management of distal peripheral vascular disease cheuk kwan yee, queenie tuen mun hospital
TRANSCRIPT
Management of distal peripheral vascular disease
Cheuk Kwan Yee, Queenie
Tuen Mun Hospital
In the past….
Below knee disease ---- >
Recently….
Our centre
• Perform endovascular procedures for infrapopliteal disease since Feb 2011
• 13 cases
• Post-op mortality : 7.7%
• Limb Salvage Rate : 84.6%
Infra-popliteal disease
• Endovascular tools
• Angiosome
CFA
SFA
Profundus
Popliteal a.
ATA Tibioperoneal trunk
ATA
Peroneal a.
PTA
ATA
R ATATibioperoneal trunk
Peroneal a.
PTA
0.018” cordis guidewire
Balloon Angioplasty
Completion
Angiogram
Pre-op Post-op
Post-op
Post-op
Endovascular• Studies for infrapopliteal disease
– Single center– Small patient size– Non randomized
• Comparable amputation free survival
• Isolated infrapopliteal revascularization : Endovascular -> better leg salvage
BASIL trial : what are its implications, Seminar in vascular surgery, Bradbury et al 2009
Tibial intervention for CLI, Wiechmann et al, Seminars in interventional radiology, vol26 no.4 2009
Treatment of lower extremity vessels disease, Annals of Surgery vol246, no.3, Sept 2007, DeRubertis et al
Endovascular approach
Global technical success= Direct flow to pedal arches
Residual stenosis <=25%
Preserve patency of treated lesion
Minimize risk of limb amputation
Limit extent of amputation
Long term clinical outcomes after endovascular therapy for patients with CLI due to isolated below the knee lesions, Lida et al, circulation vol 124 suppl, Nov 2011
Devices for infrainguinal endovascular therapy : Menu a la carte or table d’hotl, Zoccai et al, Journal of Endovascular therapy 2011;18:638-641
Endovascular approach
Restenosis :
– Immediate elastic recoil of vessel
– Myointimal hyperplasia
– Late vascular remodelling
Compromised runoff
=>early restenosis /reocclusion
Balloons
Plain Balloon Angioplasty
Peripheral Cutting Balloon– 4 atherotomes
Drug-Coated Balloon– More durable biological effect
(By small centre studies)Drug-coated balloons for the prevention of vascular restenosis. Gray et
al, Circulation June 2010
Bare Metal Stent
• Eliminate:– early abrupt vessel closure– elastic recoil– negative vessel remodelling
6m 24m Limb salvage 94 82 Amp free survival 80 62
• Problems may arise……
Stent-assisted below the ankle angioplasty for limb salvage, Kawarada et al, Journal of Endovascular therapy, 2011:18:32-42
Drug-eluting Stent
• inhibit restenosis
• Review of small scale studies :
– sup to balloon expandable bare metal• intervention free survival• patency rate
• Similar limb salvage rate
Infrapopliteal angioplasty with drug-eluting stents : from heart to toe , siablis et al, Journal of Endovascular therapy( 2010:17: 488-491)
Prime time for infrapopliteal drug eluting stents, Journal of Endovascular therapy, phoenix Apr 2002
Primary use of sirolimus-eluting stents in the infrapopliteal arteries, Rastan et al,Journal of Endovascular therapy 2010 : 17:480-487
• No sig diff in amputation free survival
• Stent : insignificant but higher limb salvage rate
Below the ankle angioplasty : to stent or not to stent, Journal of Endovascular therapy 2011: 18:43-45
Endovascular Mx as 1st therapy for chronic total occlusion of the lower extremity arteries : Comparison of balloon angioplasty, stenting and directional atherectomy ; Journal of Endovascular therapy 2011;18:624-637
VS
Other new endovascular tools
Nitinol stenting
Atherectomy
Cryotherapy
Long term outcomes and risk stratification of patency following nitinol stenting in the femoropopliteal seg :
retrospective multicenter analysis, lida et al, Journal of Endovascular therapy phoenix : Dec 2011 vol18 iss6 Cryoplasty for peripheral vascular disease , cochrane collaboration
Cryoplasty for PAD in an unselected patient population in a tertiary centre, Silva et al, Texas Heart Institute Journal
liquid nitrous oxide
Resist external compression forces
Where to attack ??
~~ANGIOSOME~~
Where to attack ??
3-D vascular territories
Supplied by specific source arteries
Drained by specific veins
Angiosomes of the leg;anatomic study and clinical implications, pleastic reconstruction surgery 1998 Sep 102(3) 599-616
ANGIOSOME
Angiosome Posterior tibial artery
Anterior tibial artery
Peroneal artery
Angiosome-oriented angioplasty
Clinical success of endovascular approach : – dilation of all critical inflow lesions with
residual stenosis < 30% – straight line outflow in at least one tibial
vessel to the pedal arch
Angiosome-oriented angioplasty : – Revascularize target vessels according to angiosome concept
Angiosome-oriented angioplasty
• Multiple single centre studies: – Angiosome-oriented angioplasty :
• improved overall limb salvage • 90 VS 84 at 1 year, 89 VS 79 at 3 year
• Limitation : – Variations of angiosomes – Non-randomized studies– Failure to cannulate target vessel
Revascularization of a specific angiosome for limb salvage : does the target artery matter?A reliable approach to diabetic neuroischemic foot wounds : below the knee angiosome-oriented angioplasty, Alexandescu et al; Journal of Endovascular therapy 2011;18: 376-387
Bring Home Messages
• New era for endovascular procedures
• Emerging new technologies
• Holistic and tailor made pre-op planning + post-op Mx
• Angiosome-oriented angioplasty
Thank You !!
THANK YOU !!!