Distal hybrids - an option in long SFA CTO accompanied by severely compromized crural runoff
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1 Distal hybrids - an option in long SFA CTO accompanied by severely compromized crural runoff P. Kuryanov, A. Lipin, A. Antropov, K. Atmadzas, A. Atmadzas, Y. Eminov, A. Borisov, R. Sobolev, A.Orlov
2 Limb Salvage Center, St.-Petersburg - Large volume hospital for pts with soft tissue infections hospital beds for CLI patients - Vascular/endovascular surgery unit arranged in Over 450 PVI yearly, ~100% CLI - 80% endo, 15% open, 5% hybrid
3 Disclosure Speaker name: PAVEL KURYANOV 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
4
5 Distribution and symmetry of arteriosclerotic lesions of the lower extremities: an arteriographic study of 200 limbs Waldren R. et al., % SFA lesions
6 Distribution of arteriosclerotic lesions of the lower extremities: Limb Salvage Center, St.-Petersburg, 600 patients 100% Rutherford 5-6 SFA lesions - 69% SFA CTO > 20 cm 37.7% Of these: 3-vessel crural CTO 37% Peronea as the sole runoff vessel 16%
7 Conventional strategies SFA PTA ± stent + Crural PTA Long tibial bypass
8 What speaks in favor of endo? Sachs T. et al., 2011 (~ cases done between ): 3-fold increase in the number of CLI cases treated in endovascular fashion 40% decrease in the number of open intereventions
9 What speaks in favor of endo? Swedvasc registry data Open 40% 37% 35% 32% 33.5% 29% Endo 60% 59% 61% 64% 62.5% 67%
10 What speaks in favor of endo? BASIL trial Bradbury A. et al., y amputation-free survival: NS
11 What speaks in favor of endo? Antoniou G. et al., 2013 Meta-analysis of 2817 cases (CLI %) Endo Open 30-day mortality rate 3% 3%, NS 1-y amputation-free survival 71% 76%, NS 1-y primary patency 62% 72% (significant)
12 What speaks in favor of endo? Studies showing impressive long-term outcome of PTA±stent in long SFA CTO Author, year N CLI% Mean lesion length Palena L., 2017 Hong S., 2013 Lichtenberg M., 2013 Lagana D., 2011 Stent Technical success 30d mortality 1y primary patency 1y AFS % 27.9 см 100% 100% 0% 94,1% 82,4% % 22.6 см 100% 94% 0% 77% % 24.5 см 100% 100% 0% 77% % - 100% 100% 0% 76,9% -
13 What speaks in favor of endo? Romiti M. et al., 2008 Meta-analysis of crural PTA studies (2653 cases, 30 studies, ) Technical success - 89% 30-day mortality rate 1.8%
14 What speaks in favor of endo? Popplewell M.A. et al., 2017 (n=104) Randomized comparison of РТА vs tibial bypass (BASIL trial)
15 What speaks in favor of endo? IIB VASCUNET report (2012): cases, 9 countries
16 What speaks in favor of endo? Bisdas T. et al., 2016 CRITISCH registry, 129 patients treated with tibial bypass 30-d bypass failure 19.4% 30-d major amputation 4.7%
17 What speaks in favor of open? TASC II (2007) Open surgery is a method of choice in TASC D lesions AHA/ACC Guideline on Management of Patients with LE-PAD (2016) Open surgery is the method of choice in multi-level disease ESC guidelines (2017) Bypass with vein a method of choice in SFA lesions >25 cm
18 What speaks in favor of open? VASCUNET report (2012): IIB cases, 9 countries
19 What speaks in favor of open? SVS/Vascular Quality Initiative (2016)* * ~1/3 of all interventions done for SFA disease are open, and mostly for long lesions
20 What speaks in favor of open? Pomposelli F. et al., 2003 >1000 bypassess to a. dorsalis pedis, 10-year follow-up Early mortality % Early failure 4.2% AMI 3.0%
21 What speaks in favor of open? Shah D. et al., patients treated with in situ bypass, 10-y follow up
22 What speaks in favor of open? BASIL trial Bradbury A. et al., y AFS NS! SFA lesions only in 80% TASC D only in ~1/4
23 What speaks in favor of open? Lofberg A. et al., 2001 SFA lesion type and the long-term patency Short stenotic lesion Long stenotic lesion SFA CTO
24 What speaks in favor of open? Ah Chong A. et al., 2009: type of SFA lesion (TASC II) and the long-term patency after SFA PTA TASC A TASC B TASC C TASC D
25 What speaks in favor of open? Davies M. et al, 2008: crural runoff and the long-term patency after SFA PTA
26 The concept of distal hybrid Open part Endo part Vein bypass to a. poplitea Outflow reconstruction with crural PTA Higher patency vs PTA Shorter bypass less likelihood of restenosis BTK amputation doesn t require bypass ligation Direct angiosomic revascularization Late reocclusion doesn t cause CLI (bypass still functioning)
27 Is it safe to perform a vein bypass to an isolated popliteal segment? Author, year n Bypass Distal anastomosis Early failure rate Brochado NF, Vein a. genu descendens, a. suralis medialis, Isolated popliteal artery 9% 2 y 73% Davis RC, Vein Isolated popliteal artery - 4 y 70% Primary patency Satiani B, Vein/ PTFE Isolated popliteal artery 0% 3 y 84.1% 3 y (PTFE) 41.7% Loh A, Vein Isolated popliteal artery - 3 y 76% Brewster DC, 1984 de Latour B, 2008 de Luccia N, 2011 Barral X, Vein/ PTFE Kram HB, Vein/ PTFE Vein Isolated popliteal artery - 5 y - 71% 51 Vein a. genu descendens, a. suralis medialis 47 Vein a. genu descendens, a. suralis medialis a. genu superior, a. suralis medialis 3,3% 3 y 65% 0% 3 y 74,7% - 1 y 77% Isolated popliteal artery - 5 y 74% 5 y 55% (PTFE)
28 Is it safe to perform a vein bypass to an isolated popliteal segment? 2 weeks 3 months 2 years 2 years 10 years
29 Is it safe to perform a vein bypass to an isolated popliteal segment? AHA/ACC Guideline on Management of Patients with LE-PAD, 2016 In addition, composite sequential femoropopliteal-tibial bypass and bypass to an isolated popliteal arterial segment that has collateral out flow to the foot are both acceptable methods of revascularization and should be considered when no other form of bypass with adequate autogenous conduit is possible (326,327).
30 Distal hybrids in Limb Salvage Center, St.-Petersburg 33 pts CLI 100% (all Rutherford 5-6) Females, n (%) 8 (24.2%) Age, y (mean, range) 69.5 (45-88) CAD, n (%) 17 (51.5%) Diabetes, n (%) 12 (36.4%)
31 Lesion distribution on angio IIB with vein 100% SFA CTO >20 cm Proximal PA always patent 5 pts (15.2%) had distal PA CTO Crural PTA 3-vessel CTO in 26 (78.8%) Peronea as the only outflow vessel in 7 (21.2%)
32 Staging and endo access Staged* N=14 (42.4%) Simultaneous N=19 (52.6%) Step 1 vein bypass Step 2 Crural PTA through crossover femoral access Side branch access N=16 (84.2%) Crossover femoral access N=3 (15.8%) * 2-14 day interval
33 Crural angioplasty* 1-vessel PTA 66.6% (n=22) 2-vessel PTA 30.4% (n=10) 3-vessel PTA 3% (n=1) Angiosomic revascularization 91% (n=30) * PTA of distal popliteal segment was done in 4 pts; Stent implanted in 3 (9%) pts.
34 AC and AP strategy NFH 60 IU/kg intraoperatively (both for open and endo steps) No AC postoperatively Simultaneous hybrids done on ASA, clopidogrel initiated postoperatively For staged hybrids: open step done on ASA, clopidogrel administered prior to crural PTA
35 30-d complications 1 (3%) death due to MI 2 (6%) cases of early graft failure (both after simultaneous hybrids) 1 (3%) crural artery reocclusion (bypass functioning, ulcer healed) 1 (3%) major amputation
36 Long-term outcome 2 years: - AFS (n=24) - 75% - Bypass primary patency (n=12) 58% - Crural PTA patency (n=12) 0% - PA patency (n=3) 66%
37 Case 1: simultaneous distal hybrid
38 Case 1: simultaneous distal hybrid
39 Case 1: 1.5 year outcome
40 Case 2: staged distal hybrid
41 Case 2: staged distal hybrid
42 Conclusions 1. Distal hybrids are a viable option in long SFA CTO accompanied by crural disaster 2. Despite outflow reocclusion in the long run you may still have high AFS due to a functioning bypass 3. Need larger comparative studies 4. Need flow-meter to compare volume flow vs tibial bypass.
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