Step by step Hybrid procedures in peripheral obstructive disease. Holger Staab, MD University Hospital Leipzig, Germany Clinic for Vascular Surgery
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1 Step by step Hybrid procedures in peripheral obstructive disease Holger Staab, MD University Hospital Leipzig, Germany Clinic for Vascular Surgery
2 Disclosure Speaker name: H.H. Staab I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest
3 Why hybrid procedures? About 14 % the population over 70 years is affected by POD Approximately 10 % of these patients have multilevel disease and need aortoiliac an infrainguinal revascularization Norgren L et al., J Vasc Surg 2007, 45,55-67 Harris PL et al., Br J Surg 1985, 72:317-20
4 Open surgery in multilevel POD 450 Patients with complex limb threatening POD undergoing aortic inflow plus complex outflow procedures like profundaplasty and/or composite bypass conduits: Morbidity rate 84.2% Mortality rate 47.4% Open surgery with simultaneous inflow and outflow bypasses is associated with high morbidity and mortality Harward TR et al. Ann Surg 1995,221,
5 Hybrid Techniques Minimal surgery + Angioplasty (inflow/outflow)
6 Hybrid Techniques + inflow angioplasty CFA endarterectomy + outflow angioplasty Femoral-femoral Bypass Femoro-popliteal Bypass Distal origin Bypass
7 Hybrid Techniques open revascularization endovascular techniques
8 What lesions and what patients do we treat in hybrid procedures? - Multilevel atherosclerotic disease - Centerpoint mostly CFA - Cardiovascular and pulmonary high risk patients - Critical limb ischemia Rutherford TASC B-D lesions
9 How do we treat? - dedicated endovascular suite - both groins sterile prepared CFA endarterectomy and closure with bovine patch
10 1. Clasical Hybrid case: Occlusion of 63 y/o male Pt. CFA, central PFA and SFA non-healing calf ulcer PAD Rutherford 6 on the right side Multiple cardio-vascular risk factors COPD Gold III
11 Angiography Occlusion of CFA and central PFA Occlusion of SFA
12 CFA endarteriectomy first Extensive endarteriectomy of CFA PFA and short segment SFA Closure with bovine patch
13 Angioplasty Cross-over access to the right SFA crossing the lesion with PT2 wire/ multipurpose catheter PTA of SFA and Implantation 6/60 Nitinol Stent
14 Final Result
15 2. CFA endarterectomy + Aorto-iliac angioplasty with bifurcated Endograft 82 y/o male Pt. CLI on the left side, PAOD Rutherford 3 on the right side Multiple cardio-vascular risk factors Chronic Occlusion of left CIA, EIA,CFA
16 2. CFA endarterectomy + Aorto-iliac angioplasty with bifurcated Endograft Retrograde puncture of the patch and placement of a 6Fr Sheath Direct angiography of the femoral bifurcation
17 2. CFA endarterectomy + Aorto-iliac angioplasty with bifurcated Endograft Retrogade access through the Patch to the left EIA after TEA (0.035 Terumo Stiff wire/ multipurpose catheter) Post Balloon dilatation (Admiral 9/40mm) Endograft at the level of the renal arteries
18 2. CFA endarterectomy + Aorto-iliac angioplasty with bifurcated Endograft Kissing Stent(Advanta V12 9/59mm) of the aortic bifurcation Final Result
19 3. CFA endarterectomy + Remote SFA Endarterectomy - 67 y/o male pt. - CLI Rutherford 5 right side - Multiple BTK arterial ulcers - Failed endovascular SFA recanalization - No venous conduit Chronic Occlusion of right SFA
20 3. CFA endarterectomy + Remote SFA Endarterectomy MollRing Cutter transecting the distal intimal core Distal intimal lap at the transection zone After tacking the intimal lap with a self-expanding stent
21 Technical Synopsis We perform first the CFA-TEA and then the interventional part Otherwise risk of subintimal wire passage in the iliac artery or SFA after puncture the occluded CFA We try to cross the iliac lesion in an antegrade fashion via a cross-over or a brachial puncture when we fail the retrograde access
22 Technical Synopsis We try to place the stents in the distal external iliac artery only AFTER CFA endarterectomy and patchplasty because of - poor clamping for proximal bleeding control (crushing the stent) - thrombosis of the stented iliac artery due to flow stagantion
23 Why Hybrid procedures? - Less invasive procedure than open repair with decreased tissue trauma in high risk patients - Overcome more complex anatomies in high-risk patients with CLI - High initial technical success (up to 95% ) - Morbidity and Mortality even better than in OR despite selection bias - Shortened hospital stay - No need for extensive venous or xenogen graft material A M Schrijver et al. J Cardiovasc Surg 2010: 51; H H Dosluoglu et al. J Vasc Surg 2010:51;
24 Thank you for your attention! 24
25 Step by step Hybrid procedures in peripheral obstructive disease Holger Staab, MD University Hospital Leipzig, Germany Clinic for Vascular Surgery
Hybrid Procedures for Peripheral Obstructive Disease - Step by Step -
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