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Peripheral Vascular Disease, Angiography - Angioplasty and Surgical Techniques. Dr. Rajdeep Agrawal, MD, DM Interventional Cardiologist & Vascular Interventionist , Sir H N Hospital,Mumbai Breach Candy Hospital Cumballa Hill Hospital. Indications of Angiography in PVD.

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peripheral vascular disease angiography angioplasty and surgical techniques

Peripheral Vascular Disease, Angiography - Angioplasty and Surgical Techniques

Dr. Rajdeep Agrawal,MD, DM

Interventional Cardiologist & Vascular Interventionist,

Sir H N Hospital,Mumbai Breach Candy Hospital Cumballa Hill Hospital

indications of angiography in pvd
Indications of Angiography in PVD
  • Life style limiting claudication
  • Critical ischemia / limb threatening ischemia (rest pain, nocturnal pain, non healing ulcer, gangrene
  • Graft stenosis
  • High surgical risk
  • Acute ischemia of lower limb

Dr. Rajdeep Agrawal

arteriogram
Arteriogram
  • Remains the ‘Gold standard’ for vascular evaluation.
  • Should be done only in patients who have clinical indications for vascular interventions (surgery or angioplasty)
  • Complications are less than 5% and mortality about 0.025%.
  • Patients should be well hydraded before and after angiograms, especially diabetics.

Dr. Rajdeep Agrawal

angioplasty history
Angioplasty -- History
  • Charles Dotter (1964)
    • First angioplasty using co-axial catheter
  • Andreas Gruentzig (1977)
    • First PTCA using double lumen catheter

Dr. Rajdeep Agrawal

percutaneous transluminal angioplasty pta in peripheral vascular disease
Percutaneous Transluminal Angioplasty (PTA) in Peripheral Vascular Disease

An over view of the arterial

pathologies of the lower limbs

and their percutaneoustreatment

modalities

Dr. Rajdeep Agrawal

percutaneous transluminal angioplasty
Percutaneous Transluminal Angioplasty
  • A non-surgical technique designed to increase the lumen of the vessel & thus prevent ischemia & its complications
  • Mechanism

Inflated balloon exerts circumferential

pressure on the plaque

1. Plaque splitting & disruption

2. Stretching of the vessel wall

3. Compression of the atheroma

Dr. Rajdeep Agrawal

slide8
Rutherford – Becker classification of PVD

Ankle Brachial Index -

> 0.90 – No significant obstructive disease

0.50 to 0.90 – Claudications (Grade I)

<0.50 – Limb threatening ischemia

(Grade II or III)

Dr. Rajdeep Agrawal

ideal settings for pta
Ideal settings for PTA

Dr. Rajdeep Agrawal

percutaneous transluminal angioplasty pta in peripheral vascular disease1
Percutaneous Transluminal Angioplasty (PTA) in Peripheral Vascular Disease

Modalities will include –

Angioplasty,

Stents,

Lasers,

Rotablaters,

And Thrombolysis

Dr. Rajdeep Agrawal

percutaneous transluminal angioplasty pta in peripheral vascular disease2
Percutaneous Transluminal Angioplasty (PTA) in Peripheral Vascular Disease

Modalities will be treated together or separately in the territories commonly affected by vascular disease

Acute arterial obstruction will be treated as a separate issue, where multimodal treatments may come together

Dr. Rajdeep Agrawal

lower limb ischemia vascular involvement in diabetic
Lower Limb Ischemia - Vascular involvement in Diabetic
  • Aorto illiac relatively spared.
  • Most of the diseases involves infrainguinal arteries (femoral - popliteal - tibial)
  • About 60% have involvement of plantar arch and digital arteries.
  • About 80% have microangiopathy

Does not adversely affect the outcome of vascular reconstruction.

Dr. Rajdeep Agrawal

angiography technique
Angiography -- Technique
  • Approach
    • Femoral / Brachial
  • Vascular accessusing Seldinger’stechnique
  • Material / Hardware
    • 0.035 guide wire
    • Renal catheter, Simmon’s cath

Dr. Rajdeep Agrawal

slide15
Arterial Occlusion just above the knee causing claudication of the calf; good collateral circulation

Dr. Rajdeep Agrawal

balloon catheter for pta
Balloon Catheter for PTA

Dr. Rajdeep Agrawal

contraindications to percutaneous revascularization
Contraindications to percutaneous revascularization

PTA C/I - Medically unstable

(Absolute) - Stenosis adjacent to aneurysm

or near an ulcerated plaque

(Relative) - (Unfavourable anatomy)

Long segment & multi-focal

stenosis

Long segment Occlusions

(thrombolysis)

Dr. Rajdeep Agrawal

percutaneous revascularization
Percutaneous revascularization

PTA Contra-indications

(Relative) - If large vessel at ankle is available

for bypass

- Heavy eccentric calcification

- Lesion in essential collateral vessel

- Stenosis with thrombus

Dr. Rajdeep Agrawal

percutaneous revascularization1
Percutaneous revascularization

Post PTA recurrence are seldom worse than before, does not interfere with the original planned surgery.

In 25% Femoro - popliteal PTFE Graft,

Popliteal gets occluded when bypass

closes

Adar etal

Dr. Rajdeep Agrawal

slide20

Percutaneous revascularization

THROMBOLYSIS is an alternate attemptable modality of treatment in PVD

Safe if cases are selected properly

Cannot be used in all cases.

Various methods are used to administer thrombolysis

Acute ischemia of lower limb is one area

Dr. Rajdeep Agrawal

slide21

Percutaneous revascularization

Intra-arterial Thrombolysis

Restores blood flow

Identifies underlying lesion

Thrombotic or embolic occlusion

Native artery or bypass graft

Dr. Rajdeep Agrawal

percutaneous revascularization2
Percutaneous revascularization

THROMBOLYSIS - CONTRAINDICATIONS

Absolute -Active internal bleeding

Irreversible limb ischaemia

Recent stroke, craniotomy

Mobile L-V thrombus

Dr. Rajdeep Agrawal

slide23

Percutaneous revascularization

THROMBOLYSIS CONTRAINDICATIONS

Relative - H/o GI bleed

- Recent major surgery/CPR/Trauma

- Diastolic BP >125 mm

- DM – Proliferative Retinopathy

- Sub acute bacterial endocarditis

- Coagulopathy

- Post partum state

Dr. Rajdeep Agrawal

percutaneous revascularization3
Percutaneous revascularization

Stents: Contra indications

- Diffuse aortic disease

- Extravasation of contrast after PTA

- Non compliant lesion on angioplasty

- Diffuse iliac disease

- Aortic tortuosity & aneurysm

- Diffuse long segment small caliber external iliac or femoral artery

Dr. Rajdeep Agrawal

percutaneous revascularization4
Percutaneous revascularization

Stent Complications (10%)

  • Almost all are minor
  • Puncture site injury
  • Distal embolization
  • Stent dislodgement
  • Pseudo anemysm formation
  • Vessel rupture

Dr. Rajdeep Agrawal

percutaneous transluminal angioplasty pta in peripheral vascular disease3
Percutaneous Transluminal Angioplasty (PTA) in Peripheral Vascular Disease

AORTO – ILIAC Percutaneous Transluminal Angioplasty

- Optimizes inflow for bypass

- Excellent patient tolerance

- Short recovery period

- No worsening of vascular status – if fails

Dr. Rajdeep Agrawal

percutaneous revascularization5
Percutaneous revascularization

AORTIC OCCLUSSIONS

  • Relatively uncommon
  • Younger population who smoke
  • Claudication and impotency
  • Risk of propagation of clot to renal and mesenteric artery

Dr. Rajdeep Agrawal

percutaneous revascularization6
Percutaneous revascularization

ABDOMINAL AORTIC STENOSIS

  • Isolated - relatively uncommon
  • More frequent in women with hypoplastic aortas
  • PTA and Stent can be tried and are useful if the lesions are amenable
  • Otherwise Grafts can be placed
  • Even thrombolysis could be attempted with angioplasty
  • Large thick atherosclerotic lesions could be common

Dr. Rajdeep Agrawal

percutaneous revascularization7
Percutaneous revascularization

AORTO – ILIAC STENTING

Indications - Residual stenosis > 30% after

percutaneous revascularization

Or if a gradient >10mm persists

Dissection

Highly eccentric stenosis

Recurrent Stenosis post PTA

Iliac artery occlusion

Dr. Rajdeep Agrawal

percutaneous revascularization8
Percutaneous revascularization

ILIAC ARTERY STENOSIS

PTA

  • PTA with/without stent
  • Focal, uncalufied sterosis <5 cm long
  • Eccentric or calufied sterosis < 3cm long

Long segment (>10cm)respond less favorably

STENTS

  • Residual pressure gradient (<5mmHg) or residual stenosis(>30%)
  • Flow limiting dissection flap
  • Restenosis (acute or subaiute)

Dr. Rajdeep Agrawal

percutaneous revascularization9
Percutaneous revascularization

ILIAC ARTERY OCCLUSIONS

  • Bilateral – Surgery treatment
  • Primary stent placement
  • PTA followed by stent
  • Thrombolysis followed by stent

Dr. Rajdeep Agrawal

percutaneous revascularization10
Percutaneous revascularization

INTERNAL ILIAC STEONSIS

  • Isolated buttock claudication
  • Impotence
  • PTA is the choice

Dr. Rajdeep Agrawal

percutaneous revascularization11
Percutaneous revascularization

CFA STENOSIS

  • Isolated is uncommon without history of injury (eg. Catheterization)
  • Endarterectomy – choice simple, LA and conscious sedations
  • Durable than PTA

Dr. Rajdeep Agrawal

percutaneous revascularization12
Percutaneous revascularization

Femoro popliteal

- Lesion 3 times commoner than iliac

- Occlusions 3 times commoner than

stenosis

- 80% of the stenosis are <10cm

- 20% occlussions < 10cm

Dr. Rajdeep Agrawal

percutaneous revascularization13
Percutaneous revascularization

Femoro popliteal

- 10 cm upper limit to select cases

- Stents disappointing beyond that

length of stenosis

- Covered (PTFF) grafts have a promise

- Over 5 years 15-20% new Femoro

popliteal occlussions develop

Dr. Rajdeep Agrawal

percutaneous revascularization14
Percutaneous revascularization

Femoropopliteal stenosis:

  • PTA is less durable than bypass.
  • Bypass 5 year patency rate is about 80%

- Complication of PTA is 10%, surgical repair required in 2% cases

Dr. Rajdeep Agrawal

percutaneous revascularization15
Percutaneous revascularization

Femoropopliteal stenosis

-Stents useful in proximal Superficial Femoral Artery

- Stents – restenosis in distal SFA or popliteal artery due to extrinsic compressions (eg. Addutor canal) is possible

- Long term consequences of placing flexible stents across joints is unknown.

Dr. Rajdeep Agrawal

percutaneous revascularization16
Percutaneous revascularization

Femoropopliteal occlussions:

  • Long segment or complete SFA occlusions does not respond well to any widely available endovascular technique
  • Amplatz thrombectomy catheter – excellent technical access, but long term patency is modest or unknown
  • Covered stents - results disappointing
  • Endovascular stent grafts show most promise

Dr. Rajdeep Agrawal

percutaneous revascularization17
Percutaneous revascularization

Femoropopliteal occlusions:

  • PTA is effective for short solitary occlusions,

< 10cm long, not involving SFA origins or distal popliteal artery

and tenders occlusions <3cm long

  • Focal occlussions (<2 to 3cm)  PTA alone
  • Long occlussions – Thrombolysis prior to PTA

Dr. Rajdeep Agrawal

percutaneous revascularization18
Percutaneous revascularization

Femoropopliteal occlusions:

  • Upper SFA occlusions – stent if PTA is sub-optimal
  • PTA long term patency rates may be substantially less than clinical patency rates
  • Technical failure almost always results from inability to cross the lesion with guide wire.

Dr. Rajdeep Agrawal

percutaneous revascularization19
Percutaneous revascularization

Infra-popliteal revascularization - Indications

Absence of pedal pulses – minimal or asymptomatic

If collaterals are not well developed or

limitation of activity results

Focal lesions

Limited in diffuse disease,

If short term patency is desired sufficient to heal superficial ulcerations or amputation sites

Dr. Rajdeep Agrawal

percutaneous revascularization20
Percutaneous revascularization

Infra popliteal revascularization –

Early results - Not impressive

Manipulations - Easier with DSA

& road mapping

Increased popularity - Safe & Successful

Decision with surgeon

Inflow lesions Treatment first

Dr. Rajdeep Agrawal

percutaneous revascularization21
Percutaneous revascularization

Tibial Artery Obstructions:

– Infra popliteal PTA is almost always performed for limb salvage

  • Short term patency may be sufficient to allow healing of an ischemic ulcer or amputation site or to avoid amputation
  • PTA is not particularly effective if run-off vessels are not visualized. Liberal Heparin use must to maintain patency

Dr. Rajdeep Agrawal

slide46

Percutaneous revascularization

STENTS RESULTS

- Technical success rate – 90-100%

- Cumulative 5 year vessel patency – 94%

- Clinical success – 93%

- (PTA 65% & 70%)

Dr. Rajdeep Agrawal

percutaneous revascularization22
Percutaneous revascularization

Infra-popliteal revascularization

Indications

- Limb threatening Ishcemia

(Disabling claudication, Rest pain, Ulcer, Gangrene)

- ABI < 0.5 Ischemic rest pain or ankle pressure <60 mm, with or without a non healing ulcer

- DM – ABI not useful - calcification

Dr. Rajdeep Agrawal

stent
Stent
  • An expandable metallic helical device which is permanently implanted in the artery.
  • Mechanism
    • The prosthesis acts as a scaffold to hold the artery open
    • Prevents recoil of the vessel
    • Reduces Restenosis

Dr. Rajdeep Agrawal

newer techniques of angioplasty
Newer Techniques Of Angioplasty
  • Atherectomy
    • Directional
    • Percutaneous Rotational
    • TEC
  • LASER
  • Stent

Dr. Rajdeep Agrawal

directional atherectomy
Directional Atherectomy
  • It excises the atheromatous plaque material into very fine slices which can be retrieved outside body

Dr. Rajdeep Agrawal

laser
LASER
  • A LASER produces an intense beam of light in uniform wavelength that can be precisely focused to deliver high energy levels to a small area
  • It converts solid plaque to gas which is soluble in blood

Dr. Rajdeep Agrawal

percutaneous revascularization23
Percutaneous revascularization

Stent Complications (5-10%)

Groin hematoma

Pseudo Aneurysm

Embolization of thrombus

Acute stent thrombosis

Dissection

Vessel perforation

Dr. Rajdeep Agrawal

percutaneous revascularization24
Percutaneous revascularization

IDDM – Reduce insulin

First case

5% Dextrose, Blood sugar,

Insulin (1-3 units/ hr) or more for higher

blood glucose levels

No protamine zinc insulin should be used

Protamine antagonizes the heparin

anticoagulation

Hybration to prevent aute tubular necrosis

Dr. Rajdeep Agrawal

slide55

Percutaneous revascularization

Cost effectiveness of PTA compared to surgical reconstruction

PTA - Bypass - 53% in Disabling Claudication

75% in critical ischemia

A cost effective analysis demonstrated that performing PTA as a initial procedure is more desirable technically feasible cases and reserving bypass surgery for those PTS in whom PTA fails, or recurs would save more lives, limbs and money.

Dr. Rajdeep Agrawal

slide56

Percutaneous revascularization

Cost effectiveness of PTA compared to surgical reconstruction

In technically feasible cases PTA would be the preferred option

Reserve bypass surgery for those PTAs in whom it fails, or recurs

It would save more lives, limbs and money.

Dr. Rajdeep Agrawal

percutaneous revascularization25
Percutaneous revascularization

Complications:

Vasospasm - Nifedipine start well before procedure

- Intra-arterial Nitroglycerins,

in the vessel to be treated –

(100 to 200 mg) before dilation

Flow limiting dissection flap – Employ Stent

Dr. Rajdeep Agrawal

percutaneous revascularization26
Percutaneous revascularization

Complications:

Post PTA occlusion –

Repeat PTA & thrombolytic therapy

OR Repeat PTA – Stent

Arterial rupture – Reinflation of baloon across rupture, followed by surgical repair

Dr. Rajdeep Agrawal

medical therapy
Medical Therapy

Exercise program

Risk factor modifications

Dr. Rajdeep Agrawal

surgical revascularization 1
Surgical revascularization - 1

Aorto-iliac Occlusions:

Aorto bifemoral bypass

- Extra anatomic

- Endarterctomy

- 5 year patency - 85 to 95%

Dr. Rajdeep Agrawal

surgical revascularization 11
Surgical revascularization - 1

Infra – inguinal occlusions:

  • Autologous veins or PTFE grafts are used

PTEF above Hunter’s canal for SFA

  • Saphenous Vein – below knee, for tibial or peroneal occlusion
  • 5 yr patency – 60% - above
  • Below knee – 3 yr patency and limb salvage 58 to 92% respectively

Dr. Rajdeep Agrawal

surgical revascularization 2
Surgical revascularization - 2

AORTIC OCCLUSSIONS

  • Aorto bifemoral graft with endarterectomy axillo bifemoral graft or thorarofemoral graft
  • Re-construction with endovascular stent graft is feasible – long term results unknown

Dr. Rajdeep Agrawal

lower limb ischemia approach to therapy
Lower Limb Ischemia - Approach to Therapy

Direct arterial reconstruction.

  • Endarterectomy
  • Vascular bypass
  • Endovascular (minimally invasive) intervention
  • Lumbar sympathectomy

Dr. Rajdeep Agrawal

lower limb ischemia results of direct reconstruction
Lower Limb Ischemia - Results of Direct Reconstruction
  • Aorto illiac reconstruction - early graft patency of about 98%, operative mortality 3%:5years graft patency of 85-90%.
  • Femoro popliteal bypass - early graft patency of over 90%, with mortality of 2-5% : 5 year patency of about 75%.
  • Infrapopliteal/ paramalleolar bypass - early patency of about 90% with 2% mortality. 5 year patency of 55%

LIMB SALVAGE about 90%

Dr. Rajdeep Agrawal

operations
OPERATIONS

Depends on the site of occlusion and the physical state of the patient.

Dr. Rajdeep Agrawal

aorto iliac occlusion
Aorto-iliac occlusion
  • Limited involvement : Iliac Endartectomy
  • Marked involvement : Aorto-femoral bypass

Aorto-iliac occlusion patient unable to undergo surgery;

  • 1 iliac artery involved : femoro-femoral or ileo-femoral bypass
  • Both iliac arteries involved : Axillo-bifemoral bypass

Dr. Rajdeep Agrawal

slide69
Atherosclerotic narrowing of aortic bifurcation

Aortobifemoral graft to bypass stenosis

Dr. Rajdeep Agrawal

femoral profunda femoris occlusion
Femoral & Profunda Femoris Occlusion
  • If conservative measures not suitable, PTA may be possible
  • For more severe disease, angioplasty or bypass maybe used
  • Femoropopliteal bypass graft is the most usual operation
  • Saphenous vein graft gives the best results

Dr. Rajdeep Agrawal

slide71
Superficial femoral artery occlusion with profunda femoris stenosis providing poor collateral circulation

Femoropopliteal graft used to bypass the occluded area

Dr. Rajdeep Agrawal

occlusion below popliteal
Occlusion below popliteal
  • Bypass to tibial vessels, even down to the ankle can be met with reasonable success.
  • Most successful is with long saphenous vein in the in situ fashion.
  • If saphenous not available, can use PTFE (Polytetrafluoroethylene) graft.

Dr. Rajdeep Agrawal

prosthetic materials
PROSTHETIC MATERIALS
  • Aortoiliac bypass - Dacron
  • Femoropopliteal - Autogenous veins (Long saphenous best)

If not available - PTFE or glutaraldehyde-tanned, Dacron supported, human umbilical vein

  • Profundoplasty - Vein/PTFE/Dacron

Dr. Rajdeep Agrawal

treatment of a c occlusion
Treatment of A/C Occlusion
  • Embolectomy - Using Fogarty’s catheter -> Catheter passed beyond emblous, balloon inflated & pulled back till blood comes
  • Direct Embolectomy - Artery exposed, transverse incision, clot removed.
  • Intra-arterial Thrombolysis - TPA preferred. Arteriography done and a catheter embedded in clot - Thrombolytic agent infused over several hrs

Dr. Rajdeep Agrawal

surgical embolectomy
Surgical Embolectomy
  • Relatively simple procedure
  • Done under LA, small incision in the groin, using Fogarty’s cath.
  • Problems

1. Blind procedure, can be traumatic

2. Not successful in 10 – 30% cases

3. Inefficient in multistenosed artery

4. Complete removal of thrombus difficult in leg arteries

Dr. Rajdeep Agrawal

post pta mx
Post PTA MX
  • Antiplatelet agents
  • LMW Heparin X 7 – 10 D
  • IV / oral Trental
  • Statins
  • Aggressive control of risk factors

Dr. Rajdeep Agrawal

conclusion
Conclusion
  • In Diabetic foot, PVD contributes to amputation by impeding the delivery of antibiotics, Oxygen, nutrients & by delaying wound healing & the ability to fight infection.
  • Aggressive therapy with debridement, antibiotics,good control of Diabetes & when indicated revascularisation results in salvage of > 90% of threatened limbs even in high risk patients

Dr. Rajdeep Agrawal

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