In foot treatment : what not to do? clinical experience. E.Ducasse MD PhD FEVBS Unit of vascular surgery CHU bordeaux
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1 In foot treatment : what not to do? clinical experience E.Ducasse MD PhD FEVBS Unit of vascular surgery CHU bordeaux
2 Disclosure Speaker name: Pr E Ducasse I do not have any potential conflict of interest
3 Actual BTK treatment strategy BTK occlusions in CLI 1,2 : 50% of CLI patient 70% of CLI patients with DM - ESRD BTA 3 55% of CLI patient have 2-3 BTA vessel disease 25% with arch disease (50% with DM - ESRD) ENDOVASCULAR FIRST 4 Ischemic angiosome 5,6 = first target artery If not possible restore as much blood flow as possible to the foot 1. Rueda et al. J Vasc Surg. 2008, 2. Norgren et al. TASC II. J Vasc Surg. 2007, 3. Ferraresi et al. Linc Adam et al. BASIL. Lancet Lond Engl. 2005, 5. Lida O, et al. OLIVE registry. Circ Cardiovasc Interv. 2013;6(1): Romiti M, et al. J Vasc Surg 2008; 47:
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6 Choose wisely your approach LESSON N 1: BE PRECISE 1/ Antegrade approach Controlateral approach with crossover If associated proximal lesion (iliac/sfa) Obese patients Ipsilateral antegrade approach +++ support, pushability and trackability CFA or proximal SFA (same morbidity) 6 Short 6F sheath Then optimal placement of long (55-110cm) 4F sheath inside for BTK segment Or short then long 4 or 5F sheath alone 6. Kweon M et Al. Vasc Interv Radiol 2012;23:1160 4
7 CHOOSE WISELY YOUR APPROACH LESSON N 1: BE PRECISE 1/ Antegrade approach 1/ Endoluminal +++ PROS Standard technique More experience Seems more physiological No re-entry problem CONS Not always possible in long calcified lesions Possible unsatisfactory results after balloon PTA 2/ Subintimal PROS Smoother lumen Less distal embolization? CONS Long learning curve Re-entry difficult to control Risk of collateral occlusion Risk of vessel perforation
8 CHOOSE WISELY YOUR APPROACH LESSON N 2: BE PRECISE AND GENTLY 2/ Retrograde approach if unsuccessful ( 20%) Indications 1) Inability to correctly identify the origin of peroneal of tibial artery 2) Rupture or loss of the antegrade vessel pathway 3) Inability to re-enter into the true lumen 4) High risk to damage distal target vessel by continuing antegrade approach while it might be the only landing zone for bypass Dedicated material 16-G x 83 mm needle / 21-G micropuncture kit Antispasmodic intra-arterial cocktail Wires = more column strength and pushability = less traumatic and lower profile Wire excalation strategy Support catheters or OTW balloon catheters Improves pushability, Facilitates reshaping/exchange
9 Tibiopedal access LESSON N 2: BE PRECISE AND GENTLY 1) Sheathless approach +++ «SAFARI» and procedure resumed by antegrade approach 2) 4 F popliteal sheath / 3F pedal sheath «CART» / «Rendez-vous» technique only Hemostasis balloon inflation from antegrade access + manual compresion Patency checked by angiography PROS Small diameter vessels : increased pushability Less likelihood of entering sidebranches Distal cap often softer Easier re-entry Limits the extension of dissection Shorter arterial segment to treat CONS Challenging Small diameter vessels prone to spasm and dissection Often calcified Sharp angulation near the ankle Long procedure time
10 Optimal patient installation is key LESSON N 2: BE PRECISE AND GENTLY Sterile preparation of both groins + entire leg 1/ ULTRASOUND-GUIDED PUNCTURE Identify the target artery in longitudinal view Puncture at 45 in transversal view Verify intraluminal positionning of guidewire in longitudinal view
11 OPTIMAL PATIENT INSTALLATION IS KEY LESSON N 2: BE PRECISE AND GENTLY 2/ FluOroscopy-Guided puncture Simple scopy if calcified / proximal injection + roadmapping Parallax adjustment +++ Needle and artery must be perfectly aligned For ATA, PTA and PA feet attached together in internal rotation For complex vascular anatomy of the foot and plantar arch Foot in abduction + Standard anteroposterior and lateral oblique projections
12 CHOOSE WISELY YOUR APPROACH 3/ Transcollateral approach LESSON N 3: LOOP-TECHNIQUE: DANGER, BE GENTLY!! 1) Pedal-plantar loop technique 8 for reconstruction of plantar arch Low-profile balloons Dedicated diameter 1.5 to 4 mm Dedicated length : Avoid long balloons High early restenosis rates (< 2 years) Post operative 6 months Werner M et al. Liepzig group - LINC 8. From Manzi et al.
13 CHOOSE WISELY YOUR APPROACH 3/ Transcollateral approach LESSON N 3: LOOP-TECHNIQUE: DANGER, BE GENTLY!! 1) Pedal-plantar loop technique for reconstruction of plantar arch Dedicated diameter 1.5 to 4 mm Dedicated length : Avoid long balloons High early restenosis rates (< 2 years) Not compliant enough arterial stress hyperplasia Prefer repeated inflations with short balloons Only treat occluded or heavely diseased foot vessels Respect the distribution system if it seems satisfactory Last picture from Ferraresi et al. LINC 2014
14 LIMIT STENTING TO MANDATORY SITUATIONS / AVOID AT ALL COSTS BELOW THE ANKLE LESSON N 3: LOOP-TECHNIQUE: DANGER, BE GENTLY!! 2 Nakama et al. 1 Technical success : 93% wound healing With bellow the ankle angioplasty = 93% Without bellow the ankle angioplasty = 60% wound healing time : 86.0±18.7 with BTA angioplasty vs 152.0±60.2 days Katsanos et al. 2 : Technical success : 95.2%, Stenting : 45.2% 1-year results Patency : 50.4±9.1% Restenosis : 64.1±8.3% Freedom from reintervention : 93.6±4.3% 1. Nakama et al. J Endovasc Ther Off J Int Soc Endovasc Spec Oct 6; 2. Katsanos et al. Cardiovasc Intervent Radiol Aug;36(4): , Ferraresi et al. LINC 2014
15 CHOOSE WISELY YOUR APPROACH 3/ Transcollateral approach LESSON N 4: IN FOOT WAY FOR RETROGRADE RECANALISATION CLI BTK case
16 CHOOSE WISELY YOUR APPROACH 3/ Transcollateral approach LESSON N 4: IN FOOT WAY FOR RETROGRADE RECANALISATION SPECIFIC 0,014 wire from 20 to 3 gf SPECIFIC support catheter very soft
17 CHOOSE WISELY YOUR APPROACH 3/ Transcollateral approach LESSON N 4: IN FOOT WAY FOR RETROGRADE RECANALISATION
18 CHOOSE WISELY YOUR APPROACH 3/ Transcollateral approach LESSON N 4: IN FOOT WAY FOR RETROGRADE RECANALISATION
19 Deep Venous Arterialization LESSON N 5: TRY ALL POSSIBILITIES Venous arterialization = not a new concept 1-4 Surgical attempts : good safety and clinical outcomes Problems : valves limit blood flow numerous draining venous collaterals steal blood flow to extremity Percutaneous deep venous arterialization (PDVA) Pilot study 5 7 end stage CLI patients with no remaining open or endovascular options LimFlow : 7F arterial catheter + 5F venous catheter + console to facilitate crossing with needle driven across crossover point into retrograde sheath 3 x 40mm balloon to predilate arteriovenous fistula exchanged for over support catheter reversed valvulotome to disrupt the valves covered stent from posterior tibial vein up to patent posterior tibial artery to cover venous collaterals 1. Lu et al. Meta-analysis Eur J Vasc Endovasc Surg. 2006;31: , 2. Mutirangura et al. Vascular. 2011;19: Alexandrescu et al. Cardiovasc Revasc Med. 2011;12:10-19., 4. Schreve al. Ann Vasc Surg. 2014;28: Changi General Hospital in Singapore. Pictures from S.KUM; Y.KAI TAN; T.TANG; A.SCHMIDT; D.SCHEINERT; R.FERRARESI, ENDOVASCULAR TODAY MAY 2015
20 Percutaneous Deep Venous Arterialization (PDVA) LESSON N 5: TRY ALL POSSIBILITIES iflow postprocessing program (Siemens) postprocedure : rapid arrival of contrast (yellow/red) No 30-day MAEs 6-month results Skin temperature improved on FLIR thermography Complete wound healing in 4 Immediate Rest pain in 1 Increased transcutaneous oximetry levels in 4 Major amputation in 1 CE Mark study underway Pre-investigational device exemption application accepted by FDA Changi General Hospital in Singapore. Pictures from S.KUM; Y.KAI TAN; T.TANG; A.SCHMIDT; D.SCHEINERT; R.FERRARESI, ENDOVASCULAR TODAY MAY 2015
21 Take home message Endo first Angiosome concept but «3 remains better than 2» Antegrade approach first IN SUMMARY: BE PRECISE, BE GENTLY, BE AGGRESIVE but always be prepared for retrograde (sheathless +++) / Transcollateral Treat BTA lesions only when clearly necessary Respect what is still functionning Limit stenting to mandatory situations / avoid at all costs Bellow the ankle Sharp debridement but not too extensive at first Pressure offloading Percutaneous deep venous arterialization (PDVA) could it become a last resort option in desert ft?
22 In foot treatment : what not to do? clinical experience E.Ducasse MD PhD FEVBS Unit of vascular surgery CHU bordeaux
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