Slide 1

PTA OVERVIEW AND HARDWAREDEEPAK NANDANINTRODUCTIONEndovascular revascularization of infrarenal aortic and iliac disease- high rate of technical success and with lower morbidity and mortality than open bypass surgery

Preferred modality for treatment of patients with Trans-Atlantic Inter-Society Consensus Document (TASC) II type A and B lesions

Surgical revascularization preferred for patients with TASC type C and D lesions

In contemporary practice, surgery is reserved for failure of endovascular approachModified TASC Morphological Classification (TransAtlantic Inter-Society Consensus)

TASC -Femoral-Popliteal Lesions

AortoIliac and Common Femoral Intervention

5 YEAR PATENCY RATES OF AORTOILIAC INTERVENTIONS

Vessel diameterVesselSize in mmInfrarenal Aorta14-20Common Iliac8-12External Iliac7-10Common femoral6-7Recommendation for vascular access of aortoiliac interventionLocation of lesionVascular accessAortic bifurcationBilateral retrograde CFAOstial common iliacIpsilateral retrograde CFA, brachial arteryCommon and EIA stenosisIpsilateral retrograde , contralateral CFACommon and EIA occlusionIpsilateral+/- contralateral CFA, brachial arteryCommon femoralContralateral retrograde CFACommon, EIA,SFA , poplitealContralateral retrograde CFA

This angiogram in the anteroposterior (AP) view shows common, internal, and external iliac arteries. If the external iliac arteries are not well visualized in the AP view, then contralateral views should be used. For example, left external iliac artery is best imaged in the right anterior oblique30. The CFA is imaged by placing a 5F multipurpose catheter in the contralateral side after crossing the contralateral CFA with an angled glide wire. The ostium of the superficial femoral artery (SFA) and the profunda femoris artery are best imaged in the ipsilateral 30 angulation. The middistal SFA and the popliteal are best visualized in the AP view. The tibioperoneal vessels are seen well in an ipsilateral 10 angulation, whereas the pedal arch vessels are imaged in the contralateral10 angulations.Vascular AccessRelatively disease-free, without signi Ca

Over a bony structure, if possible

Angle of entry- 30-45

Obtained with an 18-gauge needle that will accommodate most 0.038 or smaller Wires

A smaller 21-gauge needle with a 0.018-inch wire - micropuncture kit (Cook, Bloomington, IN)

Used for difficult femoral, brachial, radial, or antegrade femoral approaches

Retrograde Common Femoral Artery Access

Common access site used for peripheral diagnostic angiography and interventionPrevent injury to the less diseased extremity

Contralateral femoral retrograde access iliac occlusions are best treated from a contralateral approachSFA,PFA- lesions OF CFA/involve SFA/PFA ostium - allows treatment B/L disease with a single arterial puncture

Femoropopliteal Artery InterventionContralateral femoral retrograde access :

Manual of carotid and peripheral vascular Intervention, Thosaphol Limpijankit MD, Beyond Enterprise Thailand 2008;290AdvantageDisadvantageLess subsequent complications including hemorrhage from puncture siteWorking from a distance with exchange-length wires and balloonsAbility to image CFA and its bifurcation

Lack of support while traverse of critically narrowed or occluded sitesAbility to treat iliac and infrainguinal disease in the same setting

Antegrade Common Femoral Artery AccessRequired for infrainguinal procedApprox 3cm CFA lies betw ligament & FA bifurcation Inorder to access CFA, skin entry- prox to ing ligm Access too close to F bifurc inadeq working room to selectively cath SFA

Ipsilateral popliteal retrograde accessUseful in SFA occlusion with failure to cross from contralateral or antegradeOstial SFA/CFA lesions may also be approached via PA in acute angled terminal ao bifurcCI- aneurysms of PA, pathology of popliteal fossa- Bakers cyst

Brachial Artery AccessPref access for visc arterial [CA, SMA] interventions

PC approach at BA can lead to a compli rateUL arts smaller, prone to spasm A small hematoma- Could lead to brachial plexopathy

Itv req >6F sheaths/smaller ptopen approach preferred

Left BA access pref over Rt- can avoid carotid origin

A micropuncture tech should be used for all PC BA intervention

Left brachial approach has approximately 100mm greater reach than the right brachial approach

Estimated distances from FA access

GUIDEWIRESGuidewires are used to introduce, position, and exchange catheters

In a standard guide wire, a stainless steel coil surrounds a tapered inner core

A central safety wire filament is incorporated to prevent separation in case of fracture

5 charecterstics- size, length, stiffness, coating, and tip configuration

Typically they are 100 to 120 cm in length but can also be 260 to 300 cm(good rule of thumb to follow is that the guidewire should be twice the length of the longest catheter being used)

Tip of the wires can be straight, angled, or J-shaped

Varying degrees of shaft stiffness- extra support,to provide a strong rail to advance catheters in tortuous anatomy vs extremely slick hydrophilic with low friction

Wire selectionDiameter vary from 0.014 to 0.038

Most commonly used size is 0.018/0.035 ( upper extremity) and 0.014/ 0.018 ( lower extremity)

Length between 130 and 300cm

Tip configurations are; straight, angled Tip and J shape

Varying degrees of shaft stiffness ( e.g. extra support, super stiff wires) allow advancement of stiff devices

Hydr-angle tipGlidewireCan be used for crossing tight lesions and can be advanced independent of a guidewire038:18g needle, 018:21g needleGuidewire-Lesion InteractionFloppy portion moving in a linear fashionFloppy portion piles up prox to lesionno chance to cross- backup,redirect,if straight tipsteerableFloppy tip bent with min RCautiously adv wire- once crossed, wire should straighten- advancing a buckledup wire- forceembolizationFloppy tip buckledup backup,redirect,adv -dissect,embolz,wire damag

Guide wire FunctionsPTA Guidewires are designed to:

Track through the vesselAccess a lesionCross a lesionProvide device delivery support

PTA Guide wires 25A guidewire therefore needs to successfully accomplish all of the following: Track through the vesselSteer into or away from side branchesAccess the lesionCross the lesionProvide device delivery support

Core Material

Affects flexibility, support, steering and trackingStainless Steel

Nitinol (more flexible)

High Tensile Strength Stainless SteelCore DiameterLarger core diameter: increased support for device delivery and vessel straightening good torque

Smaller core diameter: for enhanced tracking and flexibility

Core-to-TipShaping ribbonForce transmissionTactile feedbackTip stiffness/Tip-loadBetter steeringBetter shapabilityFlexibility, softnessAbility to prolapse Frontline/Workhorse,floppyTip style

Long tapersIncreased steerabilityIncreased flexibility

Short tapersIncreased supportIncreased TorqueCoils & covers

Outer coils

Tip coils only

Polymer cover

Polymer sleeveTip coilsCoils & coversCoils provide tactile feedback, radiopacity and maintain constant overall diameters

Polymer covers/sleeves provide optimal lubricity to overcome resistance and access to the lesion

Allows smooth tracking through tortuous anatomy

Better device tracking over the guidewire

Not to be confused with coating (hydrophilic or hydrophobic)Covers and Coatings SummaryLubricity Delivery &Device InteractionTactile Feedback (related to coils)NoCoatingHydrophobicCoatingHydrophilic CoatingPolymer Cover with hydrophilic CoatingPTA GUIDE WIRESGlidewire (TERUMO)Peripheral Guidewires(0.032"-0.038")Standard GlidewireShapeable Tip GlidewireLong Taper GlidewireStiff Shaft GlidewireStiff Shaft Long Taper Glidewire1 cm Taper GlidewireJ-Tip GlidewireBolia Curve GlidewireGlidewire AdvantageSmall Vessel Guidewires(0.018"-0.025")GlidewireStandard and Shapeable TipGlidewireGT Super-SelectiveGlidewireGold

Terumo Glide Technologyhydrophilic coating

smooth, rapid movement through tortuous vessels crossability over difficult lesions

Core-to-tip design provides 1:1 torque ratio

elastic nitinol core for optimal performance

Resists kink &Retains shape

Tungsten in polyurethane jacket- radiopacity

Carries the risks of vessel dissectionand perforation

should not be used to traverse needles because of the potential of shearing

Terumo invents the Hybrid Technology for Guide Wires and creates the Radifocus Glidewire AdvantageT: crossing the lesion and delivering the interventional device using only one wire for a reduced risk of complications, a greater efficiency and a shorter procedure time

ABBOT

Hi-Torque Steelcore Peripheral Guide Wire (190/300 cm)

Hi-Torque Spartacore Peri WireExcellent .014" Support SS shaftSuperb Steerability and a Soft Shapeable TipCore-to-tip design130/190/300 cm lengthsMICROGLIDE CoatingPTFE up to distal 7 cm (130 cm)Available in 5 and 10 cm

Hi-Torque Supra Core 35

One-to-one torque exceptionalsteerabilityMICROGLIDE coatingRadiopaque tip 035" shaftSoft Shapeable tipHi-Torque Versacore Guide Wire

Torqueable wire for deliverability through tortuous or challenging lesions

Soft shapeable tip designed to for lesion accesBOSTON SCIENTIFIC

Amplatz Super Stiff Guide WireFor stiffness, strength and stability during catheter placement and exchange

Diameters: 0.035", 0.038"

Lengths: 145cm,180cm, 260cm

Tips Styles: Straight, J, Short

Core Material: Stainless steel

Coating: PTFE

Magic Torque Guide WireMagic Markers spaced at 1cm increments

designed for enhanced visualization and excellent torque control

Diameters: 0.035"Lengths:180cm, 260cmTips Styles: Straight (shapeable)Core Material: Stainless steelCoating: Glidex Hydrophilic Coating (tip)

Meier Guide WireStiff shaft excellent supp flexible tip is ( AAA endovascular graft procedures)

Diameters: 0.035"Lengths: 185cm, 260cm, 300cmTips Styles: J, CCore Material: Stainless steelCoating: PTFE

Platinum Plus Guide WireDesigned for negotiation of tortuous anatomy and contralateral approaches

Diameters: 0.014", 0.018", 0.025"Lengths (cm): 60, 145, 180, 260, 300Tips Styles: Straight Long or short taperCore Material: Stainless steelCoating: Glidex Hydrophilic

Thru way Guide WireDesigned for excellent performance in acutely angled vessels, such as renals and other peripheral interventions

Diameters: 0.014", 0.018"Lengths (cm): 130, 190, 300Tips Styles: Straight, JCore Material: Stainless steelCoating: Silicone

CORDIS

EMERALD GuidewiresFi xed-Core, PT F E Coated, Exchange WiresCOOK Amplatz Stiff Wire Guides

Stiff shaft Gradual transition to a very flexible distal tip

TFE Coated Stainless Steel-035,038: 145,180,260-straight

TFE Coated Stainless Steel with Heparin Coating-035: 145,180,260-straight

8 cm-flexi tip

Amplatz Extra-Stiff Wire Guides inner diameter -extra-stiff + tip flexibile

TFE Coated Stainless Steel-025,035,038: 80,145,180,260-straight & curved: 300-straight

TFE Coated Stainless Steel with Heparin Coating-035: 80,145,180,260-straight & curved

Amplatz Ultra-Stiff Wire GuidesThe increased inner diameter of the wire guide coil allows utilization of an ultra-stiff mandril while maintaining tip flexibility

TFE Coated Stainless Steel-035,038: 80,145,180-straight

TFE Coated Stainless Steel with Heparin Coating-035: 145,180-straight

8cm-flexi tip

Roadrunner Extra-Support WireComplex diagnostic/interventions - where extra support needed for cath exchange /manipulation of devices

Heavy-duty nitinol alloy mandril provides support while imparting 1:1 torque response to distal platinum spring coil tip

Angled tip facilitates directional controlLubriciousTFEcoating -low coefficient of friction

014,018180,270,300 Cope Mandril Wire Guides I

Stainless Steel

Platinum coil visualization and an angled floppy tip for precise directional control

018

40,60,100,125

Standard taper-7cm coil

Cope Mandril Wire Guides II

Nitinol kink resistant 1:1 torque controlPlatinum coil -visualization

angled floppy tip for precise directional control

018

60,100,125

Standard taper-7cm coil, short taper-7cm coil

Rosen Curved Wire GuidesThe heavy-duty mandril, 2cmflexible tip and tightened J configuration

Ideal for Renal int- less traumatic

TFE Coated Stainless Steel-035: 80,145,180,220,260

TFE Coated Stainless Steel with Heparin Coating-035: 145,180,260The Graduate Measuring Wire GuidesUsed to determine accurate sizing of vessel Gold radiopaque markers delineate 25 cm lengthSix distal markers are spaced 1cmapart.Four proximal markers are spaced at 5cmincrements.035145,180

Reuter Tip Deflecting Wire GuideUsed with Reuter Tip Deflecting Handle for curving or deflecting catheter tips during selective and superselective angiographyFacilitates catheter tip movement by controlling the deflection of the wire guide tip within catheter lumenDistal tip of wire guide must never extend beyond tip

BIOTRONIK Cruiser Guide Wire 0.014L: 190 cmTip Shape: Straight and J

Cruiser-18

Hi-support Guide Wire

0.018

Stiff: 195 cm and 300 cmMedium: 195 cm and 300 cm

Catheter An ideal catheter should be able to sustain high-pressure injections, to track well, be nonthrombogenic, have good memory, and should torque wellCatheter ( diagnostic/ guiding)Length depends on location for usingSizes are 5 to 8 Frencha) abdominal aorta = 60 to 80 cm length

b) BTK,carotid or subclavian areas 100 to 125cm length

Polyethylene- coef friction, pliablePolyurethane- softer, even pliable tracks wires betterNylon- stiffer, can tolerate ow rate- amenable to angioTeon- stiffest- used mainly for dilators & sheaths

wire braid in the wall to impart torquibility and strengthGuiding Catheter vs SheathOperator dept

Sheaths are designed with a simple diaphragm or a hemostatic valve, guiding catheters always require hemostatic valves be attached

During intervention, the guide catheter or sheath should be placed near the lesion to provide for better visualizationand improved supportFlush /Non-Sel SelectiveCATHETERS

Vascular sheaths allow for easy exchange and introduction of catheters and guidewires. They have a hemostatic valve that prevents blood reflux and air embolism. Furthermore, they protect the vessel entry point from intimal injury and should be used whenever multiple guidewire exchanges are anticipated. Sizing of sheaths is based on their internal diameter: a 7 Fr sheath will accept up to a 7 Fr catheter. Sheaths come in multiple lengths. In addition, the side port of the sheath can be used to inject contrast or measure arterial pressure. All sheaths are packaged with dilators. Dilators serve as an obturator for entry of the sheath and also help to progressively enlarge the track once guidewire entry has been established Guiding catheters and sheaths can be used to facilitate passage of a smaller endovascular device through a tortuous curve. They are particularly useful in the renal and carotid system or contralateral iliac systemBALKIN Sheath (cook) Contralateral access to the iliac artery

Flexibility without kinking or compression

Radiopaque band- identifies precise location of sheaths distal tip for positioning accuracy

The Check-Flo valve prevents blood reflux and air aspiration during catheter manipulations

5.5 Fr-8 Fr- 40cm - .038 compatible

Super Arrow-Flex Sheath /Dilator Setwith 90 curved tip (ARROW International)6-7Fr45cm length Assures successful access to the renal arteries. Y Connector + Tuohy Hemostasis Valve a+ 3-Way Stopcock90 Curved Tip Both sheath and dilator have a curved tip for easy access to the renal arterySheath replaces guide catheter -eliminates the need for using a guiding catheter - reducing size of punctureRadiopaque tip marker-locate and control sheath advancement into RA

TERUMO GUIDING SHEATH( PinnacleDestination) Guiding Sheaths (5-8 Fr)

5-8 F45,65,90Hydrophilic coatingAll dilators are 0.038" wire compatible

Simple curved catheters, e.g., Berenstein, Cobra and Headhunter, are also useful in angulated renal arteries and vertebrals.59

TERUMOGlidecath(4 Fr)-65,100,120-038GlidecathXP (5 Fr)-65,100-038 Glidecath(5 Fr)-65,100-038

TERUMO GLIDE CATHHydrophilic Coated CathetersHydrophilic coated distal tip (15 cm) for smooth passage through tortuous vasculature

Double-braided stainless steel mesh middle layer shaft rigidity and torque transmission

Nylon-rich polyurethane inner layer for smooth flow of therapeutic agents and 0.035"/0.038" embolization coils

Large lumen (0.038" wire compatible) and small profile (4 Fr) is ideal for:

Use as a guiding catheter for microcatheters

Diagnostic procedures that require high flow rates

Excellent trackability and navigation most tortuous anatomies

SOS Omni selective catheterSoft, atraumatic, Super-radiopaque tip Reforming in desc thoracic aorta below great vessels rather than transverse arch safety Pulled from the desc ao into abd ao with a floppy guidewire leading, sometimes with a rotating motion Soft, flexible atraumatic tip can be placed deeper into the artery (>1 cm), chance of catheter kickout. Shaped tip allows the guidewire to flick into the origin of the RA

Omni Flush Angiographic Catheter Flush aortography B/Lrun off studies of LL Cross ao bifurcation with ease for C/L diagnostics in interventional proceduresSuper-Radiopaque tipReforms and maintains shapeeven under injection pressurewith less catheter whipping-less vessel wall injuryLess contrast reflux than other flush catheters-lower total contrast dose

4F IMPRESS Simmons 1 Catheter 65cm..038Side Ports:N/ACatheter Shape:SIMMONS 1French Size:4

5F IMPRESS Simmons 2 Catheter 65cm..038 Side Ports:N/ACatheter Shape:SIMMONS 2French Size: 5

Microcatheters (TERUMO)

Progreat(2.4 Fr, 2.7 Fr)- 110/130- OD 2.9Fr/2.7 Progreat (2.8 Fr)- 110/130- OD 3Fr/2.8

Slip-Cath Beacon Tip Catheters (C00K)Hydrophilic Coating

Enhanced radiopaque Beacon tip

Sixteen stainless steel wire braid imparts 1:1 torque control to catheter tip & pushability

Nylon material resists softening during prolonged catheter manipulation

Slip-Cath Beacon Tip Catheters

CXI Support Catheters(C00K)For use in small vessel/superselective anatomy for diagn & interv procedures, incl peripheral use

Low profile from tip to hub ensures smooth transition through small vessels

Shaft's polymer material offers desired flexibility

Braided SS entire length -pushability

Hydrophilic coating

Embedded radiopaque markers -size the vessel segment length

Veripath Peripheral Guiding Catheter(ABBOT)Three-Layer Construction50 cm length5 catheter shapes6,7,8 F014/018

CORDIS

Kumpe catheter

Accesses and Selective Guiding Catheters for Some Basic InterventionsCarotid Artery1.First choice accesseither FA2.Alternative accessleft BA3.Selective catheterRight carotid: H1,Simmons,VitekLeft carotid : angled glidecath,H1,SimmonsSubclavian Artery1.First choiceeither FA2.Alternative accessipsilateral BA3.Selective catheter angled Glidecath,H1,Simmons,H3Celiac or SMA1.First choiceeither FA2.Alternative accessleft BA3.Selective catheterRIM,ChuangRenal Artery1.First choicecontralateral FA2.Alternative accessleft BA3.Selective catheterC2,RDC,Sos-omniInfrarenal Aorta1.First choice either FA2.Alternative accessleft BA3.Selective catheteromni-ush,RIM,C2Superior Femoral Artery1.First choicecontralateral FA2.Alternativeipsi retro FA for run-off; ipsi antegrade for interv3.Selective catheterBerenstein,Kumpe,VertebralTibial Arteries1.First choicecontralateral FA2.Alternativeipsi retro FA for run-off; ipsi antegrade for interv3.Selective catheterKumpe,VertebralVessel sizeThe vessel in each territory have their own different size, important to know to choose a proper balloon or stent

BalloonsBalloonsIn selecting a balloon, the following criteria should be considered : a) Guidewire ( 0.014, 0.018, 0.035) b) Over the wire (OTW) or monorail system c) Shaft length

Balloon shaft lengths are commonly 75 cm or 120 cm, can be coaxial or monorail and designed to be inserted over 0.014-in., 0.018-in., or 0.035-in. wires

0.014 balloon system is usually for carotid, vertebral, renal, infrapopliteal arteries

0.018 balloon system also in SFA, infrapopliteal- operator dept

0.035 balloon system for subclavian, innominate, aortoiliac, superficial femoral artery

Circumfer force/tension (T) exerted on wall of an inflatd balln ~P within balln & R (T=PR)(LAPLACE)Larger ballns -require P than smaller ballns to generate substantial dilating forcesLarger vessels (Ao) require P to dilate & rupture

Diameter matching vessel beyond lesionBalloon length should be > lesionBalloon centered on lesion & inated slowlyInation maintained for 20s- deated- reinated 3 inations of 20s

Patients complaint of low back pain during balloon inflation may be a warning sign of adventitial stretch, which may occur before aortic rupture

ATB ADVANCE PTA Dilatation CatheterAdvance 14LPAdvance 18LPAdvance 35LP (C00K)

Designed for iliac, renal, popliteal, infrapopliteal, femoral and iliofemoralAlso intended for postdilatation of balloon-expandable peripheral vascular stents40,80,120Low profileHydrophilic

Advance 14LP (C00K)Low Profile Provides the trackability and pushability to reach even the most remote infrapopliteal lesionsHydrophilic coating on balloon and distal shaft, along with a smooth tip transitionMaintains super-low profile after inflation4Frsheath compatibility for all sizes20 to 200mm in 2, 2.5, 3, 4mmD170

FoxCross .035 PTA (ABBOT)D-(3-14 mm), L-(20-120 mm), and cath L (50, 80 &135 cm)-OTWGood trackability, rapid inflation/deflationCrossability -useful in calcified lesions5-7 FGuide wire compatibility: 035Nylon PolymerJETCOAT coating ABBOT Fox sv PTA Catheter

OTW designed for challenging small vessel proceduresRange of BTK and SFA sizes (2-6 mm) 90,150Sheath Compatibility:4F for all sizesGuide wire compatibility:.014"/.018 Fox Plus PTA Catheter

Low ProfileCompatible with a 5 Fr sheath up to 7mm balloonsShaft Technology-dual lumen-Rapid infl and deflationJET coated - Reduces friction and facilitates access and crossing of target lesions

Sterling Balloon Dilatation Catheters(BOSTON SCIENTIFIC)

Breakthrough 4F Profile

Both Over-the-Wire and rapid exchange

40,80,135

Specifically designed for use in carotid, renal and lower extremity arteriesSterling SL Balloon Dilatation Cath

long lengths-BTK - specifically designed - infrapopliteal procedures

014, 018

OTW and Monorail

90,150Sterling ES Balloon Dilatation Cath

0.014" balloon cath

Ultra-low profile balloon

Both OTW and rapid exchange platforms

.017" tip entry profile

140

BIOTRONIKPasseo-18Passeo-35

Balloon Catheter 0.018 /.035 OTW

Hydrophobic patchwork coated balloon ensures a smooth crossing through tortuous vessels and across high grade stenosis whilst minimising the risk of slippage during inflation experienced using hydrophilic coated balloons

StentsBalloon-expandableSelf-expandableStent graft

Balloon-expandable stentsRequire positive pressure for expansion

Typically rigid with high radial force

Size of the balloon-expandable stent equals to the size of the reference vessel diameter

Ideal for immobile sites of the body subclavian, renal, mesenteric, iliac arteries and at ostial locations

PALMAZ Bal-Exp Stent (unmounted)CORDISClosed cellSSStent D (Expanded) 4-8mmStent L (Unexpanded) 10,15,20,29,39mmSheath Introducer 6F, 7FDynamic Renal (BIOTRONIK)

Balloon-Expandable Cobalt Chromium Stent 0.014 / Rx

Dynamic

Balloon-Expandable Stainless Steel Stent 0.035 / OTW

SELF EXPANDABLE StentsDeployed in vessels that are flexible or twist during movement of neck, shoulder or leg Carotid, Axillary, SFA, Popliteal arteryNitinol - metal - provides best flexibility and memoryStent is simply compressed over a stent delivery catheter and covered with a sheathStent deployment is achieved by pulling back the sheath Stent diameter should be 1-2mm larger than the reference vessel diameter- adequate stent apposition with the vessel wall

Self-expandable StentsSome degree of foreshortening- to be taken into account when choosing

More difcult to place with absolute precision

Generally comes in longer length than BES

Their ability to continually expand after delivery allows them to accommodate adjacent vessels of different sizeSelf-expanding stents are deployed by retracting a restraining sheath and usually consist of Elgiloy (a cobalt, chromium, nickel alloy) or Nitinol (a shape memory alloy composed of nickel and titanium), the latter of which will contract and assume a heat-treated shape above a transition temperature that depends upon the composition of the alloy. Self-expanding stents will expand to a final diameter that is determined by stent geometry, hoop strength, and vessel sizeBX- vs SX stents for iliac interventionBX stentSX stentAdvantagesHigh radial forceElasticity, flexibilityMinimal foreshorteningConformabilityGood visibilityMRI compatibility

Absolute precisionContinually expand vessel sizeDisadvantagesRisk of edge dissectionNeed post-dilStent crushingSuboptimal radial strengthIncomplete stent appositionForeshorteningArtifacts on MRINon preciseSuitable lesionsHeavily calcified lesionsNon-ostial lesionImmobileEIA; CFA -mobileOstialLong lesionsDecision between SE or BE stents in Iliac Lesions

Balloon expandableAortoiliac bifurcationCommon iliacCalcified lesionsChronic occlusions (?)

Self expandingVessels flexible/twist during movement Tortuous vesselsDistal external iliac arteryContralateral approachLong diffuse lesionsAortoiliac bifurcation (long lesions)

Stent GraftsCombination of a metal stent covered with fabric

Used to exclude aneurysm, treat perforations when prolonged balloon inflation failled

Wallgraft and Viabahn are the two options currently available for treatment of perforations of aneurysm in larg vessels

Fluency Plus(Bard)TracheobronchialSelf-expandingJostent(Abbott)Coronary perforationBalloon-expandedViabahn(Gore)SFASelf-expandingICast(Atrium)TracheobronchialBalloon-expandedEquipmentIpsilateral retrograde approachContralateral approachBrachial artery approach6-8F Sheath, length 11cm or 23cm6-8F cross- over Sheath 6-7F 90cm sheath6-7F Guiding catheter0.035 wire, length 180-190cm0.035 wire, length 180-190cm0.035 wire, length 260-300cm

0.035 wire compatible Balloon catheter , diam. 6-9mm,Shaft length 75-90cm

Balloon catheter , diam. 6-9mm,Shaft length 75-90cm

Balloon catheter , diam. 6-9mm,Shaft length 130cm

BX stent, diam. 8-9mm, shaft length 75-110cmBX stent, diam. 8-9mm, shaft length 75-110cm

BX stent, diam. 8-9mm, shaft length 130cm

SX stent , diam.8-14mm, shaft length 75-110cmSX stent , diam.8-14mm, shaft length 75-110cm

SX stent , diam.8-14mm, shaft length 130cm

Retrograde iliac stent placement

Cross-over stent placement

Subintimal angioplastyHydrophilic wire not passingCarefully adv into subintimal plane- if not spontaneously, gentle ination of balloon at edge of the plaqueWire traversed the lesion subintimaliyHydrophilic catheter or other re-entry device passed OTW to guide it back into lumenStandard angioplasty of subintimal plane performed, with stent placement

Subintimal angioplasty Femoropopliteal Artery InterventionFour potential routes of access to the SFA and popliteal:Contralateral femoral retrograde accessIpsilateral femoral antegrade accessIpsilateral popliteal retrograde accessBrachial retrograde accessBalloonBalloon size and length is matched to the size ( ~5-6mm) and lesion length( ~40- 300mm) of SFAImproved angiographic results may be accomplished with prolonged inflation times ( 3-5 minutes)Dissections are commonly seen after balloon dilation ( due to heavy calcification)

Femoropopliteal Artery Intervention Stent implantion ( always SX-Stents):

Sizing the SX- stent ~ 1mm greater than the RVD of SFAPostdilation with 5.0-6.0 mm diameter balloon

Popliteal artery -> avoid stent = high risk of stent compression or fracture

SX-Stent problems:

Stent fracture -especially in stent overlap

In-Stent-Restenoses-in long stented segments, multiple stents

DEB

Five-year patency (%) of femoral popliteal revascularization

Outcome

Kasapis C, et al Eur Heart J. 2009;30:44- 55Infrapopliteal Intervention4 anterior tibial artery5 tibio-peroneal trunk6 posterior tibial artery6a peroneal artery6b perforating branch of the peroneal artery6c communicating branch of the peroneal artery7 dorsalis pedis8 medial plantar artery9 lateral artery10 plantar arch

Infrapopliteal IntervKnee-to-foot patency of one of the three branches is usually sufficient to prevent critical lower-limb ischemiaClaudication is rarely the result of isolated disease of the infrapopliteal arteriesRe-stenosis after intervention in these vessels is typically the highest among the lower limb sitesObstructive disease in these arteries is often occlusive, diffuse and complicated by heavy calcific depositsVascular AccessCross- over technique ( retrograde access)Ipsilateral antegrade access ( recommended)Retrograde pedal accessBrachial accessRadial access

wire selectiononly atraumatic 0.014 / 0.018 guide wires should be used0.014 prefered due to vessel diamet( floppy, medium,stiff)

Balloon AngioplastyLow profile balloon with high pushability and trackability Vessel conformabilityFlexibility in small collateral branches 0.014/ 0.018" wire compatibilityDiameter 1.5mm-4.0mmLong (20-210 mm)& tapered tip to reduce procedure times and dissection

Infrapopliteal- Stent implantationRequirements - BTK BE-Stents

PTA balloon like flexibilityUltra-low profile and extreme flexible delivery system with 0.014 guidewire compatibility2 - 4 mm stent delivery system diameter Long stents ( up to ~ 80mm)4F introducer sheath compatibility braided sheath design - pushability and flexibility to enable easy negotiation in tortuous anatomies without kinking

113Infrapopliteal Intervention-EquipmentContralateral approachAntegrade Approach5F-6F cross-over-sheath, 55cm or 70cm4F-6F short sheath0.035 300cm wire0.035 190cm wire5F-6F Guiding catheter, if no long sheath is used5F-6F Guiding catheter, if no long sheath is used

0.014-0.018 wire ( 0.014 prefered)0.014-0.018 wire ( 0.014 prefered)

Balloon catheter, 1.5-4.0mm diameter, length 20mm-210mm, shaft length 150cmBalloon catheter, 1.5-4.0mm diameter, length 20mm-210mm, shaft length 120cm0.014 balloon expandable stent, 150cm shaft length0.014 balloon expandable stent, 120cm shaft length

0.014-0.018 self-expandable stent, long shaft0.014-0.018 self-expandable stent, short shaft

Guide wire support catheter ( facilitate wire Crossing)Guide wire support catheter ( facilitate wire Crossing)Limb salvage rate is high, but restenoses rate also high

Restenoses rates ~ 70% @ 3 months- depends on severity of disease

Efficacy of Coronary DES in Infrapopliteal Arteries

Renal artery stenosis

Usually occurs in the proximal 2 cm~75% of lesions are caused by atherosclerosisLesions can be single or multiple, unilateral or bilateral (~25%) Diameter: 6.0-6.5mm for men 5.5-6.0mm for women Length 3-7 cm

118Discuss plaque in aorta draw Tool Chest for RAS Treatment Diagnostic

Wires0.035 for initial catheter placementAvoid hydrophillic wiresDiagnostic catheters 4-6 Fr

Intervention

Wires0.0140.035 for catheter placementGuiding SheathGuide CatheterBalloonsLow profileUndersized for pre-dilationStentsBalloon expandable (BES)119This is not an exhaustive list of devices that are used for both diagnostic and renal intervention.Renal Stents: FDA Status Cordis Palmaz Balloon Expandable Stents FDA approved for use following sub-optimal PTRA of a de novo or restenotic lesion (< 22 mm in length) located within 10 mm of the aorto-renal artery border and with a reference vessel diameter of > 4mm and < 8mm Medtronic Bridge Extra Support Balloon Expandable Stent System FDA approved for use following sub-optimal PTRA of a de novo (< 15 mm in length) located within 10 mm of the aorto-renal artery border and with a reference vessel diameter of > 5mm and < 7mm Palmaz is a trademark of Cordis Corp.Bridge is a trademark of Medtronic AVE Inc.120Their are two FDA approved stents currently on the market.

First, the Cordis Palmaz Stents - the first stent and the stent that remains the gold standard in terms of clinical support and a newcomer the Medtronic Bridge stent.Renal artery stenting1. Catheter or sheath placement 2. Guide wire (0.014) insertion. Rosen wire has soft curled end- ideal- prevents perforating small renal branch vessels3.Stent placement -> as soon as the tip reach the lesion GC is pulled back into the Aorta4.Stent deployment, proximal struts should protrude 1-2mm into the aorta5. Flaring the ostium of the stent ( optional), opens the way for re-intervention and covers the plaque in the aorta

no touch technique, the guide catheter seeks out the ostium with the help of 2 wires

Advances in Treatment of AortoiliacOcclusions

Inability to cross an occlusion with a guidewire or to reenter the true lumen beyond the occlusion remains the most common cause for technical failure

Front Runner deviceCrosser catheterReentry devicesThe Frontrunner (Cordis) or Quickcross catheters are designed to maintain the wire in the center of the lumen and penetrate the plaque and/or thrombus in a controlled fashion

Subintimal dissection plane buckling a glide wire the subintimal plane is enteredFollowing with an angled glide catheter-re-enter the lumen distal to the obstruction This step is the limiting factor Adjuncts - Outback or Pioneer catheter which allow an angled needle to puncture back into the true lumenFRONTRUNNERXP CTO Catheter (cordis) Enables controlled crossing of CTOs using blunt microdissection to create a channel through the occlusion to facilitate wire placement.

Low profile. Features a crossing profile of .039" with actuating jaws that open to 2.3 mm.Hydrophilic coating along the entire catheter length to facilitate crossingCatheter steerability.- shapeable distal tip + effective torque control enhance maneuverability and catheter steerabilityNo guidewire lumen.Variable support from advancing and retracting the 4.5F Micro Guide Catheter.

The crossing profile is 0.039 in with the jaws closed, reaches a maximum diameter of 2.3 mm with the jaws open, and is available in 90- and 140-cm lengths. The device does not have a guidewire lumen, and once a lesion is crossed, a dedicated MicroGuidecatheter is advanced over the FrontRunner catheter to its tip, andthe catheter is then withdrawn. A guidewire can then be placedthrough the MicroGuide over which further therapies such asballoons and stents may be delivered126

CROSSER Catheter (Flow Cardia Inc, Sunnyvale, Calif) High-frequency mechanical vibrations (20, 000 cycles/ second to a depth of 20 m) propagated through a nitinol core wire to a stainless steel tip A generator, transducer, foot switch, and disposable catheterGenerator applies AC current to the piezoelectric crystals in the transducer Vibrational mechanical impact and cavitational effects - penetration 1.1 mm in diameter, monorail, and hydrophilicCan be mounted on a standard 0.014 guidewireCompatible with a 6F guiding catheterVessel size- a minimum diameter of 2.5 mm is recommended

cordisLow profile, 6F sheath compatibleHighly visible "L" and "T" markers.Orient the re-entry cannula toward the true lumen easily, eliminating the need for additional visualization equipmentEffective torque controlOn average 8 minutes to gain re-entry ( procedure time)Lubricious, hydrophilic coating along the entire catheter length to facilitate subintimal passageEasy to use

CordisOUTBACK CATHETER (J&J, Cordis, New Brunswick, NJ, USA)

Pioneer reentry catheter (Medtronic)

Distal 25-gauge nitinol reentry needle 64-element phased-array IVUS transducer120 cm longaccomm -2 -0.014guidewires (1 to track the device and 1 for the reentry needle)Compatible with a 7F sheath

The device is brought into the subintimal tract over a wire, and under intravascular ultrasound imaging, color flow is identified in the true lumen The catheter is rotated to position the true lumen at the 12 oclock position, after which the needle is advanced and the true lumen is wiredAdvances in Balloon Angioplasty-BasedApproachesDrug-coated balloons

Cryoplasty

Cutting balloonsPaclitaxel is the most commonly used agent for drug-coatedballoons (DCBs)high local drug conc and # neointimal proliferation -brief exposure had lower late loss and angiographic restenosis at 6-month follow-up (17% vs 44% in the Thunder study; 19% vs 47%in FemPac)Drug-coated balloons

Occlusion,containement &Perfusion therapy low pressure balloon infusion maximizes drug penetration locally within the vesselB-L/10-50mm,DM-1-4mm134cm-Rapid ex40,80,90,140 cm -OTW

Cryoplasty (PolarCath, Boston Scientific)Combines angioplasty with simultaneous delivery of cold thermal energy to the arterial wallliquid nitrous oxide - balloon inflation/ cooling - 10CMOA-plaque modification, reduction of elastic recoil, and induction of apoptosis in the smooth muscle cells - dissection and need for stentingInsufficient data to support its routine use

Advances in Stent TechnologyDrug-eluting stents

Nitinol self-expanding stents

Bioabsorbable stents

Nitinol stent grafts and covered stents(cook)The Zilver PTX Drug-Eluting Stent is a self-expanding stent made of nitinol and coated with the drug paclitaxel

It is a flexible, slotted tube that is designed to provide support while maintaining flexibility in the vessel upon deployment The stent is preloaded in a 6.0 French delivery catheter

0.035 inch wire

recommended for use in above-the-knee femoropopliteal arteries having reference vessel diameter from 4 mm to 9 mm

Zilver PTX ( Cook) showed good results in TASC A/ B lesions(RESILIENT STUDY)

COOK Zilver 518 Vascular Self-Expanding nitinol Stent- iliac arteries

Recomm 5.0Frsheath/7.0Frguiding cath

Accepts .018 inch wire

Zilver 518 RXVascular Self-Expanding Nitinol Stent Rapid Exchange-iliac

Recommended 5.0Frsheath/7.0Frguiding catheter

Accepts .018 inch diameter wire guide.

Zilver 635Vascular Self-Expanding Nitinol Stent

Recommended 6.0Frsheath/8.0Frguiding catheter size

Accepts .035 inch diameter wire guide

Absolute Pro LL Peripheral Self-Expanding Stent (ABBOT)035designed to treat longer SFA lesions120,150

Absolute Pro LLXpert Self-Expanding Stent(ABBOT)4F compatible -speci designed for small vesselsPeri vessels from D 2-7 mm018Nitinollow strut profileConformability

Self-Ex: S.M.A.R.T. CONTROL Iliac(cordis)MicroMesh Geometry, Segmented Design

Nitinol

12 Tantalum MicroMarkers define stent ends for easy visualization and placement

Stent D 6-10, 12, 14mm (should be 1-2mm >vessel D)

80,120 cm

Maximum Guidewire .035"

Sheath Compatibility 6F (6-10mm), 7F (12-14mm)

Guide Compatibility 8F (6-10mm), 9F (12-14mm) 4-year follow-up patency rates 79% TLR free after 4 years 59% Binary Restenosis free after 4 years (lowest published)The lowest published binary restenosis data of any self-expanding nitinolstent in SFA at 4-year follow-up, leading to the highest patency rates 79% of patients TLR free after 4 years 59% of patients Binary Restenosis free after 4 years2

144Self-Ex: PRECISE Carotid Stent System(cordis)MicroMesh Geometry, Segmented DesignNitinolStent D 5-10mm135cm, Over-the-WireMaximum Guidewire .018"Sheath Compatibility 5.5F (5-8mm diameters), 6F (9-10mm diameters)Guide Compatibility 7F (5-8mm diameters), 8F (9-10mm diameters)Self-Ex: PRECISE PRO RX Carotid Stent (cordis)MicroMesh Geometry, Segmented DesignNitinolStent Diameters 5-10mm135cm, Rapid ExchangeMaximum Guidewire .014"Sheath Compatibility 5F (5-8mm diameters), 6F (9-10mm diameters)Guide Compatibility 7F (5-8mm diameters), 8F (9-10mm diametersAstron-biotronik

Self-Expanding Nitinol Stent 0.035 / OTW

AstronPulsar-Biotronik

Self-Expanding Nitinol Stent OTW

For treatment of diseases of femoral and infrapopliteal arteries.

Self-expanding stent to the peripheral vasculature via a sheathed delivery systemFlexibte mesh tube made from NitinolIntended to improve luminal diameter in the treatment of symptomatic de-novo or restenotic lesions up to 240 mm in length in the native superficial femoral artery and proximal popliteal artery with reference vessel diameters ranging from 4.0-6.5 mm

Covered Stents

GORE

Jostent Peripheral Stent Graft (Abbot)

High grade surgical stainless steel 316L PTFE Graft materialRecommended minimum sheath size- introducer size that is two sizes larger than the sheath size

Wall thickness after expansion Standard version: 0.40 mm Large version: .45 mmMinimal crimped outer diameter Standard version: 2.3 mm = 7F Large version: 2..7 mm = 8F

Minimal deployment pressure4 bar

Biocompatibility, the ability of a material to induce a normal response within a host

Biodegradation, a biological agent like an enzyme or a microbe is the dominant component in the degradation process. Biodegradable implants are usually useful forshort-term or temporary applicationsBioresorption and bioabsorption imply that the degradation products areremoved by cellular activity, such as phagocytosis, in abiological environment

Bioerodible polymer is a water-insoluble polymer that has been converted under physiological conditions into water-solublematerials Polylactide and trimethylene carbonate

KYOTO-MED GP-JAPANBiodegradable polymer PLLA (poly-L-lactic acid)Characteristics of being dissolved into water and carbon dioxide and absorbed into vessel tissue within a few years after implantation

Metal allergies or pats who are still growing

Will not interfere with other procedures such as restenting/Sx

More useful for containing drugs compared to metal stent- intended as a platform for drug eluting stents.

Advances in Plaque Removal or DebulkingExcimer laser

Excisional and rotational atherectomyExcimer laser

The 308-nm excimer laser -fiberoptic catheters to deliver intense bursts of ultraviolet energy in short pulse durationsThe adv of uv light short penetration depth of 50 m break molecular bonds directly by a photochemicalprocess ability to ablate thrombus and to inhibit platelet aggregation.

Removes a tissue layer of 10 m with each pulse of energy.Ablated only on contact without a rise in temp to surrounding tissueAbility to treat long occlusions and complex disease

SPECTRANETICSTurbo Elitelaser catheters utilize ultraviolet light to vaporize arterial blockages into particles,most of which are smaller than a red blood cell.Treat Above-the-KneeTotal OcclusionsLong Diffuse DiseaseTreat Below-the-KneeTotal OcclusionsLong Diffuse DiseaseTreat Lesions ComprisingMultiple MorphologiesAtheromaFibrosisCalciumPlaque

Combining a laser guide catheter with an excimer laser atherectomy catheterangled ramp allows for circumferential guidance and positioning of the laser catheter within the vessel

SilverHawk Plaque Excision System (Fox Hollow Technologies)

cutter blade (long arrow) luminal plaques (small arrow) Plaques are excised (double arrows) High-speed cutting blade excises a ribbon of plaque that is collected into the catheter nose cone.7 different sizesmonorail catheters meant for rapid exchange and operate over a 0.014-inch diameter wire systemctivation of the SilverHawk catheter enables the cutter blade (long arrow) to appose the vessel wall plaques. B, By slowly advancing the SilverHawk atherectomy catheter in a forward fashion, the rotating cutting blade excises the luminal plaques (small arrow) and stores them in the distal nosecone chamber. C, Plaques are excised (double arrows) by rotating the catheter in various directions, which allows circumferential debulking of the luminal lesions159ROTATIONAL ATHERECTOMY DEVICES Pathway Medical PV system (Pathway Medical Technologies,Redmond, Wash) expandable, rotating scraping blades (flutes) ports between the flutes that allow flushing and aspiration of plaque material/thrombus

The Orbital Atherectomy System (Cardiovascular Systems,St Paul, Minn) high-speed rotational atherectomy system eccentric, diamond-coated abrasive crown When rotated at high speeds, the abrasive crown moves in an orbital path within the artery, potentially creating a lumen larger than the diameter of the crown

Pathway Jet Stream Device

BRIDGING THE GAP: ROLE OF HYBRIDPROCEDURESMultilevel peripheral arterial occlusive disease

Older patients with several comorbidities

Common examples of hybrid procedures include common femoral artery endarterectomy combined with angioplasty of the iliac or SFA

Comparable outcomes to open surgical procedures, but with decreased length of stay, morbidity, and mortalityHybrid procedure for CFA/SFA dis

THANKYOU

Antegrade puncture of the patent popliteal artery and successful crossing of the native SFA

Vascular AccessSAFARI Technique (Subintimal Arterial Flossing with AntegradeRetrograde Intervention)

Useful for completing subintimal recanalization when there is failure to re-enter distal true lumen from antegrade approach or limited target artery available for re-entry

Technique improves technical success with subintimal recanalization

Limb salvage rates comparable to those with antegrade subintimal recanalization

Reference?Below the Knee ToolsStiff, steerable guidewire

Infrapopliteal PTA Balloon Catheter OTW 0.014

Infrapopliteal Co-Cr Stent System OTW 0.014

Infrapopliteal 0.014 Guidewire

Infrapopliteal self-expanding Stent System OTW

CrossabilityCrossing occlusionsAvoiding abrasion, damage and risk of dissectionBail-out situationsDedicated long stent systemsLow-profile OTW balloon with suitable sizes in balloon length and diameter.LONG BALLOONS

Drug eluting BalloonRestenosis prevention

Paclitaxel-eluting PTA balloon catheter169International slide...Only Ampherion Deep is available in the US