Strategies for Management of Acute
Thrombosis in Patients With PAD
Zhihui Dong, Gang Fang, Weiguo Fu
Dept. Vascular Surg.
Zhongshan Hospital, Fudan University
Shanghai, China
2018
Disclosure
Speaker name:
............................ Zhihui Dong .......................................
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
I do not have any potential conflict of interest
Strategies for Management of Acute
Thrombosis in Patients With PAD
Challenges
• urgent: limb salvage; nerve function preservation
• mixed: chronic lesion covered by acute thrombi
• comorbidities: open surg. /thrombolysis contraindicated
an early case, year 2009 (PMT devices not available)
58Yrs, male
: 5P, dysuria, tissue loss at perineal region & hip
hybrid under GA:open thrombectomy+CDT+Stent
Pre D1 Post @4 Yr
Chronic
lesion
Chronic
lesion
1st stent
2nd stent
acute & chronic
diffusely
acute removed
chronic discovered
Urgency
mixed
minimized
stenting
@ 4Wks
plastic surgery
@4Yrs
Thrombectomy incision
hip ulcer
skin
transplantation
skin graft
donor area
Current Tx Algorithm
critical comorbidities
Not limb-threatening
Medical Tx
Operation
Otherwise
AmputationLimb salvage
EndovascularOpen surgery Hybrid
PMT
(Rotarex / Angiojet)
CDT
Stent
(1/ 2 stages)
CFA involvedclose to renal A
coexistent AAA
Representative Case 1
high-risk for open surg.
Strategy:CDT+2nd-stage stenting
• 71 Yr, male
• HT, DM, AMI & PCI
• Rest pain for 1M; paralysis for 2 D
• Referred from Dept. Neurology
• CTA: aorta-iliac occlusion
Lt Brachial Approach
Pass the easier side (Lt.)
just to place a cath
gentle Pre-dilation
(Pacific, 3*120mm)CDT (Unifuse)
Chronic
stenosisUnifuse
Occlusive
segment
@36h
significantly thrombolyzed
chronic lesion @ bifur revealed@1M
Kissing (bare)
Rt Femoral+Lt Brachial @8M
Representative Case 2
challenge: contraindication for CDT
Strategy: single-stage PMT (Angiojet) + stenting
• 47Yr, male
• Progressive rest pain & ED for 3 days
after use of Reptilase for hemoptysis
• Absent bilateral femoral artery pulses
• PAH for over 20 Yr, recurrent hemoptysis,
CTA: aorta-iliac occlusion
Lt brachial
approachAngiojet RCIA Angiojet LCIA
thrombi removed markedly
Kissing
(complete)Bare stents
Preserve ICA and lumber A
stent
Occlusive
segment
@1M
ED relieved
@6M
Representative CASE 3
challenge: whole popliteal A (PA) involved
Strategy: recanalization without stent @ PA, esp. @P2-3
• 62 Yr, male
• Claudication for 1 Yr
• Lt leg rest pain for 1M, progression over 1 Wk
• DM & HT
• CTA:Total occlusions of the Lt SFA & PA
• ABI:Lt 0.25,Rt 0.48
to realize PMT, stay in true lumen, at least in PA
Pre-dilation
(Pacific ø3mm)Rotarex
On-table
250,000 u
urokinase
@PA
Clear prox. thrombi as much as possible
Leave more time & urokinase for PA
Unifuse
HOPE😊
Unifuse
Left @ PAStent @ SFA prior to CDT
Ensure adequate inflow to
optimize the distal thrombolysis
@36h 1 additional Stent @ completion
Chronic
lesion
Stent
end
@1M@3M
300-m claudication
@1Yr
Pain-free walking
>1-2Km
exercise
collaterals
reocclusion
Representative case 4
➢ 83Yr, female
➢ acute pain, paresthesia for 1w
➢ HT, DM, but without Af
➢ CTA: total SFA – PA involved
Lesson: CDT failed without adequate inflow
D0
D1
Proximal stenting
(Everflex)
Only PMT, without proximal stenting Prior to CDT
CDT for another
24Hr
Pre Post-PMT
Post-CDT
D2
Stent
end
@3M: 800-m claudication
ABI
L R
Pre 1.08 0.33
@ 1W 1.14 1.07
@3 M 1.02 0.89
Summary
• Systemically & locally balanced
• Remove the acute, reveal and fix the chronic
• Ensure an adequate inflow during distal thrombolysis
• Hopefully, leave nothing @ PA
• Even if reoccluded, limb salvage could be kept
www.zs-hospital.sh.cn [email protected]
Strategies for Management of Acute
Thrombosis in Patients With PAD
Zhihui Dong, Gang Fang, Weiguo Fu
Dept. Vascular Surg.
Zhongshan Hospital, Fudan University
Shanghai, China
2018