Endovascular Treatment of Infrageniculate Vascular Disease
Endovascular Treatment of Infrageniculate Vascular Disease
Endovascular Treatment of Infrageniculate Vascular Disease
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<strong>Endovascular</strong> <strong>Treatment</strong> <strong>of</strong><br />
<strong>Infrageniculate</strong> <strong>Vascular</strong><br />
<strong>Disease</strong><br />
Amir Motarjeme, M.D.<br />
Midwest <strong>Vascular</strong> Institute <strong>of</strong> Illinois
INFRAGENICULATE<br />
DISEASE<br />
•Thromboembolic <strong>Disease</strong><br />
•Atherosclerotic Occlusive <strong>Disease</strong><br />
•Systemic Vasculitis<br />
•Thromboangiitis Obliterans<br />
(Buerger’s <strong>Disease</strong>)<br />
•Fibromuscular Dysplasia
Thromboembolic <strong>Disease</strong><br />
•Acute ischemia<br />
•Cholesterol Embolism<br />
(Blue-toe Syndrome)
ACUTE<br />
LIMB<br />
ISCHEMIA
Acute Limb Ischemia<br />
Etiology<br />
Arterial Emboli<br />
Arterial Thrombosis<br />
Trauma
Etiology<br />
Arterial Emboli<br />
1. Cardiogenic<br />
2. Aortic Aneurysm<br />
3. Ulcerated Plaques<br />
4. Arterial Embolization Products<br />
5. Broken Cath, Wire and<br />
Balloon
Acute Limb Ischemia<br />
Arterial Emboli<br />
Cardiac 75-90%<br />
Atrial Fibrillation 70%<br />
(atrial mural thrombus)<br />
MI<br />
Vertebral<br />
Prosthetic Heart Valves<br />
Acute & Subacute Endocarditis<br />
(microemboli)<br />
Intracardiac Tumors<br />
(atrial myxoma)
Acute Limb Ischemia<br />
Arterial Emboli<br />
Extra Cardiac<br />
Aorta<br />
Iliac<strong>of</strong>emoral Arteries<br />
Foreign Body<br />
Paradoxic Embolization
Acute Limb Ischemia<br />
Thrombosis<br />
1. SFA<br />
2. Iliac<br />
3. Popliteal Aneurysm
Acute Limb Ischemia<br />
Symptoms<br />
Pulselessness<br />
Pain<br />
Pallor<br />
Paresthesia<br />
Paralysis
Acute Limb Ischemia<br />
Author Year N Mortality<br />
Blaisdell 1978 35 Series 15-48% (25%)<br />
1963-1977<br />
Dale 1984 140 7.1%<br />
Cambria 1984 53 Thromb. 8%<br />
220 Emb. 20%<br />
Clason et al 1989 181 29.3%
Acute Ischemia<br />
Thrombolysis<br />
<strong>Treatment</strong> <strong>of</strong> Choice
Below Knee <strong>Endovascular</strong><br />
Therapy<br />
Thrombolysis
Below Knee <strong>Endovascular</strong> Therapy<br />
Thrombolysis Techniques<br />
Approach<br />
Contralateral<br />
Ipsilateral<br />
Sheaths<br />
Contralateral Crossover<br />
Ipsilateral 5F 10 cm<br />
Catheters 4, 5F<br />
Infusion Wires Sos, Katzen<br />
Agents UK, TPA, r-PA and<br />
TNK
Acute Limb Ischemia<br />
Thrombolysis<br />
Patients 204<br />
Success 95%<br />
Limb Salvage 95%<br />
Mortality 2%<br />
Amputation 3%
Chronic<br />
Limb<br />
Ischemia
Below Knee <strong>Endovascular</strong><br />
Indications<br />
Therapy<br />
1. Limb Salvage<br />
2. Claudication
Chronic Limb Ischemia<br />
1. Claudication<br />
2. Limb Salvage
Chronic Limb Ischemia<br />
Etiology<br />
Atherosclerosis<br />
Old Emboli<br />
Giant Cell Arteritis<br />
Buerger’s <strong>Disease</strong><br />
Raynaud’s Phenomenon
<strong>Treatment</strong> <strong>of</strong> Peripheral<br />
Occluded Vessels<br />
PTA<br />
Laser<br />
Atherectomy<br />
Thrombolysis<br />
ThrombolysoAngioplasty<br />
Arterial Stents<br />
Stent Graft
Limb Threatening Ischemia<br />
Definition<br />
I. Ischemia<br />
1. Ischemic Rest Pain<br />
2. Ischemic Ulceration<br />
3. Gangrene<br />
II. ABI < 0.40 (non diabetic)<br />
III. TBI < 0.30 (diabetic)<br />
Ad Hoc Committee on Reporting Standards,<br />
Society for <strong>Vascular</strong> Surgery, International<br />
Society for Cardiovascular Surgery
Infrapopliteal <strong>Endovascular</strong><br />
Therapy in Limb Salvage<br />
Goal:<br />
Straight Line Arterial Flow<br />
to the Ischemic Lesions
Below Knee <strong>Endovascular</strong><br />
Therapy<br />
Patients 911<br />
Arteries 2,784<br />
Tibioperoneal 1,478<br />
Pedal 58
204<br />
Acute<br />
Ischemia<br />
Limb Salvage<br />
806<br />
Chronic<br />
Ischemia
Below Knee <strong>Endovascular</strong><br />
Therapy<br />
PTA<br />
Approach Ipsilateral<br />
Sheath 5F<br />
Catheters 4F Glide Cath<br />
Wires Glidewire 0.035”<br />
Roadrunner 0.018”<br />
Balloons Symmetry<br />
Coronary
Below Knee <strong>Endovascular</strong><br />
Therapy<br />
PTA<br />
Mechanics:<br />
Long Balloons<br />
Single Long Inflation<br />
Gradual Inflation
PTA and Thrombolysis in Leg<br />
Salvage<br />
Amir Motarjeme, M.D.<br />
J Endovasc Surg 1994;1:81-87
Limb Salvage<br />
Available to Follow-up 771 100%<br />
Total Salvage 551 71.46%<br />
Small Part Amputation 62 8%<br />
TMA 16 2%<br />
Total Salvage 629 81.5%<br />
Five Year Survival Rate 72%
Infrapopliteal<br />
Stenting
Infrapopliteal Stenting<br />
Small Vessels 2.5 - 4 mm<br />
(noncoronary<br />
noncoronary)<br />
CTPT 3 - 4 mm<br />
Anterior Tibial 3 mm<br />
Posterior Tibial 3 mm<br />
Peroneal 2.5 - 3 mm
Infrapopliteal Stenting<br />
Characteristics<br />
Low Flow Arteries<br />
Long Segment <strong>Disease</strong><br />
Multiple Focal Stenoses<br />
Long Segment Occlusions<br />
Calcification
Infrapopliteal Stenting<br />
Information<br />
No Published Data<br />
No Randomized Study<br />
No Extensive Personal Experiences
Infrapopliteal Stenting<br />
Stents<br />
No Especially Designed Stents<br />
Coronary Stents<br />
Peripheral Stents
Infrapopliteal Stenting<br />
Stents<br />
G-R R II<br />
Crown<br />
Palmaz<br />
Wallstent
Infrapopliteal Stenting<br />
Indications<br />
As PTA<br />
(limb salvage)
Infrapopliteal Stenting<br />
• Patients 75<br />
• Arteries 82<br />
(Stents)
Infrapopliteal Stenting<br />
Results<br />
Acute Results Excellent<br />
Long Term Results Poor<br />
Limb Salvage Effective
Infrapopliteal Stenting<br />
Recommendations<br />
Correctly Designed Stents<br />
Stent Graft<br />
Randomized Study<br />
Long Term Limb Salvage<br />
Followup
Conclusion<br />
Infrapopliteal stents are effective<br />
devices for improving the outcome <strong>of</strong><br />
PTA in the treatment <strong>of</strong> limb salvage.<br />
Although the patency rate is short, it is<br />
long enough for healing the ischemic<br />
lesions.
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