overview of pad: anatomy, considerations for treating cli ......artery 14.2% 63% of pad patients had...
Post on 13-Oct-2020
0 Views
Preview:
TRANSCRIPT
Curtiss T. Stinis, M.D., F.A.C.C., F.S.C.A.I.Director, Peripheral Interventions
Director, Interventional Cardiology Fellowship Program
Scripps Clinic
La Jolla, CA
Overview of PAD:Overview of PAD: Anatomy, ConsiderationsAnatomy, Considerationsfor Treating CLI, and Case Examplesfor Treating CLI, and Case Examples
SCRIPPS CLINIC
Arteriosclerosis is a Systemic Disease
SCRIPPS CLINIC
Scope of the Problem:Polyvascular Disease
Coronaryartery
14.2%
63% of PAD patientshad polyvascular disease
N = 7013
Cerebro-vascular
SCRIPPS CLINIC
Bhatt DL, et al. Presented at: ACC Scientific Session; March 6-9, 2005; Orlando, Fla.
Peripheralartery
39.4%
Polyvasculardisease
Normal subjects
Asymptomatic PAD
100
75
Su
rviv
al
(%)
PAD: Long Term Survival
SCRIPPS CLINIC
Criqui MH et al. N Engl J Med. 1992;326:381-386.
Asymptomatic PAD
Symptomatic PAD
Severe symptomatic PAD
50
25
0 2 4 6 8 10 12
Su
rviv
al
(%)
Year
PAD is alive and well….
SCRIPPS CLINIC
Clinical Presentations of PAD
SCRIPPS CLINIC
Classification of PAD
FONTAINEStage Clinical Grade Category Clinical
I Asymptomatic 0 0 Asymptomatic
IIa Mild claudication I 1 Mild claudication
RUTHERFORD
SCRIPPS CLINIC
IIb Moderate–severe claudication I 2 Moderate claudication
I 3 Severe claudication
III Ischemic rest pain II 4 Ischemic rest pain
IV Ulceration or gangrene III 5 Minor tissue loss
IV 6 Ulceration or gangrene
Dormandy JA, Rutherfors RB J Vasc Surg 2000; 31(1): S1-S296
SCRIPPS CLINIC
Revascularization Therapy forPeripheral Arterial Disease
Intermittent Claudication
Analogy: Angina
Timing: Elective
Revascularization is only considered forsymptomatic patients who have failed
SCRIPPS CLINIC
Critical Limb Ischemia
Analogy: Acute Coronary Syndrome
Timing: Urgent!
symptomatic patients who have failedguideline-directed medical therapy(including a supervised exercise program)
Critical Limb Ischemia:A Unique and Difficult Patient Subset
•15-20% of patients with intermittent
claudication deteriorate to ischemic
rest pain/ulceration/gangrene
SCRIPPS CLINIC
rest pain/ulceration/gangrene
•Therefore, 20 million Americans
will present with critical limb
ischemia annually
J CardiovascSurg(Torino)..1989;30:50-57
Critical Limb Ischemia:Current Reality
•Shockingly primary amputations are still the mostcommon treatment for critical limb ischemia
•In 2010-2011 67% of American CLI pts had primaryamputation as initial treatment
•More shockingly 50% of primary amputations are
SCRIPPS CLINIC
•More shockingly 50% of primary amputations areperformed without angiography or even a simple ABI!!
•40% of amputees die within 2 years of amputation
•The professional nursing home care costs in the US afteran amputation have been estimated at $100,000 per year
Allie et al, Eurointerventions, May 2013
SCRIPPS CLINIC
Survival After Limb Amputation
SCRIPPS CLINIC
Revascularization for CLI:Key Requirements
• Knowledge of lower extremity arterialanatomy
• Knowledge and skill set with advanced
SCRIPPS CLINIC
• Knowledge and skill set with advancedendovascular techniques
• Prompt and effective revascularization
Key Anatomy of the Abdominal Aorta
SCRIPPS CLINIC
Key Arterial Anatomy of the Pelvis
SCRIPPS CLINIC
Key Arterial Anatomy of the Pelvis
SCRIPPS CLINIC
Internal Iliac, Lumbar,Inferior Epigastric areall Important Sourcesof Collaterals
Key Anatomy of the Femoral Region:Critical to Good Access and Closure
Anatomic
SCRIPPS CLINIC
Functional
Key Anatomy of the Femoral Region:Important to Think in 3D!
SCRIPPS CLINIC
The Pubis: a Key Structure inFemoral Access Management
PUBIS
SCRIPPS CLINIC
Access Above or Below the Pubis isAssociated with Significant Complications
SCRIPPS CLINIC
ProfundaFemorisHunter’s Canal
SCRIPPS CLINIC
SFA
The Profunda is an ImportantSource of Collaterals
SCRIPPS CLINIC
SFA Passes Posteriorly through Hunter’sCanal to become the Popliteal Artery
SCRIPPS CLINIC
The SFA & Popliteal Artery AreSubjected to Multiple Stressors
SCRIPPS CLINIC
The SFA & Popliteal ArteryExhibits Complex 3D Anatomy
SCRIPPS CLINIC
Popliteal
Anterior tibial
Posterior tibial
Geniculate popliteal
Anterior tibial artery
Hunter’s Canal
Suprageniculate popliteal
Infrageniculate popliteal
SCRIPPS CLINIC
Posterior tibial
Peroneal
Posterior tibial artery
Peroneal artery
Tibioperoneal trunk
Geniculate Branches are anImportant Source of Collaterals
SCRIPPS CLINIC
Anterior Tibial
Peroneal
To resolve ischemicrest pain or heal an
Lateral View of the Foot is Key forDefining Distal Target Vessels
SCRIPPS CLINIC
Dorsalis Pedis
Anterior Tibial
Posterior Tibial
rest pain or heal anulcer, one continuouslypatent infrapoplitealvessel to the foot isnecessary
Medial & LateralPlantar Arteries
SCRIPPS CLINIC
Surgical Treatment for CLI:Bypass Surgery
SCRIPPS CLINIC
Fundamental Principles of LowerExtremity Bypass Surgery
Requires an Adequate Conduit
Often UNAVAILABLE due to priorlower extremity bypass or previousCABG
SCRIPPS CLINIC
CABG
Requires adequate distal targetand outflow
Often UNAVAILABLE in ESRD andDiabetes
2 weeks post-op from
Femoral-Popliteal Bypass….
SCRIPPS CLINIC
SCRIPPS CLINIC
Downsides of Vascular Surgery forthe Treatment of CLI
•Higher risk
•More invasive
•Cannot address runoff disease
Mismatch issues between conduit and target
SCRIPPS CLINIC
•Mismatch issues between conduit and targetvessels
•Complications of seroma, infection, chronicpain, scars, chronic edema
Endovascular Therapy:The Dominant Revascularization Strategy
SCRIPPS CLINIC
DiffuselyDiffuselyDiseasedDiseasedFemoralFemoralArteriesArteries
TotallyTotallyOccludedOccludedSegmentsSegments
2893 Lesions in 417 patients with DMand foot ulcer
The Challenge: PAD patients oftenpresent with complex multi-level
disease and long occlusions
SCRIPPS CLINIC
Scripps Clinic CLI Program:Latest Techniques and Technologies
Standard Retrograde Approach
Access to distal cap via donor vessel
Retrograde Transcollateral Approach
Access to distal cap via retrograde collaterals
SCRIPPS CLINIC
Access to distal cap via retrograde collaterals
Antegrade Transcollateral Approach
Access to distal cap through antegrade collaterals
Combined with Latest Lesion Treatment Technologies:• Drug-coated balloons• Drug-eluting stents
CART Technique:Combined Anterograde and Retrograde Tracking
SCRIPPS CLINIC
• 0.014 supportcatheter acts as asheath and supportdevice for wire
• Allows muchsmaller hole in
Pedal Access
SCRIPPS CLINIC
smaller hole inartery and allowsflow around it intofoot
• Analogous to radialaccess forcoronaryprocedures
76yo male with DMII,BKA of left leg, openand non-healingwound on bottom ofright foot for 6 months
SCRIPPS CLINIC
DSA image of the foottaken after intra-arterial verapamil
DP suitable target forretrograde access
SCRIPPS CLINIC
Direct dorsalis pedisaccess obtained ontop of foot
Pilot 200 initiallypassed retrogradeand Quickcrossadvanced
SCRIPPS CLINIC
Pilot swapped forConfienza Pro 12which successfullyadvances further intoAT
SCRIPPS CLINIC
Confienza Pro 12successfullyadvanced further intoAT
SCRIPPS CLINIC
Confienza Pro 12advanced to poplitealartery
Corsair with Fielderwire advancedantegrade into
SCRIPPS CLINIC
antegrade intopopliteal arteryocclusion
Retrograde ConfienzaPro 12 maneuveredinto vicinity of inflatedballoon
Balloon deflated andwire successfully
SCRIPPS CLINIC
wire successfullypassed into spacecreated by balloonand passedretrograde up leg intotrue lumen of SFA
Wire snared fromantegrade sheath andpulled into antegradesheath whilesimultaneouslyfeeding wire intoQuickcross at pedal
SCRIPPS CLINIC
Quickcross at pedalaccess point
Snared wireexternalized viaantegrade sheath andCorsair advancedover wire whileQuickcrosssimultaneously
SCRIPPS CLINIC
simultaneouslyretracted from pedalaccess point
Once antegradecatheter passed distalto original occlusion,retrograde wire andcatheter removed
Point pressure overDP access done for 5
SCRIPPS CLINIC
DP access done for 5minutes to achievehemostasis
New wire passed viaOTW catheter andOTW catheterexchanged for ballooncatheter and inflationperformed
Entire occludedsegmentangioplastied
SCRIPPS CLINIC
Coronary DESdeployed in proximalAT
SCRIPPS CLINIC
Popliteal arteryundergoes additionalangioplasty with DCB
SCRIPPS CLINIC
Final Results
SCRIPPS CLINIC
Wound completely healed in 6 weeks
SCRIPPS CLINIC
68yo male with DMII,previous heavysmoker, large openwound on the rightforefoot for 2 months
Total occlusion of the
SCRIPPS CLINIC
Total occlusion of thepopliteal artery, AT,and PT
AT reconstitutes atankle, but diffuselydiseased in foot
Plan for antegradetranscollateralapproach to avoidgoing through area ofopen wound on foot
Asahi Scion wire with
SCRIPPS CLINIC
Asahi Scion wire withCorsair catheter
Collateral traversedwith Scion andCorsair
SCRIPPS CLINIC
Collateral traversedwith Scion andCorsair
SCRIPPS CLINIC
Second Corsair andwire advanced fromabove into subintimalspace
Both wires are withinvessel architecture,
SCRIPPS CLINIC
vessel architecture,but neither is in truelumen
Balloon passed overantegrade wire andinflated to createlarger subintimalspace
SCRIPPS CLINIC
Balloon passed overantegrade wire andinflated to createlarger subintimalspace
Retrograde wire andCorsair successfully
SCRIPPS CLINIC
Corsair successfullypassed into newspace and up intotrue lumen of SFA
Wire snared andexternalized, OTWcatheter advancedpast occlusion andnew wire inserted
Angioplastyperformed ofoccluded poplitealartery
SCRIPPS CLINIC
Coronary DES placedat origin of peronealartery
SCRIPPS CLINIC
Zilver PTX self-expanding DESplaced acrosspopliteal occlusiondue to continuedvessel recoil despiterepeated angioplasty
SCRIPPS CLINIC
repeated angioplasty
Final Results
SCRIPPS CLINIC
Final Results
SCRIPPS CLINIC
Final Results
SCRIPPS CLINIC
Wounds healed after skin grafting and 12 weeks
SCRIPPS CLINIC
Success in CLI Treatment:It Takes a Village!
Vascular Specialists
SCRIPPS CLINIC
Wound CareSpecialists
Endocrinology
Infectious Disease Specialists
PATIENT
Thank You
SCRIPPS CLINIC
top related