Endovascular intervention for patients with femoro-popliteal and aorto-iliac TASC D lesions

Transcription

1 Endovascular intervention for patients with femoro-popliteal and aorto-iliac TASC D lesions Poster No.: C-2012 Congress: ECR 2014 Type: Educational Exhibit Authors: E. Thomee, W. C. Liong, D. R. Warakaulle; Aylesbury/UK Keywords: Vascular, Interventional vascular, Arteries / Aorta, CTAngiography, MR-Angiography, Angioplasty, Arteriosclerosis DOI: /ecr2014/C-2012 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 48

2 Learning objectives 1. To illustrate the range of TransAtlantic Intersociety Consensus Document (TASC) D lesions that can be treated using endovascular techniques 2. To list and illustrate endovascular devices and techniques that can be particularly useful in this challenging group of patients Background Lower extremity peripheral arterial disease affects 20% of the UK population aged of whom 5% are symptomatic. Symptoms range from claudication to critical limb ischaemia which can lead to limb loss. The TransAtlantic Intersociety Consensus Document on management of Peripheral Arterial Disease II (TASC II) recommends endovascular vs open surgical treatment based on the location and complexity of arterial lesions. TASC D aortoiliac lesions are classified as: Infra-renal aorto-iliac occlusion Diffuse disease involving the aorta and both iliac arteries requiring treatment Diffuse multiple stenoses involving the unilateral common iliac artery (CIA), external iliac artery (EIA) and common femoral artery (CFA) Unilateral occlusions of both CIA and EIA Bilateral occlusions of EIA Iliac stenoses in patients with aortic aneurysms requiring treatment and not amenable to endograft placement or other lesions requiring open aortic or iliac surgery TASC D femoropopliteal lesions are classified as: Chronic total occlusions of CFA or superficial femoral artery (SFA) (>20cm, involving the popliteal artery) Chronic total occlusion of popliteal artery and proximal trifurcation vessels Surgical management is recommended for both aorto-iliac and femoro-popliteal TASC D lesions, as these are considered particularly complex and challenging for endovascular techniques. Page 2 of 48

3 However, as a result of improved endovascular techniques and devices many centres manage TASC D lesions endovascularly. At our institution, both aorto-iliac and femoro-popliteal TASC D lesions are frequently treated with endovascular techniques. The technique used is mainly an evolution of subintimal angioplasty augmented with devices including re-entry catheters, low profile wires and balloons, and the judicious use of self-expanding and balloon mounted stents. Findings and procedure details We reviewed 38 consecutive patients (29 femoro-popliteal and 9 aorto-iliac TASC D lesions) who underwent endovascular intervention from May 2012 to October The mean age was 72 years. All patients underwent diagnostic peripheral MR or CT angiography or Duplex ultrasound, and were discussed at our multidisciplinary meeting to ensure optimal management of their disease. Endovascular deivces and techniques used for challenging TASC D patients: Re-entry devices such as Outback (Cordis), Offroad (Boston Scientific) (fig. 1-9) These devices are used to gain re-entry into the lumen of an artery following subintimal dissection accross an occlusion, when the guidewire does not re-enter spontaneously. Devices designed to cross calcified chronic total occlusions (CTOs) such as TruePath (Boston Scientific) and Frontrunner (Cordis). These devices engage CTOs and cross them to facilitate intraluminal guidewire placement beyond the occlusion. Sharp dissection using back end of a Radiofocus (Terumo) standard or stiff guidewire to engage occlusions, to push through occlusions and occasionally to re-enter the true lumen (fig ). This technique is useful in dealing with calcified, resistant lesions, and when used judiciously is very safe, with a very low risk of complications such as perforation. Retrograde tibial puncture (fig 13-18). This technique can be used if an antegrade approach is unsuccessful in crossing tibial lesions. Ultrasound or fluroscopic guided puncture of a patent segment of distal tibial vessel is performed, to allow retrograde passage of a guidewire through the lesion. The guidewire is then snared from the antegrade access, to perform angioplasty. For occlusions involving the iliacs and CFA, the iliacs are stented as low as possible (just above the acetabulum), followed by angioplasty of the CFA. If there is insufficient length of patent CFA for retrograde access, the SFA or sometimes the profunda is punctured. Page 3 of 48

4 6. SAFARI (subintimal arterial flossing with antegrade-retrograde intervention) - this technique involves the simultaneous passage of guidewires from the antegrade and retrograde approaches in the subintimal plane across an occlusion. When the guidewires are located adjacent to each other, one of them is exchanged for a snare, to capture the other guidewire. This allows placement of a single, continous "flossing" wire through the occlusion to facilitate angioplasty +/- stent placement. Further examples of endovascular management of difficult TASC D patients are presented in figures Images for this section: Page 4 of 48

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6 Fig. 1: Outback re-entry device (Image provided by Johnson & Johnson Medical NV/SA) Fig. 2: Video illustrating deployment of the Outback device (Used with permission from Johnson & Johnson Medical NV/SA) Page 6 of 48

7 Fig. 3: 76 year old female patient with short distance claudication. Digital subtraction angiogram (DSA) shows tight distal aortic stenosis with hypertrophic lumbar collaterals, tight left CIA origin stenosis, occluded right CIA, EIA and proximal CFA Page 7 of 48

8 Fig. 4: Stents placed into aorta and left CIA from left, with a gap left between the stents. Page 8 of 48

9 Fig. 5: Outback deployed from the right into the gap. Page 9 of 48

10 Fig. 6: Completion angiogram after stenting of the right CIA and EIA and angioplasty of the right CFA demonstrates good result. Page 10 of 48

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12 Fig. 7: 76 year old female patient with bilateral rest pain and a gangrenous left toe. MR angiogram image shows occlusive disease of the distal aorta and both proximal CIAs. Page 12 of 48

13 Fig. 8: Preliminary DSA Page 13 of 48

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15 Fig. 9: Completion DSA shows a good result after bilateral stents extending from just below the inferior mesenteric artery to just above the internal iliac arteries. An Outback device was used on the right. Page 15 of 48

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17 Fig. 10: DSA shows occluded left CIA stent Fig. 11: Fluoroscopic image shows sharp dissection using the back end of a Radiofocus standard(terumo) guidewire passed through a 5 Fr PIER (Cordis) catheter. Page 17 of 48

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19 Fig. 12: Completion DSA post angioplasty shows a good result Page 19 of 48

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21 Fig. 13: 81 year old male patient with left foot ulcer: left antegrade DSA shows extensive tibial disease - unable to cross from the antegrade approach Page 21 of 48

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23 Fig. 14: Left antegrade DSA shows extensive tibial disease - long anterior tibial (AT)occlusion, with reconstituted dorsalis pedis artery Page 23 of 48

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25 Fig. 15: inch V 18 Control (Boston Scientific) guidewire advanced into AT after dorsalis pedis puncture (Cook micropuncture set) Page 25 of 48

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27 Fig. 16: Contrast injection through a 4 Fr dilator confirms intraluminal position Page 27 of 48

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29 Fig. 17: Completion DSA shows good result Page 29 of 48

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31 Fig. 18: Completion DSA shows good result Fig. 19: 82 yr old male patient with bilateral short distance claudication. MR angiogram shows bilateral EIA occlusions. Page 31 of 48

32 Fig. 20: Completion DSA shows good result post bilateral EIA stents Page 32 of 48

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34 Fig. 21: MR angiogram shows occluded left distal CIA, EIA, CFA and proximal SFA. Page 34 of 48

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36 Fig. 22: DSA post stenting of left iliacs and angioplasty of left CFA and proximal SFA shows good result Page 36 of 48

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38 Fig. 23: 64 year old male patient with a sudden onset of bilateral rest pain. MR angiogram shows extensive bilateral SFA, popliteal and proximal tibial occlusions. The following completion angiograms show good results after SFA and popliteal stents on right, angioplasty on left. Fig. 24: Post procedure result Page 38 of 48

39 Fig. 26: Post procedure result Page 39 of 48

40 Fig. 27: Post procedure result Page 40 of 48

41 Fig. 28: Post procedure result Page 41 of 48

42 Fig. 30: Post procedure result Page 42 of 48

43 Fig. 29: Post procedure result Page 43 of 48

44 Fig. 31: DSA shows occlusion of distal popliteal and the origins of all 3 tibial vessels Page 44 of 48

45 Fig. 32: DSA shows occlusion of distal popliteal and the origins of all 3 tibial vessels Page 45 of 48

46 Fig. 33: DSA post successful recanalisation of all 3 tibial run off vessels. Page 46 of 48

47 Fig. 25: Post procedure result. Page 47 of 48

48 Conclusion Published literature and our experience show that a significant proportion of patients with TASC D lesions can be treated with technical and clinical success using endovascular approaches. Technological innovations and refinement of endovascular techniques have increased the number of patients to whom this option is available. Endovascular treatment can be particularly beneficial to frail patients who would tolerate open surgery poorly. A multidisciplinary approach, appropriate patient selection, operator experience and novel devices are key to success in treatment of this challenging subset of vascular disease. Personal information References Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG; TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg Jan;45 Suppl S:S5-67. Nice Guidelines; NICE cost impact statement: QOF indicators for peripheral arterial disease. July 2011 Baril DT, Chaer RA, Rhee RY, Makaroun MS, Marone LK. Endovascular interventions for TASC II D femoropopliteal lesions. J Vasc Surg Jun;51(6): Yin MY, Jiang ME, Huang XT, Lu M, Lu XW, Huang Y, Li WM. Endovascular interventions for TransAtlantic InterSociety Consensus II C and D femoropopliteal lesions. Chin Med J (Engl) Feb;126(3): Han DK, Shah TR, Ellozy SH, Vouyouka AG, Marin ML, Faries PL. The success of endovascular therapy for all TransAtlantic Society Consensus graded femoropopliteal lesions. Ann Vasc Surg Jan;25(1): Spinosa DJ, Harthun NL, Bissonette EA et al. Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) for subintimal recanalization to treat chronic critical limb ischemia.j Vasc Interv Radiol Jan;16(1):37-44 Page 48 of 48