Lets go on a SAFARI and Discover Novel Tactics. Awais Siddique MD Endovascular Interventional Radiology AZH/WAVE Centers Milwaukee WI

Transcription

1 Lets go on a SAFARI and Discover Novel Tactics Awais Siddique MD Endovascular Interventional Radiology AZH/WAVE Centers Milwaukee WI

2 Subintimal Arterial Flossing with Antegrade Retrograde Intervention (SAFARI) for Subintimal Recanalization to Treat Chronic Critical Limb Ischemia David J. Spinosa MD, Nancy L. Harthun, MD, Eric A. Bissonette, MD, Dorothy Cage, RN, MSN, ACNP, Daniel A. Leung, MD, John F. Angle, MD, Klaus D. Hagspiel, MD, John A. Kern, MD, Ivan Crosby, MD, Harry A. Wellons, Gary D. Hartwell, DSc, Alan H. Matsumoto, MD A term Coined by the University of Virginia Group

3 The SAFARI Technique was further described by Gandini to Perform Difficult Subintimal Infragenicular Vessel recanalizations Roberto Gandini, Vincenzo Pipitone, Matteo Stefanini, Luciano Maresca, Alessio Spinelli, Vittorio Colangelo, Carlo Andrea Reale, Enrico Pampana, Giovanni Simonetti Department of Diagnostic Imaging and Interventional Radiology, University of Tor Vergata, Viale Oxford 81, 00133, Rome, Italy

4 Gandini If reentry into the distal true lumen was unsuccessful..a retrograde subintimal channel was created

5 WHAT IS SAFARI? A guide wire is used to connect the retrograde and antegrade subintimal channels simultaneously, to create a flossing guide wire, and eventually a through and through access

6 Traditional Antegrade recanalizations have a 5-7% or higher failure rate Failure occurs due to: A Flush occlusion Small Vessel size Heavy calcification Poor distal outflow Failure to distally re-enter

7 The precursor The Inventor of sub-intimal technique Dr Amman Bolia MBChB, DMRD FRCR - Interventional Radiologist, Leicester, United Kingdom

8 SAFARI is a Modification to the Traditional Sub- Intimal Technique An Initial Channel is created utilizing the Bolia Technique. Re-entry may be difficult due to the length of the occlusion, calcifications etc Antegrade approach is initiated. If re-entry is not successful then a distal vessel access is performed and a retrograde approach is initiated. The "kissing" wires are then manipulated to "feel" for each other. Antegrade/retrograde simultaneous angioplasties of the subintimal channel can be performed to tear the intimal membrane and gain re-entry.

9 SAFARI

10 My Current Technique Involves utilizing a 4 fr (0.035 inch) antegrade (Contralateral femoral) catheter followed by a retrograde (Pedal) 2.6 fr (0.018 inch) catheter The advantage being that the 2.6fr Cook CXI catheter could be telescoped into the Cook 4 fr CXI catheter In an OBL setting this has a large cost savings advantage as this prevents utilization of an expensive snare device However at times, a snare may be the only option Once through and through access is obtained, the railing technique is utilized, either by pulling the antegrade catheter caudally or the retrograde catheter cranially

11 Clamp Clamp Rail Unclamp

12 CXI catheters

13 Re-entry devices are very expensive

14 Types of Re-entry Devices Pioneer Enteer Re-entry System

15 Patient 71 year male patient. History of CAD. Stage 4 renal disease. COPD, Smoking 1.5ppd x 53 years. Hx of BPH. History of 2 months of toe ulcerations, Fontaine 4, Rutherford 5. CT angiogram could not be performed given the Stage 4 renal disease. CO2 angiograms are performed.

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17 THE NIPPLE IS OUR FRIEND

18 OBLIQUITY IS ALSO A FRIEND

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21 Zilver PTX

22 Patient 74 yo male History of ulceration of the left 2 nd and 3 rd digit DM Smoker, COPD,CAD, PAD Hx of ETOH use Sent as a consultation for revascularization Toe infection Rutherford 5, Fontaine 4 CT angiogram demonstrated CTO of the left out flow

23 SAFARI via AT Intimal Antegrade Subintimal Retrograde

24 Patient

25 Patient

26 Case 86 year old female. Admitted with back pain. History of CAD. DJD. Leg pain. Stage 3 ESRD. Previous history of GI bleeds. Orthopedic Spine surgery consulted, who consulted Endovascular Radiology for CLI of the left leg. Rutherford 6, Fontaine 4.

27 CLI SAFARI

28 CLI SAFARI VIA AT

29 Case 72 year old smoker with finger tip ulcerations Subclavian steal syndrome

30 Atypical Flossing technique CTO Subclavian Delayed

31 Right Subclavian CTO

32 Case 82 y/o diabetic CLI Multiple toe ulcers ABI of 0.62

33 Flush CTO with heavy calcification SAFARI via AT

34 Case 77 y/o with left toe ulcers. Right TMA CLI with Limb salvage attempt

35 Collateral TIBIAL CTO SAFARI Right CFA and Left AT approach Ulcers AT territory

36 Case 68 y/o diabetic smoker heavily calcified vessels. ABI of 0.5

37 SAFARI AGAIN MULTIPLE LONG SEGMENTAL OCCLUSIONS Nightmare Scenario with skip lesions

38 Case Diabetic with forefoot ulcer. ABI of 0.6

39 SAFARI to establish in-line flow/supera Stent

40 Case Smoker, Diabetic with toe ulcers CT angio shows a heavily calcified short outflow occlusion Short occlusion can also be mighty tricky at times

41 SAFARI for a tricky short occlusion

42 Case 84 y/o with right foot ulcers Limb Salvage No infragenicular in-line flow on CT angiogram

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44 Laser Atherectomy

45 Prolonged Angioplasty

46 SUMMARY In summary, the SAFARI procedure is an optimal option for CTOs of long and short segmental nature It is ideal for heavily calcified lesions It works well for complex occlusions It may be one of the best option for infragenicular lesions It does not place undue monetary stress on the system, however it does require persistence and prolonged elbow grease It is extremely safe in experienced hands The limb salvage rate with SAFARI was 90% Cardiovasc Intervent Radiol May-Jun;30(3): Gandini R, Pipitone V, Stefanini M, Maresca L, Spinelli A, Colangelo V, Reale CA, Pampana E, Simonetti G.

47 Lets go on a SAFARI and Discover Novel Tactics Awais Siddique MD Endovascular Interventional Radiology AZH/WAVE Centers Milwaukee WI