below the knee interventions and angiosome concept › wp-content › uploads › es › pdfs ›...
TRANSCRIPT
![Page 1: Below the Knee Interventions and Angiosome Concept › wp-content › uploads › es › pdfs › ... · Luis A Guzman, MD Director, Cardiovascular Cath Lab University of Florida-Jacksonville](https://reader035.vdocuments.us/reader035/viewer/2022081406/5f161fa95c63377d0640dca3/html5/thumbnails/1.jpg)
Luis A Guzman, MD
Director, Cardiovascular Cath Lab
University of Florida-Jacksonville
Below the Knee Interventions
and Angiosome Concept
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• Improve healing
• Limb salvage
• Improve functional capacity
• Improve quality of life
• Prolong life
Treatment Goals
Critical Limb Ischemia
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Critical Limb Ischemia
Revascularization
Revascularization is better
Amputation 8-20% vs >50% if no revasc
Revasc Strategy evolution
• Single line to the foot
• Two main vessel to foot
• As many vessels as possible
• Open inflow as source of collaterals
• Angiosome oriented revascularization
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Balloon Devices
Angiosculpt
Cutting Balloon POBA
PolarCath Balloon
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Atherectomy Devices
CSI 360 Orbital Atherectomy
Silver Hawk Turbo-Laser
Rotablator
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Drug Eluting Devices
Drug Eluting Stents Drug Eluting Balloon
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Total lesions 907 (3.0 L/patient)
Bellow the knee 406 lesion (1.9 L/patient)
CTO 57% of procedures
Multilevel 49% of procedures
BK alone 33% of procedures
Antegrade 40%
Antegrade-Retrograde 10%
Non-CTO success 99%
CTO success 89%
Critical Limb Ischemia
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• Imaging (CTA, MRA and DA)
• Know the entire anatomy, including foot
• Understanding of entry and exit areas
• Presence of side branches
• Collateral circulation
• Distal target
• Use of road mapping
• Appropriate support
• Appropriate antithrombotic
Pre and procedural preparation
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Critical Limb Ischemia
Angiosoma Concept
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Direct vs Indirect Revasc in BK
interventions for CLI (360 pts)
Iida O et al. Journal of Vascular Surgery : 2012;563
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Metaanalysis of reported studies
Biancari F et al. European Journal of Vascular and Endovascular Surgery May 2014
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Biancari F et al. European Journal of Vascular and Endovascular Surgery May 2014
Limb Salvage
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Wound Healing
Biancari F et al. European Journal of Vascular and Endovascular Surgery May 2014
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Diabetes vs Non-Diabetes Status
Iida O et al. European Journal of Vascular and Endovascular Surgery : 2013;576
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Below the knee Interventions
Adequate Imaging
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Below the knee Interventions
Long Balloons
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• Arterial Access
• Procedural imaging preparation
• Understand the anatomy
• Intraluminal approach
• Subintimal approach
• Assisted re-entry devices
• Antegrade-Retrograde approach
BK Interventions in CTO
![Page 18: Below the Knee Interventions and Angiosome Concept › wp-content › uploads › es › pdfs › ... · Luis A Guzman, MD Director, Cardiovascular Cath Lab University of Florida-Jacksonville](https://reader035.vdocuments.us/reader035/viewer/2022081406/5f161fa95c63377d0640dca3/html5/thumbnails/18.jpg)
• Arterial Access
• Procedural imaging preparation
• Understand the anatomy
• Intraluminal approach
• Subintimal approach
• Assisted re-entry devices
• Antegrade-Retrograde approach
BK Interventions in CTO
![Page 19: Below the Knee Interventions and Angiosome Concept › wp-content › uploads › es › pdfs › ... · Luis A Guzman, MD Director, Cardiovascular Cath Lab University of Florida-Jacksonville](https://reader035.vdocuments.us/reader035/viewer/2022081406/5f161fa95c63377d0640dca3/html5/thumbnails/19.jpg)
Understand the Anatomy
Below the knee Interventions
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Understand the Anatomy
Below the knee Interventions
![Page 21: Below the Knee Interventions and Angiosome Concept › wp-content › uploads › es › pdfs › ... · Luis A Guzman, MD Director, Cardiovascular Cath Lab University of Florida-Jacksonville](https://reader035.vdocuments.us/reader035/viewer/2022081406/5f161fa95c63377d0640dca3/html5/thumbnails/21.jpg)
Understand the Anatomy
Below the knee Interventions
![Page 22: Below the Knee Interventions and Angiosome Concept › wp-content › uploads › es › pdfs › ... · Luis A Guzman, MD Director, Cardiovascular Cath Lab University of Florida-Jacksonville](https://reader035.vdocuments.us/reader035/viewer/2022081406/5f161fa95c63377d0640dca3/html5/thumbnails/22.jpg)
Understand the Anatomy
Below the knee Interventions
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CTO via collateral channel
Below the knee Interventions
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CTO via collateral channel
Below the knee Interventions
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CTO via collateral channel
Below the knee Interventions
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CTO via collateral channel
Below the knee Interventions
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CTO via collateral channel
Below the knee Interventions
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CTO via collateral channel
Below the knee Interventions
![Page 29: Below the Knee Interventions and Angiosome Concept › wp-content › uploads › es › pdfs › ... · Luis A Guzman, MD Director, Cardiovascular Cath Lab University of Florida-Jacksonville](https://reader035.vdocuments.us/reader035/viewer/2022081406/5f161fa95c63377d0640dca3/html5/thumbnails/29.jpg)
• Arterial Access
• Procedural imaging preparation
• Understand the anatomy
• Intraluminal approach
• Subintimal approach
• Assisted re-entry devices
• Antegrade-Retrograde approach
BK Interventions in CTO
![Page 30: Below the Knee Interventions and Angiosome Concept › wp-content › uploads › es › pdfs › ... · Luis A Guzman, MD Director, Cardiovascular Cath Lab University of Florida-Jacksonville](https://reader035.vdocuments.us/reader035/viewer/2022081406/5f161fa95c63377d0640dca3/html5/thumbnails/30.jpg)
Pedal Access Tools
Below the knee Interventions
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Pedal Access Tools
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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CART or Reverse CART
Retrograde wire
crossing
The antegrade balloon can get into CTO body and the retrograde wire can reach the antegrade balloon advanced in
CTO body.
yes reverse CART
CART/ knuckle wire
no
If 1° failed
proximal distal
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Pedal Access techniques
• CART
• Reverse CART
• Direct intervention from pedal
• Snaring wire and reverse
• Initial pedal PTA and reverse
Below the knee Interventions
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Angiosome Concept
• No prospective evaluation
• Used of historical controls
• Most studies used different definitions with
no anatomical information
• Not information from studies of degree of
tissue loss between groups
• Studies performed at different times
• Possible selection bias. Good targets versus
diffuse atherosclerosis. More advanced
disease versus less disease, etc
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Angiosome Concept
• Not beneficial in non-diabetics (collateral
circulation is not as affected)
• The presence of good plantar arch might be
the best predictor
• Patients with ischemic limbs have different
angiosome distribution
• Interangiosome connection
• Not able to get direct revascularization
might be the main predictor
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Thank you
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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Pedal Access
Below the knee Interventions
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• Treatment of Spasm
• Anticoagulation
• Antiplatelets agents
Pharmacology During the Procedure
PTA in Limb Ischemia
• Heparin
• Bivalirudin
• Additional bolus
• Aspirin
• Clopidogrel
• GP 2b/3a
• Prasugrel
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Thank you
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Thank you