Post on 03-Jun-2018
transcript
8/12/2019 Tibial Angioplasty
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Dr. Aniruddha Bhuiyan
1st yr Postgraduate In Vascular Surgery
MS Ramaiah Medical College and HospitalsBangalore
Tibial Angioplasty –
Tips and Tricks
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INTRODUCTION
• Arterial reconstruction for occlusions of below knee
vessels
• Valuable treatment – diabetic patients : adequate wound
healing and limb salvage rates
• Variable quality of reports – exclusive tibial interventionsnot well studied – cannot compare, challenging
• Development of low-profile balloon catheters, Small-
caliber stents, Steerable and hydrophilic guide wires
• Time-resolved CE MRA and superselective DSA with
proper catheter positioning
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WHEN and WHAT
•Do’s - CLI patients with rest pain, ulcers & gangrene
• Don’t - No distal runoff, fixed flexion deformity, inability
to remain immobile, acute septicemia (wet gangrene)
• More options for vessel revascularisation
• BASIL suggested – Conducive anatomy ? for plasty,
primary PTA first line – even if good bypass candidate
• Angiosome targetted revascularisation
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PROCEDURE CHECKLIST
• Access Options
• Inflow / Run-off Assessment / Infra-popliteal status
• Lesion assessment:
- Length, stenosis, occlusion, calcium• Hardware, amount of contrast
• Bailout options
• Short/long-term success
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TECHNIQUES
• Puncture : Ipsilateral antegrade femoral, pedal
• Angiography : Dilute non-ionic, CO2
• Crossing lesion : 0.014”, 0.018” hydrophilic GW
•Balloon angioplasty : Low profile, non compliant, longlength balloons
• Stents : controversial : balloon expandable – proximal ;
self expanding – distal
• Reocclusion : stent, prolonged inflation, lysis, aspiration
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WHAT TO DO IF DIFFICULT ?
•
SNARING OF RETROGRADEGUIDEWIRE
• DOUBLE BALLOON / REZENDEVOUS
- Double balloons tracked subintimally
- plasty to break membrane to enter
true lumen
• SAFARI
- True lumen cannot be reentered,distal wire is snared inside subintimal
space via proximal access
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OUTCOMES
• POBA - (24m limb salvage – 70%)
• Improve blood flow – long enough for ulcer to heal
• DEB - offer the antiproliferative effect of local drug
elution (limb salvage – 95.6%)
- Long, Complex lesions, restenosis, poor outflow- Restenosis: 27% vs. 63%
• Stents - residual stenosis, flow limiting dissections,
perforations – reocclusion 50% < 1 yr• DES – under trials
• Cryoplasty , Atherectomy (orbital)
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• Image the anatomy well – selective injections
• Intra-luminal strategy in general
• Assess hemodynamic end-point , not just
arteriographic appearance
• Learning curve for crossing occlusions
• Not being overaggressive
• Tibial arteries–
more prone for vasospasm – vasodilators….
• Option for distal bypass
TRICKS
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CONCLUSION
•
Tibial angioplasty vs Bypass (long term patency poorbut limb salvage rates similar)
• Unstable looking lesions, limited outflow - SURGERY
• Chance to tide over crisis – 2nd option of distal bypass
• With improved techniques and better hardware……
TIBIAL ANGIOPLASTY is being rewarded with better
LIMB SALVAGE
Thank You