Endovascular Repair of Combined Occluded Femoral and Popliteal Arteries

MEET 2013 Endovascular Repair of Combined Occluded Femoral and Popliteal Arteries ALI AMIN MD, FACS,FACC, RVT CHIEF OF ENDOVASCULAR INTERVENTIONS READING HOSPITAL AND MEDICAL CENTER READING, PA USA

Chronic Total Occlusion (CTO) Percutaneous treatment of peripheral arterial occlusion has evolved greatly. Endovascular Revascularization of the totally occluded SFA, Iliac, Aorta remains a challenge, greatly because of the risk of access the distal reconstituted artery.

SIA - History Developed in Leicester, UK by Amman Bolia Technique discovered inadvertently in 1987 15-cm popliteal occlusion Subintimal channel accidentally created and balloon dilated Authors recognized this occurrence and its potential for therapy for PAOD * That particular PTA remained patent for > 9 years Bolia A, Bell PRF. Subintimal Angioplasty. In: Dyet JF, Ettles DF, Nicholson AA, Wilson SE, eds. Textbook of Endovascular Procedures. 1st ed. Philadelphia, PA: Churchill Livingstone; 2000. p. 126-138.

Subintimal Angioplasty/CTO Permits creation of Dissection plane + Reentry without reducing future bypass options Successful Case without complications and morbidity (Perforation)

Arterial Occlusion Femoral/Popliteal Cross the Lesion Enter the True Lumen Endovascular Intervention

Arterial Occlusion Femoral/popliteal Wires & Catheters Cross Lesion DEVICE Wires & Catheters Enter True Lumen DEVICE Endovascular Intervention

CTO and Subintimal Angioplasty (SIA) Irrespective of Technique or Device to be used: -POBA -Bare metal stent -Covered stent -Drug coated stent -Atherectomy -Laser -Cryoplasty - Drug Coated Balloon and Stent

Re-entry Must Be: RASP Reproducible Accurate Safe Predictable Treatment of Claudication Claudication Acute Limb Ischemia (ALI)

Techniques for Crossing Total Occlusion (CTO) Femoral Artery Use Contralateral approach: 1) short proximal SFA stump 2) Obese patients 3) Groin scar Use Ipsilateral approach: 1) mid to distal SFA occlusion 2) infrapopliteal lesion 3) severe aorto-iliac tortuosity 4) thin patient

CTO- Contralateral SFA 6 or 7 Fr. 55cm into CFA Perform a selective Agram of the entire extremity Place I.I. to cover at least the Start and possibly the End point Perform a Roadmap to at least visualize the Start point at the top of I. I. Mag Up the field 55 cm 6 Fr. sheath

Catheter and Wire.035 Angle hydrophilic Wire CTO of SFA, Pop

Distal SFA Occlusion START END

Advance Catheter & Wire under Roadmap Advance angle 4 Fr. catheter over a.035 angle Hydrophilic wire toward Start point Force the wire into the Occlusion For Long occlusion form a loop by passing wire back and forth. Angle catheter Angle Glide wire START END

Advance Catheter & Wire under Roadmap Advance the Wire and Catheter and into the occlusion (FORCE IT!) catheter wire

Advance Catheter & Wire under Roadmap Advance the Wire followed by the Catheter until the End point is reached catheter At this point End point and distal native vessel should be visualized on the Roadmap wire END

Advance Catheter & Wire under Roadmap Pass the loop 0.5-1.0 cm into the patent distal native vessel followed by the catheter catheter wire END

Advance Catheter & Wire under Roadmap by this point the wire and catheter has entered the True Lumen (feel the resistance). Wire easily pass distally Pull out the wire and back bleeding from catheter (+) for true lumen access catheter wire

True Lumen Gently hand inject contrast to confirm (True Lumen) DO NOT inject if No back bleeding (stain the area) Distal patent True Lumen

Critical Point Must Enter Wire into the True Lumen at the END Point wire END

Do Not Pass the wire too far beyond the END point Extend the dissection distally Convert AK to BK bypass Compromise important collaterals

Completion Arteriogram

BASIL Trial Angioplasty Attempts/Immediate Failures Of the 224 patients allocated to angioplasty, 216 underwent attempted angioplasty Of these, 43 (20%) were considered immediate failures: 23% 2% 5% 5% N = 43 42% 23% Lumen could not be crossed with guidewire Lesion crossed subintimally, but could not be re-entered Perforation Patient could not tolerate procedure No lesion upon angiography Lytic/Aspiration Resistant Thrombosis BASIL trial participants, Lancet 2005; 366:1925-34.

Crossing and Re-Entry Devices Have increased the success of CTO and having a successful outcome Decreased need for retrograde approach esp popliteal Decreased need for Bypass Surgery Decreased stenting of NO STENT zone Decreased length of stented segment Decreased amount of Radiation and Contrast

Re-entry Devices Not a Crossing tool, but a Re-entry tool (RD) Must pass through the Occlusion first before using (RD) Must get to the Point of Reconstitution

Arterial Occlusion Femoral/popliteal Cross Lesion FrontRunner Crosser Avinger Wild Cat Enter True Lumen Outback Re-entry Pioneer Catheter Endovascular Intervention

Crossing Device Frontrunner XP Peripheral CTO Crossing device

Crossing the Lesion

The tip is actuated and delivers enough force to displace plaque, while minimizing the risk of vessel perforation FRONTRUNNER XP CATHETER Percutaneous catheter-based technique of controlled blunt microdissection (CMD) The catheter s blunt tip engages the lesion to penetrate the proximal cap of the CTO

Micro-channel creation enables guidewire access for percutaneous intervention FRONTRUNNER XP CATHETER Repeated application of controlled blunt microdissection enables further device advancement until it reaches the distal end of the occlusion

Crossing Device (Frontrunner XP)

Penetrate Cap with Jaws Open Advance FR with Jaws Closed

May enter True Lumen by FR Blood return, inject 3 cc thru Micro Guide Pass Wire thru MGC

Completion Arteriogram after EVI runoff

Have already Crossed the Occlusion failure to Enter! Re-Entry Device Must enter the True Lumen to avoid open surgery

Re-entry Device---Pioneer Catheter

True Lumen Entry Using IVUS component, orient catheter toward true lumen by rotating the entire catheter. Verify position with fluoro.

Outback LTD Orientation Markers Locate Tune Deploy Rotate 90º Hold On to the Handle while L and T

Deploy Needle Non Hydrophilic Wire

Gently Pass.014 wire while Needle is deployed Remove OB, only after Needle is pulled back

Completion Arteriogram after EVI

Always Check Distal Run Off

Summary Bypass surgery is invasive procedure associated with higher M & M Subintimal Angioplasty: inexpensive, minimally invasive and durable procedure to provide limb salvage in patients with femoral and popliteal occlusion