Leg arteries : MANAGEMENT and STRATEGY
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1 Leg arteries : MANAGEMENT and STRATEGY Prof E. Ducasse Unit of vascular surgery BORDEAUX ESVB May 14th 2011 BARD Symposium
2 CLI : definition Fontaine Rutherford ABI Symptoms class category Asymptomatic I none Mild claudication IIa walking distance > 200m Moderate claudication IIb walking distance = m Severe claudication IIb walking distance <100 Ischemic rest pain III 4 <0.5 rest pain Minor tissue loss IV 5 <0.5 minor tissue loss (ulceration) Major tissue loss IV 6 <0.5 major tissue loss (gangrene)
3 DIABETES : EPIDEMIOLOGY Population diabétique (en millions) Scénario 1 : constant obesity + 114% Scénario 2 : obesity!! +??? Epidemiology of «DIABESITY» Wild S, Diabetes Care, 2004
4 OBESITY : EPIDEMIOLOGY! Booming of obesity
5 OBESITY : EPIDEMIOLOGY! Obesity is equaly dangerous!
6 EPIDEMIOLOGICAL NIGHTMARE! Diabetes + obesity : evolution in the US Diabetes BOOMING + obesity BOOMING = CLI explosion
7 HENCE!! To battle! to avoid major amputation! TASC 2 : ENDOVASCULAR USE FOR BTK LESIONS
8 ENDOVASCULAR BTK! An Upside-down presentation!devices!guide-wires!access
9 DEVICES! Stents for BTK! DES: ACHILLES study! Cypher Select Plus! versus angioplasty in BTK lesions! 200 patients - primary endpoint : in segment restenosis at 12 months! 99 Pt DES / 101 Pt PTA (bailout for 8 Pt: DES)! 79.2% Pt available for 12 months follow-up! Treated population! Restenosis rate: 18.7% (DES) Vs 45.5% (PTA) ONLY Balloon Expandable Stent Coronary stents short lesions! DES: DESTINY trial! DES (Xience V) Vs Bare Metal Stent (Multi-link Vision)! 12 months patency: 85.2% (DES) Vs 54.4% (BMS)
10 DEVICES! IMPORTANT TO STENT!Scheinert et al. EuroPCR 2003, N=74 Vs 58! Technical success 79% Vs 95%! M12: 53% Vs 84%!Rand et al. CVIR 2005 N! Randomized prospective study N=52! 6 months patency : 83.7% (stent) Vs 61.1% (PTA)! Overall LS: M6
11 Angioplasty what does it means??! Atherosclerotic lesion compression! Atherosclerotic lesion compressed Plaque ruptured = instability
12 INSTABILITY what does it means??! It means risk of complications Parietal instability Problems!!! Wall support = security
13 What is the solution?? To maintain the arterial wall = STENT to maintain the lumen = haemorrhage dissection Lumen free of complications Hence : one solution: to stent the highly calcified lesion, the recanalisation and the remaining lesions
14 DEVICES for BTK! Dedicated stents for BTK lesions!bes good radial force and good visibility!palmaz blue OTW! Ø mm! L 10,20,30,40 mm!ses less radial force length superior (up to 200 mm) Xpert mm mm Astron Pulsar over the wire! 0.018! Ø mm! L 20,30,40,60,80 mm
15 DEVICES for BTK! BES!They may brake!
16 STENTING: OBVIOUSNESS! Stent on balloon! Precise placement! Good visibility! High radial force (calcifications)! Stent self-expanding! Superior flexibility! Crush resistance! Homogenous parietal covering! dedicated! Low profile! Good radial force BES crush Treatment adding a SES
17 STENTING : OBVIOUSNESSES! BTK arterial mobility evaluation Knee flexion up to 90 TA TPT TA TPT
18 PERSONAL ATTITUDE! For lesions < 2 cm without residual flow-limiting lesions : PTA alone! After recanalisation with residual lesion " stenting.!! 1/3 proximal (TPT, ostia TAA, TPA and PA) : ONLY SEStent! Distal part of BTK arteries : BEStent
19 DEVICES : Balloons! Dedicated balloons!0.018 or balloon Oversize the lenght of balloon, But NEVER oversize the diameter size!dedicated diameter and length Ultraverse! OTW 2 to 6 mm 2 to 100 mm / shaft 100 and 120 cm
20 DEVICES! Example: Pre-op Dilation BALLOON 2.5x150 Post-op
21 ! Bad example DEVICES
22 DEVICES! BAD example : restoration TRICKS Reinflation for remaining lesion = longer balloon
23 GUIDEWIRES! Guidewires antegrade way! ! GuideWire (Terumo) 180cm!0.018! SV Wire (Cordis) 180cm! V-18 ControlWire (BSci) 180cm! Cruiser (Biotronik) 195 cm and 300 cm!0.014! Asahi (Abbott) 180cm / Pilot and Win wires 300 cm! Cruiser (Biotronik) 190 cm : IDEAL : Chromium enriched Nitinol wire! Coating : Proximal " PTFE on stainless steel shaft Distal " hydrophylic coating! Tip stiffness : high flexible flexible medium! Tip shape : straight Angled
24 GUIDEWIRES SUMMARY! are dedicated for navigation!multistenosed lesions!in foot lesions! are dedicated for recanalisation!thrombosis and preocclusive lesions
25 GUIDEWIRE! Cross the lesion with a wire
26 GUIDEWIRES! Cross the lesion with a 0.014
27 GUIDEWIRE! No pushability for balloon
28 GUIDEWIRE! From to : increase the pushability
29 GUIDEWIRE! dedicated balloon cross the lesion
30 ! Dilatation 3 mm GUIDEWIRE
31 GUIDEWIRE! Control remaining lesion
32 GUIDEWIRE! Calcified lesion! stent (SES)
33 ! Final control GUIDEWIRE
34 PERSONAL ATTITUDE Antegrade approach! Antegrade approach TRICKS Under general anaesthesia minor amputation in the same time Don t loose the road mapping : less iodic product Surgical approach of SFA direct closure: no haematoma Clampage: injection, reflux! less iodic product Placement of short sheath at puncture site! 6F, 11cm or 4F long sheath
35 ACCESS FOCUS! In more than 80% of case, when there is only one remaining BTK artery this is the peroneal artery! If antegrade recanalisation impossible: NO HESITATION: PERONEAL PUNCTION
36 PERONEAL ACCESS
37 PERONEAL ACCESS
38 PERONEAL ACCESS
39 PERONEAL ACCESS! Retrograde access: same technique, same tools
40 PERONEAL ACCESS! Remaining peroneal artery
41 PERONEAL ACCESS! Recananlisation antegrade impossible
42 PERONEAL ACCESS! Peroneal retrograde punction
43 PERONEAL ACCESS! guidewire recanalisation TPT
44 CONCLUSION 1! With a good technique and dedicated material:!large and dedicated stenting!dedicated balloon!adapted guide wire!no fear for exotic access! nothing impossible
45 CONCLUSION 2! Most advanced endovascular treatment for BTK lesions is efficient BEFORE AFTER Thank you
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