"Loop" technique in endovascular treatment of CLI (Critical Limb Ischemia).

Transcription

1 "Loop" technique in endovascular treatment of CLI (Critical Limb Ischemia). Poster No.: C-1991 Congress: ECR 2013 Type: Scientific Exhibit Authors: M. Tecame, G. Cangiano, E. Cavaglia, M. Cirillo, F. Maglione, R. Grassi ; Napoli/IT, San Sebastiano al Vesuvio (NA)/IT, 3 4 Napoli, NA/IT, Frattamaggiore, Naples/IT Keywords: Arteries / Aorta, Interventional vascular, Vascular, Catheter arteriography, CT-Angiography, Percutaneous, Angioplasty, Arterial access, Blood, Ischemia / Infarction, Obstruction / Occlusion DOI: /ecr2013/C-1991 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 15

2 Purpose Background Critical limb ischemia (CLI) is affecting an increasing number of patients, mainly due to an ageing population and the growing number of diabetics. Clinically, CLI is characterized by rest pain, non-healing foot wounds and gangrene, due to insufficient arterial blood supply. Limb preservation should be the goal in patients with diabetic foot due to tibial occlusive disease. As surgery is associated with considerable morbidity and mortality rates, endovascular therapy can offer a valuable alternative. Small-diameter below-theknee arteries that were previously unamenable to surgical methods, can now be reached and treated. The purpose of our study is to present our experience and to evaluate the efficacy of "loop" technique in endovascular treatment of CLI. Methods and Materials From 2009 to 2012 a total of 245 patients with obstructive injury of tibial vassels were treated in our operating unit. A severe atheroma of pedidia artery and/or of the plantar artery associated with obstruction of metatarsal arterial arch was detected in 54 of them. "Loop thechnique " is an advanced technique used to recanalize tibial vassels, used nowadays in III level pricipals references centers for the tratment of diabetic foot. With this tecnique, we approach stenotic-obtructive lesions of pedidia and plantars artery, using the anatomic comunication between dorsal and plantar circle of the foot ("loop"). In some cases infact, it is almost impossibile to use an anterograde aproach due to the creation of subintimal way of the guidewire or the iatrogenic lesions that can occur during the recanalization ( ruptures or AV fistula). The "Loop Tecnique" allows to attack this lesions in retrograde way,obtaining at the same time, the possibility of recanalize the tibial vassel and the trans-metatarsal artery ("loop"), whence the digitals artery born. This approach appeared feasible in about 50% of cases, in the remaining cases can happend that the transit of guidewire was blocked due to extensive calcific infiltration of artery wall. In this cases we used guidewire (Pilot cm -Abbott o PT2 300cm Page 2 of 15

3 di BostonScientific) and low profile baloon overthewire (diameter mm and mm long - AmhirionDeep di Medtronic e Coyote ES di BS). We present some our cases. Images for this section: Fig. 2: Anterogrede puncture with 5 Fr. Introducer Occlusion of 3 limb vassels, with rehabitation of the only AT. Page 3 of 15

4 Fig. 3: Recanalization and PTA with baloon x 210mm (Medtronic. Amphirion-deep). good patency of AT but low perfusion in plantar region. Page 4 of 15

5 Fig. 4: Retrograde recanalization of PT with loop technique and PTA multiple 2.5x60mm. Page 5 of 15

6 Fig. 5: Final result: Patency of AT, loop and PT. Page 6 of 15

7 Fig. 6: Angiography: complete occlusion of AT and Pedidia artery. Important infiltration of the loop and lateral plantar. Page 7 of 15

8 Fig. 7: Subintimal recanalizationof AT; intraluminal recanalization of the loop and retrograde recanalization of lateral plantar. Page 8 of 15

9 Fig. 8: Final result: patency of AT, Pedidia, Loop and lateral plantar artery. Page 9 of 15

10 Fig. 9: Angiograpy: distal occlusion of AT. Occlusion of PT,plantars ad loop. Page 10 of 15

11 Fig. 10: Anterograde recanalization of AT (baloon 2.5x80) and loop. Retrograde recanalization of lateral plantar artery (baloon 2x80mm). Page 11 of 15

12 Fig. 11: Anterograde Recanalization of PT with second guidewire Overlapping of the two guidewire on level of lateral plantar artery. Page 12 of 15

13 Fig. 12: Final result: recovery of patency of the loop and PT artery. Page 13 of 15

14 Results A recanalization with angioplasty of pedidia or plantar artery with "loop" technique obtaining at same time retrograde recanalization of plantar or pedidia artery and the restoration of patency of transmetatarsal artery from which digital artery branch out, was performer in 37 cases. In 3 cases we need a double aproach (anterograde-retrograde) due to the presence of abundant vassels wall calcification. In 7 cases we had a technical failure for iatrogenic vassels lesions (2 cases), embolization (1 case) and difficulty of crossing the obstruction (4 cases). Conclusion In conclusion, the pedal-plantar loop technique for percutaneous recanalization of belowthe-knee arterial disease appears to be a promising new tool in the interventionist's armamentarium, either on a bailout basis (i.e., in cases when antegrade revascularization fails), or electively (when traditional approaches are deemed infeasible). References Cardiovasc Intervent Radiol Jan 29. Endovascular Treatment of Diabetic Foot in a Selected Population of Patients with Below-the-Knee Disease: Is the Angiosome Model Effective? Fossaceca R, Guzzardi G, Cerini P, Cusaro C, Stecco A, Parziale G, Perchinunno M, De Bonis M, Carriero A. Alternative Techniques for Treatment of Complex Below-the Knee Arterial Occlusions in Diabetic Patients With Critical Limb Ischemia Roberto Gandini, Luigi Uccioli, Alessio Spinelli, Costantino Del Giudice, Valerio Da Ros, Tommaso Volpi, Marco Meloni, Giovanni Simonetti Pedal-Plantar Loop Technique for a Challenging Below-the-Knee Chronic Total Occlusion: A Novel Approach to Percutaneous Revascul Massimiliano Fusaro, MD, Luca Dalla Paola, MD, Giuseppe Biondi-Zoccai, MD Page 14 of 15

15 Volume 19 - Issue 2 - February, 2007 Clinical results of below-the knee intervention using pedal-plantar loop technique for the revascularization of foot arteries. Manzi M, Fusaro M, Ceccacci T, Erente G, Dalla Paola L, Brocco E. J Cardiovasc Surg (Torino) Jun;50(3):331-7 Plantar to dorsalis pedis artery subintimal angioplasty in a patient with critical foot ischemia: a novel technique in the armamentarium of the peripheral interventionist. Fusaro M, Dalla Paola L, Brigato C, Marangotto M, Nicolini S, Rripay R, Biondi-Zoccai GG. J Cardiovasc Med (Hagerstown) Nov;8(11): Personal Information Page 15 of 15