tibial angioplasty _pps by dr. moustafa abd elhamid elshal medics index member

8/9/2019 Tibial Angioplasty _pps by Dr. MOUSTAFA Abd Elhamid ELSHAL Medics Index Member

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IBIAL ANGIOPLASTY

By .r oustafa Abd Elhamid Elshal

,Specialist of Vascular Surgery Endovascular Surgery and Diabetic Foot mangement

National Institute Of Diabetes and Endocrinology-Cairo Egypt

: -Tele 0113437474 0106011656

2010

http://www.medicsindex.com/



In the name of ALLAHIn the name of ALLAH

the almighty and mercifulthe almighty and merciful




eview of Literature

# Surgical anatomy of lower limb arteries.

# Equipments for angioplasty.

# Techniques of tibial angioplasty.

# Transluminal versus subintimal angioplasty.

# Causes and mechanisms of restenosis after angioplasty.

# Surgery versus angioplasty in treatment of tibial arteries diseases.




ARTERIES

1- Femoral Artery: Is a continuation of theexternal iliac. It begins behinndthe inguinal ligament, midway

between the anterior superioriliac spine and the pubicsymphysis, enters and passesthrough the adductor(subsartorial) canal, and

becomes the popliteal artery asit passes through an opening inadductor magnus near the

junction of the middle and distalthirds of the thigh. (Gray and Lewis , 2004)



-Profunda femoris artery (deep femoral artery) :

Is a la rg e b ra n ch th a t

a rise s la te ra lly fro m th e

.fe m o ra l a rte ry 3 5 cm

d ista l to th e in g u in a l

lig a m e n t a n d is th e m a in

,su p p ly to th e a d d u cto r

e x te n so r a n d fle xo r;m u scle s it a lso

a n a sto m o se s w ith th e

in te rn a l a n d e x te rn a l ilia c

a rte rie s a b o v e a n d th e

p o p lite a l a rte ry b e lo w it

g ive s th re e p e rfo ra tin g

,b ra n ch e s a n d th e

p rofu n d a itself b eco m es

.th e fo u rth p e rfo ra to r. .i l li am s e t a l 1 9 99

http://www.bartleby.com/107/157.htm



-3 op li tea l a rt er y : Is th e co n tin u a tio n

,o f th e fem ora l artery

cro sse s th e p o p lite a l

.fo ssa T h e a rte ry is

re la tiv e ly tig h te n e d a t

th e a d d u cto r m a g n u s

h ia tu s a n d a g a in d ista lly b y th e fa scia re la te d to

.so le u s it d iv id e s in to th e

a n te rio r a n d p oste rio r

tib ia l a rte rie s ( ,a l en ti n e a n d W i nd

) .0 0 3




- :Anterior Tibial Artery

Is a b ra n ch o f th e

p o p lite a l a rte ry th a t a rise s

a t th e d ista l b o rd e r o f

p o p lite u s D e sce n d in g

a n te rio rly o n th e

in te ro ssio u s m e m b ra n e a t

th e an kle it is m id w ay,b e tw e e n th e m a lle o li a n d

con tin u es on th e d orsu m

o f th e fo o t a s th e d o rsa lis

p e d is a rte ry ( , ) .i n na ta m by 2 0 00




- :Posterior Tibial Artery

B e g in s a t th e d ista l

,b o rd e r o f p o p lite u s b e tw e e n th e tib ia a n d

.fib u la It d e sce n d s

m e d ia lly in th e fle xo r

co m p a rtm e n t a n d

d ivid e s m id w a y b e tw e e n th e m e d ia l

m a lle olu s a n d th e

m e d ia l tu b e rcle o f th e

,ca lca n e u s in to th e

m e d ia l a n d la te ra l

p la n ta r a rte rie s

( . ,il l ia m s e t a l

) .9 9 9





- :PERONEAL ARTERY

Arises from the posterior tibial

.artery 2 5 cm distal to popliteus and

passes obliquely to.the fibula Distally

it is overlapped by

flexor hallucis longus ( a le n ti n e an d

, ) .i nd 2 00 3




EQUIPMENTS FOR ANGIOPLASTY

1-Choosing an imaging system:

.E xcellen t im ag in g is th e key to en d ov ascu lar th erap ies B oth

-p o rta b le C a rm a n d a n a n g io suite im a g in g u n it h a ve spe cia lized.fu n ctio n s th a t a re co m m o n ly u sed d u rin g in te rve n tio n s D e spite

-th e sig n ifica n t te ch n ica l im p ro ve m e n ts in th e cu rre n t m o d e l o f C

,a rm syste m s th e im a g e q u a lity re m a in s slig h tly in fe rio r to th a t

.o b ta in e d from th e a n g io suite A sta n d a rd im ag in g suite im ag e

.in te n sifie r is 1 5 in ch in d ia m e te r ( , ) .a o a n d P e a rc e 2 0 02



- :Im ag in g tab le **Fixed tables: -A re co n stru cte d o f a n o n m e ta llic ca rb o n fib e r su p p o rte d

u su ally at on ly on e en d Th ese tab les are relative ly

.frag ile an d do n ot sup po rt ob ese pa tien ts (Yao and

Pearce , 2002).* * :o v ab l e t a b le s A llo w p o sitio n in g o f th e p a tie n t in th e h o rizo n ta l

.p lan e Th e y co m e w ith a set of b e d sid e con trols th at

a lso p e rm it se le ctio n o f th e ra d io g ra p h ic se ttin g s

,in clu d in g ro ta tio n im a g e in te n sifie r lo ca tio n a n d

ta b le h e ig h t

(Yao and Pearce , 2002).




- :P o w er in jector T h e re a re tw o m e th o d s fo r d e liv e rin g

:contrast

# H a n d in je ctio n w ith a sy rin g e Fo r m o st sm a llv e sse l a n d sele ctive

, .a n g io g ra p h y h a n d in je ctio n is a d e q u a te

# E le ctro n ica lly ca lib ra te d p o w e r in je ctio n fo r op tim a l o p a cifica tio n o f

-h ig h flo w b lo o d v e sse ls like th e a o rta

( l u ge a n d

. , ) .a u b e r e t a l 2 0 0 3




- :E q u ip m e n ts o f v e sse l p u n ctu re- - :The single wall puncture needle is most familiar to

. - -surgeons and the one most commonly used It is a bevel tipped 16- .or 18 gauge hollow needle that accommodates a 0 035 inch guide

.wire

- -The Double wall puncture needles: which are two-component systems that combine a blunt tipped hollow needle with

-a bevel tipped stylet that projects slightly out the end of the needle

( , ) .y er d i a n d Ho d g so n 2 0 0 5



- :S h e a th s

# Sheaths are essentially access to the vascular system placed at the time of initial vascular access is achieved and removed after

.completion of the diagnostic study or intervention

# - - (Diameters most commonly used are in the 5 to 6 French range 1= . . ).French 0 33 mm or 0 013 inch

# .Placement of stents requires the use of sheaths in the 6F# ( )The size designation denotes the internal diameter ID of the

,sheath as opposed to catheters which are sized in French by their( ).outer diameters OD

( . , ) .lu g e a nd R a ub e r e t al 2 00 3



- :W ire s

# , .Major classification is often by size grouping 0 035 inch and. / . .0 014 0 018 in diameter wires

# Access wires for the femoral approach and for diagnostic- .angiography of large and medium sized vessels are usually 0 035.inches in diameter

# Hydrophilic wires ,are essentially used in tortuous vessels,recanalization work are more difficult to handle potentially more

,traumatic and should not be used as routine access . # . / . -0 014 0 018 in systems are super tools for intervention on smaller

vessels These wires generally have a shapeable tip that is visible.under fluoroscopy They are less traumatic than thicker wires and-are conveniently paired with low profile balloons and stents that

.easily cross tight lesions

( . , ) .u gh e s a n d Sc o t t et a l 2 0 00



- :B a llo o n s

# Angioplasty balloons Made with a thin wall of materials such as,polyethylene terephthalate or nylon they tend to maintain their shape

( -and size under high inflation pressure typically 8 20 atm and

).sometimes as high as 30 atm

# ,Of these 2 materials polyethylene terephthalate is stronger and the.balloon can have a thinner wall and lower profile

# Compliance refers to the relationship between changes in volume and

.pressure Balloon compliance is also important when expanding a stent

# The following equation defines the stress on a typical angioplasty:balloon

( ) = ( × )/( × Radial hoop stress pressure radius 2 ) thickness

# Cryoplasty balloons produce a cold thermal injury to the vessel by

.inflating with liquid nitrous oxide that turns to gas These balloons,have recently received considerable attention in the media but their

.superiority remains unproven

# Cutting balloons have blades that are brought into contact with the.vessel wall during inflation and are useful in resistant lesions

d g l ti g th t d ig d ifi ll t t t th l i i



-d ru g e lu tin g ca th e te r d e sig n e d sp e cifica lly to tre a t ath e ro scle ro sis in

.a rte rie s lo ca te d b e lo w th e kn e e A p ro p rie ta ry co a tin g th a t fre e s a n d

se p a ra te s p a clita xe l m o le cu le s a n d fa cilita te s th e ir a b so rp tio n in to th e

.w a ll o f th e a rte ry



- :Stents

# Vascular stents are metal frameworks that support the lumen from.within

# ,Stents work well to prevent acute recoil after angioplasty maximize, “ ” .lumen diameter and tack down dissection flaps

# ,Earlier stents were stainless steel with newer designs favoring- .cobalt chromium alloys The most biocompatible material has yet to be

. -determined Magnesium based and other absorbable stents are under

.investigation

# -Drug eluting stents and newer stent designs have lower restenosis.rates

# - -Stents may be broadly classified as balloon expandable or selfexpanding

* -alloon Expandable Stents-Balloon expandable stents rely on inflation of an angioplasty balloon to expand the stent from its collapsed configuration and push it into contact with the vessel wall * -elf Expanding Stents

, -As the name implies self expanding stents are released from their constraining delivery mechanism and expand within the vessel until the

stent reaches its predetermined maximum diameter or is constrained by.the vessel wall

d i i 1 9 6 1



.d iscov e ry in 1 9 6 1

# N itin o l ste n ts a re a p p e a lin g b e ca u se th e y re ve rt to th e ir orig in a l

.sha p e w h en w arm ed to b od y tem p era tu re Th is allo w s bo th a com p a ct

d e liv e ry sy ste m a n d a n o u tw ard ra d ia l fo rce in th e ve ssel a fte r

. , , .p la ce m e n t T h e ste n ts are M R I safe fle xib le a n d fo re sh o rte n little A n d.u sua lly h a ve m arker d ots a t b oth en d s

( y e r d i

, ) .n d H o d g s o n 2 0 0 5



:ther Types of Stents “ ”stent grafts -Covered Stents Are terms loosely used to describe metal stents that are

(either covered or lined with fabric usually polytetrafl).uoroethylene

Benefits include the ability to treat aneurysms and perforations

.while maintaining lumen patency

- -Drug Eluting Stents The most recent and dramatic advance in stent design is

- .the drug eluting stent These stents provide local release of a drug. -to prevent restenosis Agents used include the anti proliferative

( ).drugs paclitaxel

, ,However they are expensive and patients must remain on clopidogrel for 6 months after placement to prevent thrombosis

( ,y e r di an d H o d gs o n

) .0 0 5



TECHNIQUES OF TIBIAL ANGIOPLASTY

Endovascular therapy for infrapopliteal vascular disease is gaining acceptance as there is growing evidence demonstrating its safety and

effectiveness

:ndications and Patient Selection

# Indication for PTA of infrapopliteal vascular disease is in limb( ).salvage patients with CLI This patient often has limited

.surgical options

# Extending the indications for endovascular interventions on the

.tibial arteries to include lifestyle altering claudication

# Technical and more importantly clinical success depends on the ability to select cases which are most suitable for endovascular.therapy

#The ideal lesions for tibial angioplasty are focal stenoses with

.good distal runoff

# -The necessity of establishing straight line flow to the foot is.another key feature in tibial angioplasty for limb salvage

( . , ) .o f b er g a n d K ar a c ag i l e t al 20 0 0



Te chn iq u e s

-1 :m a g in g

- .A high quality digital subtraction angiography

- .Use of road mapping greatly aids in performing the procedureThe preferred contrast agent for lower extremity arteriography is- , .low osmolar nonionic contrast material

( . , )o u g ia s a n d N g uy e n e t al 20 0 6




- :A cc e s s

Through an antegrade puncture of the ipsilateral common femoral.artery This provides the greatest control to direct catheters and

.wires

( . , )o u gi a s a nd Ng u y en e t a l 2 00 6: -B al lo on A ng io pl as ty

# , . - - -To cross infrapopliteal stenoses 0 018 inch hi torque floppy. ,tipped guide wires are ideal For difficult occlusions hydrophilic

.guide wires are useful

# -PTA of infrapopliteal lesions are best accomplished using high. .profile small vessel balloons catheters ranging from 2 5 to 4 0

.French

# Inflation times of 5 to 10 seconds are usually adequate a balloon is positioned in each one of the two vessels arising from

.the bifurcation This will protect both vessels from intimal.dissection or embolization

# In performing infrapopliteal PTA it is usually best to treat the proximal lesions before the distal lesions for Prevention of

thrombosis around the proximal stenoses and better manipulation of.the catheter and guide wire when treating the distal lesions

( . , ) .ea r ce an d M at s um u r a e t al 20 0 0



- :Stents

- .stents have not been widely used in the infra popliteal vessels The primary reason is because of the small caliber and slow flow in

. ,these vessels Currently stents are only typically used below the

,knee when PTA fails such in the case of a flow limiting dissection or elastic recoil ( . , ) .ip s i tz a nd V e it h e t al 20 0 5

: -Postprocedure Care

, , ,includes bed rest monitoring of vital signs hydration and

.observation for complications

: -Pharmacologic Agents

:n t i s p a s m o d i c s - (use of intra arterial nitroglycerin 100.) .microgm either once vasospasm is seen

:h r o m b o l y t i c s catheter directed thrombolysis with urokinase

.is appropriate :n ti co ag ul at io n A ge nt s ( ,intravenous bolus of heparin 5 000 to

, ) . ,7 000 U after vascular assess is obtained An additional 5 000 units may be needed during the procedure postprocedure heparin

.may be continued overnight The routine use of postprocedure warfarin is not indicated

( , ) .na n d a n d Cr e ag e r 2 00 0



:n tip la te le t A g e n ts

# Aspirin is by far the most commonly used of the antiplatelet agents available.

# , ( )Recently clopidogrel Plavix has gained increased acceptance as.an antiplatelet agent Clopidogrel has been shown to be superior to

aspirin in reducing the rates of all types of vascular occlusive.events

( . , )l a r k a nd Gr o f fs k y et a l 2 0 01 .

w approaches to infrapopliteal angioplasty

- :L a s e r

laser athermic catheters and saline infusion techniques can minimize thermal

injury and significantly reduce arterial

.dissection Excimer laser is a pulsed laser,system working at a wavelength of 308 nm which ablates or vaporizes the lesion

material ( , ) .e Sa nc t is 2 0 0 1



-C o a te d ste n ts

Recently stents coated with a thin and highly

adherent film of Carbonfilm , a material which showsexcellent high haemocompatibility and mitigation of inflammatory response (high biocompatibility)

(De Sanctis , 2001).

-A bs or ba bl e s te nt s

Recently a magnesium alloy absorbable stent has been used in focal

infrapopliteal stenoses in patients with

.CLI ( . , ) .u r ad i n a n d Bo s c h et al 2 00 3

TRANSLUMINAL VERSUS




TRANSLUMINAL VERSUS

SUBINTIMAL ANGIOPLASTY

# Important determinants of successful percutaneous transluminal( ) , , ,angioplasty PTA are lesion location length plaque composition and.morphology

# , -Pooled results of infrapopliteal PTA indicate 1 3 and 5 year primary% %, % %, % %,patency rates of 65 to 77 48 to 66 and 42 to 55

.respectively

# , ,Subintimal angioplasty described by Bolia in 1989 is a variant of PTA that allows the treatment of long occlusions when intraluminal

.wire crossing is not possible an extraluminal dissection is created, - .and pass the occlusion with re entry into the true lumen distally

-Technical failure is mainly due to an inability to re enter the true. %lumen 90 of the subintimal angioplasties were performed in TASC D

, .lesions with skin ulceration or necrosis Clinical success and limb% %, .salvage at 2 years was 72 and 88 respectively

( ,er e ra a n d L yd e n

) .0 0 7




Subintimal angioplasty of Peroneal artery



actors A ffectin g P aten cy o f S u b in tim al A n g iop lasty in P atien ts

:ith C ritical Low er Lim b Isch em ia

# -The most important are the number of patent run off vessels after the.procedure and the length of angioplasty

# Neither gender nor any risk factor of atherosclerosis such as, ,diabetes mellitus arterial hypertension coronary artery disease and, .history of smoking affect the outcome

# -the patency rate of SIA with more than one run off vessels at 12% % - .months is 81 compared to the 25 of SIA with one run off vessel

# None of the factors predisposing to atherosclerosis was found to.affect the SIA outcome Arterial hypertension has been reported to

.increase the risk of occlusion in claudicant patients

# Smoking is not related to the angioplasty outcome but the continuation of smoking after the procedure is related to a higher

.reocclusion rate

( . ,a z ar i s a n d S al a s e t a l) .0 06



AFTER ANGIOPLASTY

:lar events in response to endovascular interventions

:g i c a l r e sp o n s e to b a l l o on a n g i op l a s t y

The objective of the balloon angioplasty is to exert a dilating force on the endoluminal

.surface of a vessel at the desired location This causes desquamation of endothelial cells

( )ECs and histological damage proportional to the

diameter of the balloon and the duration of the.inflation

The predominant effect of balloon angioplasty in enlarging vessel lumen is by

stretching the elastic components of the.arterial wall

Inelastic portion of the plaque fracture or tear results in a definite arterial

wall dissection histologically evident arterial dissection is nearly present in all diseased

vessels following balloon angioplasty.procedures

( . , ) .o u g ia s an d N gu y e n e t a l 20 0 6



,The oxidative stress that follows angioplasty invasion of, - ,neutrophils macrophages and T lymphocytes mobile vascular smooth

( )muscle cells SMCs which migrate close to the site of injury all these

, .events favor restenosis or intimal hyperplasia

:iological response to intraluminal stenting

,within 15 min following stent implantation there is an.accumulation of red blood cells and platelets on the stent surface At

. ,24 h this cellular layer is replaced by a layer of fibrin strands

oriented in the direction of blood flow as the positive electrical potential of the metallic stents attracts the negatively charged

.circulating proteins on the stent surface ( o u g ia s a nd N g uy e n e t

. , ) .l 2 0 0 6

Stents placed into the venous system exhibit a faster rate- .of endothelialization than do intra arterial stents ( o u gi a s a n d

. , ) .g u y e n e t a l 2 00 6

- ,Soon after the intra arterial stent deployment the positive electrical potential of the metal attracts the negatively charged circulating proteins to form a thin layer of fibrinogen strands on

.the stent surface The proteins neutralize the stent surface and decrease thrombogenicity ( . , ) .e e a n d D a vi d et a l 2 0 04



( )Severe angiographic restenosis arrow is

.seen within a Anterior tibial artery stent 4.months following implantation of a stent

( . , ) .o ug i a s an d N g u ye n e t al 2 0 06

,Ideally stents should be deployed in such a way that the metal ends are embedded deep enough into the vessel wall

The achievement of this ideal deployment is dependent on:multiple factors the ratio of the diameter of the stent to that of

,the blood vessel the depth of penetration of the struts into the, ,vessel wall thickness of the struts and the composition and

.integrity of the intimal surface

Stent struts will be embedded adequately if the final stent diameter is – %0 15 larger than the diameter of the adjacent vessel

.

( . ,ee an d D av i d e t a l



:e ch a n ism s o f R e ste n o sis # Three mechanisms are responsible for the development of: , ,restenosis elastic recoil intimal hyperplasia and late vascular

.constriction

# - -Restenosis is seen mainly in small sized and medium sized.arteries

( . , ) .id a w y a n d We i s wa s se r e t a l 20 0 2:essel remodeling

# Refers to a pattern of chronic over weeks or months changes of

.the structure of the vessel wall that follows injury

# The factors linked to remodeling after angioplasty include, ,hemodynamic changes in blood pressure flow rates patterns of sheer

, .stress and changes in extracellular matrix composition

# , ,Production deposition or organization of collagen is impaired

, ,under the influence of growth factors cytokines and matrix metalloproteinases with resultant increased extracellular matrix

.deposition

( . , ) .o u gi a s a n d Ng u y en e t a l 2 00 6



:e o in tim a l h yp e rp la sia

# Responsible for – %0 50 of the clinical failures of all.vascular interventions

( . , ) .ou g i as a nd N g uy e n e t a l 2 0 0 6

# Represents a chronic structural change in the blood vessel that leads to formation of a thickened fibrocellular layer

between the endothelium and the inner elastic lamina of the.arterial wall

ellular and molecular mechanisms of neointimal:yperplasia

# Neointimal hyperplasia after vascular injury involves three: ( ),phases medial SMC proliferation first wave medial SMC

( )migration into the intima second wave and intimal SMC( ).proliferation and extracellular matrix production third wave

( . , ) .a z a ri s an d S al a s e t a l 2 0 0 6



:lin ical stra te g y fo r re ste n o sis

harmacologic approach- :A nt i p l at el e t d ru gs Low dose Aspirin has documented

efficacy for prevention of rethrombosis in the early phase of balloon angioplasty and should be administered 2 h before the

.procedure ( . , ) .o r el i c k a n d B o rn et a l 2 0 05

- :A n t i c o a g u l a n t s :Heparin is important because( ) .1 It reduces the risk of thrombosis

( ) - .2 Heparin has anti SMC proliferative activity

( . , ) .or e l ic k a n d Bo r n e t al 20 0 5

-E s s e n t ia l f a t t y a c i d s : Attenuate free radical generation’and modify the body s inflammatory response to tissue injury

( , ) .e rn s an d A v a de s 20 0 0

- :G e n e t h e ra p y Involves overexpression of genes that are considered protective or blockade of genes that are involved in

the pathogenesis of the intimal hyperplasia achieved through the use of nucleic acids known as antisense oligodeoxynucleotides

( ).ODN ( . , ) .o u gia s a nd N g uy e n e t a l 2 00 6



:n d o va scu lar strate g y fo r re sten o sis

-r u g e l u t i n g s t e n t d e s ig n

:r i n c i p l e s- -Drug eluting stents are composed of a three dimensional

. -complex The stent based drug delivery system can be accomplished-through application of thin layers of a drug polymer solution to

.the stent surface

The key component of using any biopolymer is that the

polymer is a non inflammatory inert non thrombogenic.component

, ,Unfortunately without a polymer to aid in drug delivery% ,40 of the drug can be lost during stent placement and after

, –placement the remainder of the drug will completely elute in 1.2 weeks

An alternative approach for drug delivery is direct application of the drug to a bare stent or incorporation of the

.drug into microscopic fenestration in the stent This approach- .is currently being used for the paclitaxel eluting stents

( . , ) .ru b e a nd S i lb e r e t al 20 0 3



:ru g e lu tin g a g e n ts

The basic function is to create an antiproliferative

environment around the stent in order to prevent luminal stenosis.and neointimal hyperplasia

-The drug should have a reasonably long half life of at least 4 weeks postprocedure since this is the time during which

the greatest endothelial injury and reactivity to stent placement occurs

( . , ) .r u b e an d S il b e r e t a l 20 0 3

TREATMENT OF TIBIAL ARTERIES



TREATMENT OF TIBIAL ARTERIES

DISEASES

The technical success rate of angioplasty is often reported%.to be in the range of 90

The initial hemodynamic success defined as an increase in the.ABIs or PVRs at the ankle for infrgenicular PTA

( )Percutaneous transluminal angioplasty PTA has been proposed

, ,as a safe effective less expensive alternative to lower extremity-arterial bypass graft surgery for treating limb threatening ischemia

.and claudication The effectiveness of PTA in the treatment of, -tibial occlusive disease is well established with good long term

.patency achieved

Early success with PTA in the treatment of focal stenoses in

the tibial arteries led us to expand the indications for PTA to, ,include longer more distal lesions with less favorable runoff

-particularly in high risk patients and those whose surgical options.are less promising

( ,e r er a a n d Ly d e n

) .0 0 7



C o n trib u tio n

HANK YOU HANK YOU O MUCHO MUCH


tibial angioplasty _pps by dr. moustafa abd elhamid elshal medics index member

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