawal

Angiography -- Technique ApproachApproach

Femoral / BrachialFemoral / Brachial

Vascular accessVascular access using Seldinger’susing Seldinger’s techniquetechnique

Material / HardwareMaterial / Hardware 0.035 guide wire 0.035 guide wire Renal catheter, Simmon’s cathRenal catheter, Simmon’s cath

Dr. Rajdeep Agrawal

Seldinger needle & guide wire for introducing an arterial catheter

Dr. Rajdeep Agrawal

Arterial Arterial Occlusion just Occlusion just above the knee above the knee causing causing claudication of claudication of the calf; good the calf; good collateral collateral circulationcirculation

Dr. Rajdeep Agrawal

Balloon Catheter for PTA

Dr. Rajdeep Agrawal

Contraindications to percutaneous

revascularizationPTA C/I - Medically unstablePTA C/I - Medically unstable(Absolute) - Stenosis adjacent to aneurysm(Absolute) - Stenosis adjacent to aneurysm or near an ulcerated plaqueor near an ulcerated plaque(Relative) - (Unfavourable anatomy)(Relative) - (Unfavourable anatomy) Long segment & multi-focal Long segment & multi-focal stenosisstenosis Long segment OcclusionsLong segment Occlusions (thrombolysis)(thrombolysis)

Dr. Rajdeep Agrawal

PTA Contra-indicationsPTA Contra-indications

(Relative) - If large vessel at ankle is (Relative) - If large vessel at ankle is availableavailable

for bypassfor bypass - Heavy eccentric calcification- Heavy eccentric calcification - Lesion in essential collateral vessel- Lesion in essential collateral vessel

- Stenosis with thrombus - Stenosis with thrombus

Percutaneous revascularization

Dr. Rajdeep Agrawal

Post PTA recurrence are seldom worse than Post PTA recurrence are seldom worse than before, does not interfere with the original before, does not interfere with the original planned surgery.planned surgery.

In 25% Femoro - popliteal PTFE Graft, In 25% Femoro - popliteal PTFE Graft, Popliteal gets occluded when bypassPopliteal gets occluded when bypassclosescloses Adar etalAdar etal


Dr. Rajdeep Agrawal

THROMBOLYSIS THROMBOLYSIS is an alternate is an alternate attemptable modality of treatment in attemptable modality of treatment in PVDPVD

Safe if cases are selected properlySafe if cases are selected properlyCannot be used in all cases. Cannot be used in all cases. Various methods are used to administer Various methods are used to administer

thrombolysisthrombolysisAcute ischemia of lower limb is one area Acute ischemia of lower limb is one area


Dr. Rajdeep Agrawal

Intra-arterial ThrombolysisIntra-arterial Thrombolysis

Restores blood flowRestores blood flowIdentifies underlying lesionIdentifies underlying lesionThrombotic or embolic occlusionThrombotic or embolic occlusionNative artery or bypass graftNative artery or bypass graft


Dr. Rajdeep Agrawal

THROMBOLYSIS - CONTRAINDICATIONSTHROMBOLYSIS - CONTRAINDICATIONS

Absolute -Absolute - Active internal bleedingActive internal bleedingIrreversible limb ischaemiaIrreversible limb ischaemiaRecent stroke, craniotomyRecent stroke, craniotomyMobile L-V thrombusMobile L-V thrombus


Dr. Rajdeep Agrawal

THROMBOLYSIS CONTRAINDICATIONSTHROMBOLYSIS CONTRAINDICATIONSRelative - H/o GI bleedRelative - H/o GI bleed - Recent major - Recent major

surgery/CPR/Traumasurgery/CPR/Trauma - Diastolic BP - Diastolic BP >>125 mm 125 mm - DM – Proliferative Retinopathy- DM – Proliferative Retinopathy - Sub acute bacterial endocarditis- Sub acute bacterial endocarditis

- Coagulopathy- Coagulopathy - Post partum state- Post partum state


Dr. Rajdeep Agrawal

Stents: Contra indicationsStents: Contra indications

-- Diffuse aortic diseaseDiffuse aortic disease-- Extravasation of contrast after PTAExtravasation of contrast after PTA-- Non compliant lesion on angioplastyNon compliant lesion on angioplasty-- Diffuse iliac diseaseDiffuse iliac disease-- Aortic tortuosity & aneurysmAortic tortuosity & aneurysm-- Diffuse long segment small caliber Diffuse long segment small caliber

external iliac or femoral arteryexternal iliac or femoral artery


Dr. Rajdeep Agrawal

Stent Complications (10%)Stent Complications (10%)- Almost all are minorAlmost all are minor- Puncture site injuryPuncture site injury- Distal embolizationDistal embolization- Stent dislodgementStent dislodgement- Pseudo anemysm formationPseudo anemysm formation- Vessel ruptureVessel rupture


Dr. Rajdeep Agrawal


Vascular DiseaseAORTO – ILIAC Percutaneous AORTO – ILIAC Percutaneous

Transluminal AngioplastyTransluminal Angioplasty

- - Optimizes inflow for bypassOptimizes inflow for bypass- Excellent patient tolerance- Excellent patient tolerance-- Short recovery period Short recovery period-- No worsening of vascular status – if No worsening of vascular status – if

failsfails

Dr. Rajdeep Agrawal

AORTIC OCCLUSSIONSAORTIC OCCLUSSIONS- Relatively uncommonRelatively uncommon- Younger population who smokeYounger population who smoke- Claudication and impotencyClaudication and impotency- Risk of propagation of clot to renal Risk of propagation of clot to renal

and mesenteric arteryand mesenteric artery


Dr. Rajdeep Agrawal

ABDOMINAL AORTIC STENOSISABDOMINAL AORTIC STENOSIS

- Isolated - relatively uncommonIsolated - relatively uncommon- More frequent in women with hypoplastic aortasMore frequent in women with hypoplastic aortas- PTA and Stent can be tried and are useful if the PTA and Stent can be tried and are useful if the

lesions are amenablelesions are amenable- Otherwise Grafts can be placed Otherwise Grafts can be placed - Even thrombolysis could be attempted with Even thrombolysis could be attempted with

angioplastyangioplasty- Large thick atherosclerotic lesions could be Large thick atherosclerotic lesions could be

commoncommon


Dr. Rajdeep Agrawal


AORTO – ILIAC STENTINGAORTO – ILIAC STENTINGIndications - Residual stenosis > 30% afterIndications - Residual stenosis > 30% after percutaneous revascularizationpercutaneous revascularization Or if a gradient >10mm persists Or if a gradient >10mm persists

DissectionDissection Highly eccentric stenosisHighly eccentric stenosis Recurrent Stenosis post PTARecurrent Stenosis post PTA Iliac artery occlusionIliac artery occlusion

Dr. Rajdeep Agrawal

ILIAC ARTERY STENOSISILIAC ARTERY STENOSISPTAPTA- PTA with/without stentPTA with/without stent- Focal, uncalufied sterosis <5 cm longFocal, uncalufied sterosis <5 cm long- Eccentric or calufied sterosis < 3cm longEccentric or calufied sterosis < 3cm longLong segment (Long segment (>>10cm)10cm) respond less favorablyrespond less favorablySTENTSSTENTS- Residual pressure gradient (<5mmHg) or residual Residual pressure gradient (<5mmHg) or residual

stenosis(>30%)stenosis(>30%)- Flow limiting dissection flapFlow limiting dissection flap- Restenosis (acute or subaiute)Restenosis (acute or subaiute)


Dr. Rajdeep Agrawal

ILIAC ARTERY OCCLUSIONSILIAC ARTERY OCCLUSIONS

- Bilateral – Surgery treatmentBilateral – Surgery treatment- Primary stent placementPrimary stent placement- PTA followed by stentPTA followed by stent- Thrombolysis followed by stentThrombolysis followed by stent


Dr. Rajdeep Agrawal

INTERNAL ILIAC STEONSISINTERNAL ILIAC STEONSIS

- Isolated buttock claudicationIsolated buttock claudication- ImpotenceImpotence- PTA is the choicePTA is the choice


Dr. Rajdeep Agrawal

CFA STENOSISCFA STENOSIS- Isolated is uncommon without history of Isolated is uncommon without history of

injury (eg. Catheterization)injury (eg. Catheterization)- Endarterectomy – choice simple, LA and Endarterectomy – choice simple, LA and

conscious sedationsconscious sedations- Durable than PTADurable than PTA


Dr. Rajdeep Agrawal

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

stent

Dr. Rajdeep Agrawal

Femoro popliteal Femoro popliteal - Lesion 3 times commoner than iliac- Lesion 3 times commoner than iliac - Occlusions 3 times commoner than - Occlusions 3 times commoner than

stenosisstenosis

- 80% of the stenosis- 80% of the stenosis are are <<10cm10cm - 20% occlussions - 20% occlussions << 10cm 10cm


Dr. Rajdeep Agrawal

Femoro popliteal Femoro popliteal - 10 cm upper limit to select cases- 10 cm upper limit to select cases

- Stents disappointing beyond that - Stents disappointing beyond that length of stenosis length of stenosis - Covered (PTFF) grafts have a - Covered (PTFF) grafts have a

promise promise - Over 5 years 15-20% new Femoro - Over 5 years 15-20% new Femoro popliteal occlussions developpopliteal occlussions develop


Dr. Rajdeep Agrawal

Narrowed superficial femoral artery before & after dilatation

Dr. Rajdeep Agrawal

Femoropopliteal stenosis:Femoropopliteal stenosis:

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

80%80%-- Complication of PTA is 10%, surgical Complication of PTA is 10%, surgical

repair required in 2% casesrepair required in 2% cases


Dr. Rajdeep Agrawal

Femoropopliteal stenosisFemoropopliteal stenosis-- Stents useful in proximal Superficial Stents useful in proximal Superficial

Femoral ArteryFemoral Artery-- Stents – restenosis in distal SFA or popliteal Stents – restenosis in distal SFA or popliteal

artery due to extrinsic compressions (eg. artery due to extrinsic compressions (eg. Addutor canal) is possibleAddutor canal) is possible

-- Long term consequences of placing flexible Long term consequences of placing flexible stents across joints is unknown.stents across joints is unknown.


Dr. Rajdeep Agrawal

Femoropopliteal occlussions:Femoropopliteal occlussions:- Long segment or complete SFA occlusions Long segment or complete SFA occlusions

does not respond well to any widely does not respond well to any widely available endovascular techniqueavailable endovascular technique

- Amplatz thrombectomy catheter – Amplatz thrombectomy catheter – excellent technical access, but long term excellent technical access, but long term patency is modest or unknownpatency is modest or unknown

- Covered stents - results disappointingCovered stents - results disappointing- Endovascular stent grafts show most Endovascular stent grafts show most

promisepromise


Dr. Rajdeep Agrawal

Femoropopliteal occlusions:Femoropopliteal occlusions:- PTA is effective for short solitary occlusions,PTA is effective for short solitary occlusions, < 10cm long, not involving SFA origins or < 10cm long, not involving SFA origins or

distal popliteal artery distal popliteal artery and tenders occlusions <3cm longand tenders occlusions <3cm long- Focal occlussions (<2 to 3cm) Focal occlussions (<2 to 3cm) PTA alone PTA alone- Long occlussions – Thrombolysis prior to PTALong occlussions – Thrombolysis prior to PTA


Dr. Rajdeep Agrawal

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

optimal optimal - PTA long term patency rates may be PTA long term patency rates may be

substantially less than clinical patency ratessubstantially less than clinical patency rates- Technical failure almost always results from Technical failure almost always results from

inability to cross the lesion with guide wire.inability to cross the lesion with guide wire.


Dr. Rajdeep Agrawal

Infra-popliteal revascularization - Infra-popliteal revascularization - IndicationsIndications

Absence of pedal pulses – minimal or Absence of pedal pulses – minimal or asymptomaticasymptomaticIf collaterals are not well developed orIf collaterals are not well developed or

limitation of activity resultslimitation of activity results Focal lesionsFocal lesions Limited in diffuse disease, Limited in diffuse disease, If short term patency is desired If short term patency is desired

sufficient to heal superficial ulcerations sufficient to heal superficial ulcerations or amputation sitesor amputation sites


Dr. Rajdeep Agrawal

Infra popliteal revascularization –Infra popliteal revascularization – Early results - Not impressiveEarly results - Not impressive

Manipulations - Easier with DSAManipulations - Easier with DSA & road mapping& road mapping

Increased popularity - Safe & Successful Increased popularity - Safe & Successful Decision with surgeon Decision with surgeon Inflow lesions Treatment firstInflow lesions Treatment first


Dr. Rajdeep Agrawal

Tibial Artery Obstructions:Tibial Artery Obstructions:

– – Infra popliteal PTA is almost always performed Infra popliteal PTA is almost always performed for limb salvagefor limb salvage

- Short term patency may be sufficient to allow Short term patency may be sufficient to allow healing of an ischemic ulcer or amputation site healing of an ischemic ulcer or amputation site or to avoid amputationor to avoid amputation

- PTA is not particularly effective if run-off vessels PTA is not particularly effective if run-off vessels are not visualized. Liberal Heparin use must to are not visualized. Liberal Heparin use must to maintain patency maintain patency


Dr. Rajdeep Agrawal

STENTS RESULTSSTENTS RESULTS

-- Technical success rate – 90-100%Technical success rate – 90-100%-- Cumulative 5 year vessel patency – 94%Cumulative 5 year vessel patency – 94%-- Clinical success – 93%Clinical success – 93%-- (PTA 65% & 70%)(PTA 65% & 70%)


Dr. Rajdeep Agrawal

Infra-popliteal revascularizationInfra-popliteal revascularizationIndicationsIndications-- Limb threatening IshcemiaLimb threatening Ishcemia (Disabling claudication, Rest pain, Ulcer, (Disabling claudication, Rest pain, Ulcer,

Gangrene)Gangrene)-- ABI < 0.5 Ischemic rest pain or ankle pressure ABI < 0.5 Ischemic rest pain or ankle pressure

<60 mm, with or without a non healing ulcer<60 mm, with or without a non healing ulcer-- DM – ABI not useful - calcificationDM – ABI not useful - calcification


Dr. Rajdeep Agrawal

Stent An expandable metallic helical An expandable metallic helical

device which is permanently device which is permanently implanted in the arteryimplanted in the artery. .

MechanismMechanism The prosthesis acts as a The prosthesis acts as a

scaffold to hold the artery openscaffold to hold the artery open Prevents recoil of the vesselPrevents recoil of the vessel Reduces Restenosis Reduces Restenosis

Dr. Rajdeep Agrawal

Newer Techniques Of Angioplasty

AtherectomyAtherectomy DirectionalDirectional Percutaneous Rotational Percutaneous Rotational TEC TEC

LASERLASER StentStent

Dr. Rajdeep Agrawal

Directional Atherectomy

It excises the atheromatous It excises the atheromatous plaque material into very plaque material into very fine slices which can be fine slices which can be retrieved outside bodyretrieved outside body

Dr. Rajdeep Agrawal

Percutaneous Rotational Atherectomy (Rotablator)

Dr. Rajdeep Agrawal

LASER A LASER produces an intense A LASER produces an intense

beam of light in uniform beam of light in uniform wavelength that can be wavelength that can be precisely focused to deliver high precisely focused to deliver high energy levels to a small areaenergy levels to a small area

It converts solid plaque to gas It converts solid plaque to gas which is soluble in bloodwhich is soluble in blood

Dr. Rajdeep Agrawal

Stent Complications (5-10%)Stent Complications (5-10%)Groin hematomaGroin hematomaPseudo AneurysmPseudo AneurysmEmbolization of thrombusEmbolization of thrombusAcute stent thrombosisAcute stent thrombosisDissectionDissectionVessel perforationVessel perforation


Dr. Rajdeep Agrawal

IDDM – Reduce insulinIDDM – Reduce insulin First caseFirst case 5% Dextrose, Blood sugar, 5% Dextrose, Blood sugar, Insulin (1-3 units/ hr) or more for higher Insulin (1-3 units/ hr) or more for higher blood glucose levelsblood glucose levels

No protamine zinc insulin should be usedNo protamine zinc insulin should be used Protamine antagonizes the heparin Protamine antagonizes the heparin

anticoagulationanticoagulation Hybration to prevent aute tubular Hybration to prevent aute tubular

necrosis necrosis


Dr. Rajdeep Agrawal

Cost effectiveness of PTA compared to Cost effectiveness of PTA compared to surgical reconstructionsurgical reconstruction

PTA - Bypass - 53% in Disabling ClaudicationPTA - Bypass - 53% in Disabling Claudication 75% in critical ischemia75% in critical ischemia

A cost effective analysis demonstrated that A cost effective analysis demonstrated that performing PTA as a initial procedure is more performing PTA as a initial procedure is more desirable technically feasible cases and reserving desirable technically feasible cases and reserving bypass surgery for those PTS in whom PTA fails, or bypass surgery for those PTS in whom PTA fails, or recurs would save more lives, limbs and money.recurs would save more lives, limbs and money.


Dr. Rajdeep Agrawal

Cost effectiveness of PTA compared to Cost effectiveness of PTA compared to surgical reconstructionsurgical reconstruction

In technically feasible cases PTA would be In technically feasible cases PTA would be the preferred option the preferred option

Reserve bypass surgery for those PTAs in Reserve bypass surgery for those PTAs in whom it fails, or recurs whom it fails, or recurs

It would save more lives, limbs and money.It would save more lives, limbs and money.


Dr. Rajdeep Agrawal

Complications:Complications:

Vasospasm - Nifedipine start well before Vasospasm - Nifedipine start well before procedure procedure

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

Flow limiting dissection flap – Employ StentFlow limiting dissection flap – Employ Stent


Dr. Rajdeep Agrawal

Complications:Complications:

Post PTA occlusion – Post PTA occlusion – Repeat PTA & thrombolytic therapyRepeat PTA & thrombolytic therapy OR Repeat PTA – StentOR Repeat PTA – Stent

Arterial rupture – Reinflation of baloon Arterial rupture – Reinflation of baloon across ruptureacross rupture, , followed by surgical followed by surgical repairrepair


Dr. Rajdeep Agrawal

Medical Therapy

Exercise programExercise program

Risk factor modificationsRisk factor modifications

Dr. Rajdeep Agrawal

Results of percutaneous therapy

Site & Site & DiseaseDisease

Of arterial Of arterial stenosisstenosis

TherapTherapyy

SuccesSuccesss

% of % of TechnicTechnic

1 year 1 year patencpatency (%)y (%)

3 3 year year

patenpatency cy (%)(%)

Abdominal Abdominal AortaAorta

PTAPTA 9595 ?? ??

Iliac Iliac PTAPTA 9595 8080 7070IliacIliac StentStent 9595 9090 8585Iliac Iliac occlusionocclusion

StentStent 8080 7070 6565

Two year limb salvage of 60 to 80%Two year limb salvage of 60 to 80%

Dr. Rajdeep Agrawal

Results of percutaneous therapy

Site & Site & DiseaseDisease

Of arterial Of arterial stenosis / stenosis / occlusionocclusion

TherapTherapyy

SuccesSuccess % of s % of TechniTechni

cc

One One year year

patencpatency (%)y (%)

Three Three year year

patencpatency (%)y (%)

Proximal Proximal femoralfemoral

StentStent 9595 8585 7575

Femoro Femoro popliteal popliteal OcclusionOcclusion

Lysis, Lysis, PTAPTA

8080 5050 4040

Tibial Tibial stenosisstenosis

PTAPTA 9090 -- --

Two year limb salvage of 60 to 80%Two year limb salvage of 60 to 80%

Dr. Rajdeep Agrawal

Aorto-iliac Occlusions:Aorto-iliac Occlusions:

Aorto bifemoral bypass Aorto bifemoral bypass - Extra anatomic- Extra anatomic- Endarterctomy- Endarterctomy- 5 year patency - 85 to 95%- 5 year patency - 85 to 95%

Surgical revascularization - 1

Dr. Rajdeep Agrawal

Infra – inguinal occlusions:Infra – inguinal occlusions: - Autologous veins or PTFE grafts are used Autologous veins or PTFE grafts are used PTEF above Hunter’s canal for SFAPTEF above Hunter’s canal for SFA- Saphenous Vein – below knee, for tibial or Saphenous Vein – below knee, for tibial or

peroneal occlusionperoneal occlusion- 5 yr patency – 60% - above 5 yr patency – 60% - above - Below knee – 3 yr patency and limb salvage 58 Below knee – 3 yr patency and limb salvage 58

to 92% respectivelyto 92% respectively


Dr. Rajdeep Agrawal

AORTIC OCCLUSSIONSAORTIC OCCLUSSIONS

- Aorto bifemoral graft with Aorto bifemoral graft with endarterectomy axillo bifemoral graft or endarterectomy axillo bifemoral graft or thorarofemoral graftthorarofemoral graft

- Re-construction with endovascular stent Re-construction with endovascular stent graft is feasible – long term results graft is feasible – long term results unknownunknown


Dr. Rajdeep Agrawal

Lower Limb Ischemia - Approach to Therapy

Direct arterial reconstruction.Direct arterial reconstruction. EndarterectomyEndarterectomy Vascular bypassVascular bypass Endovascular (minimally invasive) Endovascular (minimally invasive)

interventionintervention Lumbar sympathectomyLumbar sympathectomy

Dr. Rajdeep Agrawal

Lower Limb Ischemia - Results of Direct Reconstruction

Aorto illiac reconstruction - early graft patency of Aorto illiac reconstruction - early graft patency of about 98%, operative mortality 3%:5years graft about 98%, operative mortality 3%:5years graft patency of 85-90%.patency of 85-90%.

Femoro popliteal bypass - early graft patency of Femoro popliteal bypass - early graft patency of over 90%, with mortality of 2-5% : 5 year patency of over 90%, with mortality of 2-5% : 5 year patency of about 75%.about 75%.

Infrapopliteal/ paramalleolar bypass - early patency Infrapopliteal/ paramalleolar bypass - early patency of about 90% with 2% mortality. 5 year patency of of about 90% with 2% mortality. 5 year patency of 55%55%

LIMB SALVAGE about 90%LIMB SALVAGE about 90%

Dr. Rajdeep Agrawal

OPERATIONS

Depends on the site of occlusion Depends on the site of occlusion and the physical state of the and the physical state of the patientpatient..

Dr. Rajdeep Agrawal

Aorto-iliac occlusion Limited involvement : Iliac EndartectomyLimited involvement : Iliac Endartectomy Marked involvement : Aorto-femoral bypassMarked involvement : Aorto-femoral bypass

Aorto-iliac occlusion patient unable to Aorto-iliac occlusion patient unable to undergo surgeryundergo surgery;;

1 iliac artery involved : femoro-femoral or 1 iliac artery involved : femoro-femoral or ileo-femoral bypassileo-femoral bypass

Both iliac arteries involved : Axillo-Both iliac arteries involved : Axillo-bifemoral bypassbifemoral bypass

Dr. Rajdeep Agrawal

Atherosclerotic Atherosclerotic narrowing of narrowing of aortic aortic bifurcationbifurcation

Aortobifemoral Aortobifemoral graft to bypass graft to bypass stenosisstenosis

Dr. Rajdeep Agrawal

Femoral & Profunda Femoris Occlusion

If conservative measures not If conservative measures not suitable, PTA may be possiblesuitable, PTA may be possible

For more severe disease, angioplasty For more severe disease, angioplasty or bypass maybe usedor bypass maybe used

Femoropopliteal bypass graft is the Femoropopliteal bypass graft is the most usual operationmost usual operation

Saphenous vein graft gives the best Saphenous vein graft gives the best resultsresults

Dr. Rajdeep Agrawal

Superficial femoral Superficial femoral artery occlusion with artery occlusion with profunda femoris profunda femoris stenosis providing stenosis providing poor collateral poor collateral circulationcirculation

Femoropopliteal Femoropopliteal graft used to bypass graft used to bypass the occluded areathe occluded area

Dr. Rajdeep Agrawal

Occlusion below popliteal Bypass to tibial vessels, even down to Bypass to tibial vessels, even down to

the ankle can be met with reasonable the ankle can be met with reasonable success.success.

Most successful is with long Most successful is with long saphenous vein in the saphenous vein in the in situin situ fashion. fashion.

If saphenous not available, can use If saphenous not available, can use PTFE (Polytetrafluoroethylene) graft.PTFE (Polytetrafluoroethylene) graft.

Dr. Rajdeep Agrawal

PROSTHETIC MATERIALS Aortoiliac bypass - DacronAortoiliac bypass - Dacron Femoropopliteal - Autogenous Femoropopliteal - Autogenous

veins (Long saphenous best)veins (Long saphenous best) If not available - PTFE or If not available - PTFE or

glutaraldehyde-tanned, Dacron glutaraldehyde-tanned, Dacron supported, human umbilical veinsupported, human umbilical vein

Profundoplasty - Vein/PTFE/DacronProfundoplasty - Vein/PTFE/Dacron

Dr. Rajdeep Agrawal

Treatment of A/C Occlusion

Embolectomy - Using Fogarty’s catheter -> Embolectomy - Using Fogarty’s catheter -> Catheter passed beyond emblous, balloon Catheter passed beyond emblous, balloon inflated & pulled back till blood comesinflated & pulled back till blood comes

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

Intra-arterial Thrombolysis - TPA preferred. Intra-arterial Thrombolysis - TPA preferred. Arteriography done and a catheter Arteriography done and a catheter embedded in clot - Thrombolytic agent embedded in clot - Thrombolytic agent infused over several hrsinfused over several hrs

Dr. Rajdeep Agrawal

Surgical Embolectomy Relatively simple procedureRelatively simple procedure Done under LA, small incision in the Done under LA, small incision in the

groin, using Fogarty’s cath.groin, using Fogarty’s cath. ProblemsProblems 1. Blind procedure, can be traumatic1. Blind procedure, can be traumatic 2. Not successful in 10 – 30% cases2. Not successful in 10 – 30% cases 3. Inefficient in multistenosed artery3. Inefficient in multistenosed artery 4. Complete removal of thrombus 4. Complete removal of thrombus

difficult in leg arteries difficult in leg arteries

Dr. Rajdeep Agrawal

Post PTA MX Antiplatelet agentsAntiplatelet agents LMW Heparin X 7 – 10 DLMW Heparin X 7 – 10 D IV / oral TrentalIV / oral Trental StatinsStatins Aggressive control of risk Aggressive control of risk

factorsfactors

Dr. Rajdeep Agrawal

Conclusion In Diabetic foot, PVD contributes to In Diabetic foot, PVD contributes to

amputation by impeding the delivery amputation by impeding the delivery of antibiotics, Oxygen, nutrients & by of antibiotics, Oxygen, nutrients & by delaying wound healing & the ability to delaying wound healing & the ability to fight infection.fight infection.

Aggressive therapy with debridement, Aggressive therapy with debridement, antibiotics,good control of Diabetes & antibiotics,good control of Diabetes & when indicated revascularisation when indicated revascularisation results in salvage of > 90% of results in salvage of > 90% of threatened limbs even in high risk threatened limbs even in high risk patients patients

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