Endovaskulárne techniky rekanalizácie femoropliteálnych okluzií

Rekanalizácia dlhých
femoropopliteálnych oklúzií
Zdeněk Opravil, Matej Vozár

TASC II

Techniky
• intraluminálna rekanalizácia – nízka
technická úspešnosť
• PIER (percutaneous intentional
extraluminal recanalisation) – Bolia
1990, Reekers 1998 – metóda SIR
Bolia et al. PTA of occlusions of the femoral and popliteal arteries by subintimal
dissections. CVIR 1990; 13: 357-363
Reekers JA, Bolia A. Percutaneous intentional extraluminal (subintimal) recanalisation:
how to do it yourself. EJR 1998; 8: 192-198

Re-entry

Výsledky na SÚSCCH a.s.
• 05/2009 – 05/2011: 59 pacientov s
chronickou oklúziou fem-pop. riečiska
> 10cm (63 oklúzií/končatín)
• TASC II B-D; Fontain IIb-IV
• intraluminálna rek. 15,9% x SIR 84,1%
• 16x reentry katéter,1xTE
• nitinolové SE stenty v 100%
• primárna technická úspešnosť 90,5%
• 8 reangiografií u 7 pacientov: 1xDSA,
3xS/PTA pre restenózu, 3xTE, 1x neúsp.
rekanalizácia FP bypass

Kazuistika I
• 72r. muž, DM II na inzulíne, ICHS, st.p.
NSTEMI, st.p.impl. PM, AHT, HLP, st.p.
operácii moč. mechúra pre ca
• PAO DK bilat., st.p. femoropopliteálnom
bypasse vľavo s včasnou oklúziou, posl. 2
mesiace kľudové ischemické bolesti (CLI)
• LABI 0,41

Kazuistika II
• 58r. muž, DM II na inzulíne s org.
komplikáciami (nefropatia, makroangiopatia),
ICHS s EF 35%, AHT, HLP, st.p. RAS sin
• PAO DK, st.p. FP bypasse vpravo, st.p.
amputácii P predkolenia pre diabetickú
gangrénu
• vľavo intermitentné lýtkové klaudikácie do
20m a v poslednej dobe kľudové ischemické
bolesti

Komplikácie
• 64r. pacient 3t. po rekanalizácii CTO AFS
sin, 2t. po PVI relaps krátkych klaudikácií v
ľavom lýtku a počínajúce pokojové bolesti,
ĽDK chladná, ABI nemerateľné
• CDUS suponovaná in-stent reoklúzia

Komplikácie
• 73r. žena prijatá 3t. po PVI na panvovom a
FP riečisku vľavo (rekanalizácia CTO)
• 3 dni po PVI vynechaná duálna
antiagregácia pred stomatologickým
zákrokom a podávaný LMWH 0,3ml
1xdenne, 3.deň po vysadení ANP a
clopidogrelu obraz ALI, konzervatívny
postup zlyhal
• pri prijatí ľavé predkolenie chladné, livídne,
s akrálnou poruchou citlivosti aj motoriky

po 24h lokálnej TL

EBM: SIR vs BG
Bypass: zlatý štandard ale…
Morbidita
•Zlyhanie graftu 0-24%
•Infekcia rany 10-20%
•Chirurgická revízia >20%
•Infekcia graftu
•Komplikácie v mieste odberu žily
•Opuch končatiny – min. 2-3 mesiace po BG
•Peri-operačné komplikácie ako IM, pneumónia, HVT
Operačná mortalita 1.3-6%
TASC Consensus; J Vasc Surg, Jan 2000, Part 2, Vol. 31 2. Ann Vasc Surg. 2003 Mar;17(2):198-
202. Epub 2003 Mar 6. Complication registration in patients after peripheral arterial bypass
surgery. Schepers A, Klinkert P, Vrancken Peeters MP, Breslau PJ

EBM: SIR vs BG
• 1076 pacientov s PAO DK
2002 – 2007
• 206 SIR u 190 pacientov
• 128 BG u 119 pacientov
• Cost-per-QALY
(quality-adjusted life year):
SIR €5663 vs BG €9172
Clinical
Improvement
Five-year all
cause survival
Amputationfree
survival
Five-year
freedom from
binary
restenosis
Five-year
freedom from
TLR
SIR BG p
82.8% 68.2% p=0.106
78.6% 80.1% p=0.734
72.9% 71.2% p=0.976
72.8% 65.3% p=0.700
85.9% 72.1% p=0.262
Five-Year Irish Trial of CLI Patients With TASC II Type C/D Lesions Undergoing Subintimal
Angioplasty or Bypass Surgery Based on Plaque EcholucencySherif Sultan et all, J Endovasc
Ther. June 2009, Vol. 16, No.3, pp. 270-283

EBM: SIR vs BG
Subintimal Angioplasty as a Primary Modality in the Management of
Critical Limb Ischemia: Comparison to Bypass Grafting for Aortoiliac and
Femoropopliteal Occlusive Disease
Niamh Hynes, et all, J Endovasc Ther. 2004 Aug;11(4):460-71

Subintimal angioplasty for advanced lower extremity ischemia due to
TASC II C and D lesions of the superficial femoral artery. Sidhu R et al.
Vasc Endovascular Surg. 2010 Nov;44(8):633-7. Epub 2010 Jul 30
OBJECTIVE:
Subintimal angioplasty (SA) has evolved into a viable
revascularization procedure for complex lower extremity lesions. Although
patency rates are lower than those for autogenous bypass, limb salvage rates
are comparable. This study reviewed the 8-year experience of SA in a single
center.
METHODS:
Records of patients undergoing SA were reviewed. Clinical presentation and
noninvasive exams were used to classify patients. Lesions were categorized by
TransAtlantic InterSociety Consensus (TASC) II guidelines. Outcomes included
technical success, patency, amputation-free survival, and limb salvage.
RESULTS:
120 patients with TASC II C/D lesions underwent SA. Technical success was
91%. Primary patency at 6 and 12 months was 90% and 73%. Secondary
patency at 6 and 12 months was 94% and 85%. One-year amputation-free
survival was 90%. One-year limb salvage was 98%.
CONCLUSIONS:
SA for TASC C/D lesions is a safe procedure and may be considered an
alternative to bypass, especially in high-risk patients.

Clinical follow-up in endovascular treatment for TASC C-D lesions in femoro-popliteal
segment. Rabellino M et al. Catheter Cardiovasc Interv 2009; 5: 701 - 705
Objective:
To demonstrate the technical success and clinical follow-up after endovascular treatment of femoropopliteal
segment TASC II C and D lesions.
Methods:
From July 2002 to February 2007, 234 limbs in 190 patients with femoropopliteal segment TASC II C (n = 112)
and D (n = 122) lesions were treated. Endovascular treatment consisted of PTA, fibrinolysis and PTA,
subintimal recanalization and PTA, and finally stent graft. Patients were clinically evaluated at 30 days, 3, 6
month, and at 1 year in the outpatient setting with clinical examination and ankle-brachial indices (ABI). In the
case of stent placement, additional ultrasound evaluation was performed at 12, 24, and 48
month.
Results:
49.5% of procedures were performed on patients with lifestyle-limiting claudication (IC) and 50.5% were
performed for critical limb ischemia (CLI). Technical success, defined as successful recanalization and
treatment of the occluded vessel, was achieved in 97% of cases. Periprocedural mortality was 3.15% and
all deaths occurred in the CLI group. A follow-up 13 ± 6 months and was achieved in 76%. During the
follow-up, clinical outcome for IC group and clinical CLI group was asymptomatic 72% vs. 29.8%,
symptomatic with clinical improvement 22% vs. 33.7%, and major amputation 3% vs. 23.3%.
Conclusion:
The majority of claudicating patients with femoropopliteal TASC II C and D lesions will benefit from the
endovascular treatment. Patient presenting CLI have a worse outcome, nevertheless the endovascular
treatment can delay amputation, preserving the native vessel and does not impede surgical bypass if needed.
For this reason, we consider that endovascular treatment may be the first choice treatment even in
femoropopliteal TASC II C and D lesions. © 2009 Wiley-Liss, Inc.

EBM – nitinolové stenty
1. Mewissen MW Tech Vasc Interv Radiol 2004; 7:2-5.
2. Vogel TR et all. J. Vasc Surg 2003; 38:1178-84.
3. Ansel et Al. Catheter Cardiovasc Interv 2006; Jan 11.
4. Duda SH et all SIROCCO II. J Vasc Interv Radiol 2005; 16: 331-38.
5. Biamino G et all FESTO Trial. TCT 2004C

Záver
• EVL je vo fem-pop riečisku
plnohodnotnou alternatívou
chirurgických rekonštrukcií aj u dlhých
oklúzií (TASC II C-D)
• u chirurgicky rizikových pacientov
metóda voľby