Leg arteries : MANAGEMENT and STRATEGY Prof E. Ducasse Unit of vascular surgery BORDEAUX ESVB May 14th 2011 BARD Symposium
CLI : definition Fontaine Rutherford ABI Symptoms class category Asymptomatic I 0 0.85-1 none Mild claudication IIa 1 0.5-0.8 walking distance > 200m Moderate claudication IIb 2 0.5-0.8 walking distance = 100-200m Severe claudication IIb 3 0.5-0.8 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)
DIABETES : EPIDEMIOLOGY Population diabétique (en millions) 400 300 200 100 2000 2030 Scénario 1 : constant obesity + 114% Scénario 2 : obesity!! +??? Epidemiology of «DIABESITY» Wild S, Diabetes Care, 2004
OBESITY : EPIDEMIOLOGY! Booming of obesity
OBESITY : EPIDEMIOLOGY! Obesity is equaly dangerous!
EPIDEMIOLOGICAL NIGHTMARE! Diabetes + obesity : evolution in the US Diabetes BOOMING + obesity BOOMING = CLI explosion
HENCE!! To battle! to avoid major amputation! TASC 2 : ENDOVASCULAR USE FOR BTK LESIONS
ENDOVASCULAR BTK! An Upside-down presentation!devices!guide-wires!access
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)
DEVICES! IMPORTANT TO STENT!Scheinert et al. EuroPCR 2003, N=74 Vs 58! Technical success 79% Vs 95%! Patency @ 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: 98% @ M6
Angioplasty what does it means??! Atherosclerotic lesion compression! Atherosclerotic lesion compressed Plaque ruptured = instability
INSTABILITY what does it means??! It means risk of complications Parietal instability Problems!!! Wall support = security
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
DEVICES for BTK! Dedicated stents for BTK lesions!bes good radial force and good visibility!palmaz blue - 0.018 - OTW! Ø 2 2.5 3 3.5 4 4.5 5 mm! L 10,20,30,40 mm!ses less radial force length superior (up to 200 mm) Xpert 4-5-6 mm 20-40 mm Astron Pulsar over the wire! 0.018! Ø 4 5 6 7 mm! L 20,30,40,60,80 mm
DEVICES for BTK! BES!They may brake!
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
STENTING : OBVIOUSNESSES! BTK arterial mobility evaluation Knee flexion up to 90 TA TPT TA TPT
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
DEVICES : Balloons! Dedicated balloons!0.018 or 0.014 balloon Oversize the lenght of balloon, But NEVER oversize the diameter size!dedicated diameter and length Ultraverse! 0.018 OTW 2 to 6 mm 2 to 100 mm / shaft 100 and 120 cm
DEVICES! Example: Pre-op Dilation BALLOON 2.5x150 Post-op
! Bad example DEVICES
DEVICES! BAD example : restoration TRICKS Reinflation for remaining lesion = longer balloon
GUIDEWIRES! Guidewires antegrade way!0.035 0.032! 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
GUIDEWIRES SUMMARY! 0.014 are dedicated for navigation!multistenosed lesions!in foot lesions! 0.018 are dedicated for recanalisation!thrombosis and preocclusive lesions
GUIDEWIRE! Cross the lesion with a 0.014 wire
GUIDEWIRES! Cross the lesion with a 0.014
GUIDEWIRE! No pushability for 0.014 balloon
GUIDEWIRE! From 0.014 to 0.018 : increase the pushability
GUIDEWIRE! 0.018 dedicated balloon cross the lesion
! Dilatation 3 mm GUIDEWIRE
GUIDEWIRE! Control remaining lesion
GUIDEWIRE! Calcified lesion! stent (SES)
! Final control GUIDEWIRE
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
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
PERONEAL ACCESS
PERONEAL ACCESS
PERONEAL ACCESS
PERONEAL ACCESS! Retrograde access: same technique, same tools
PERONEAL ACCESS! Remaining peroneal artery
PERONEAL ACCESS! Recananlisation antegrade impossible
PERONEAL ACCESS! Peroneal retrograde punction
PERONEAL ACCESS! 0.018 guidewire recanalisation TPT
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
CONCLUSION 2! Most advanced endovascular treatment for BTK lesions is efficient BEFORE AFTER Thank you