management of distal peripheral vascular disease

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Management of distal peripheral vascular disease. Cheuk Kwan Yee, Queenie Tuen Mun Hospital. In the past. Below knee disease ---- >. Recently. Our centre. Perform endovascular procedures for infrapopliteal disease since Feb 2011 13 cases Post-op mortality : 7.7% - PowerPoint PPT Presentation

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  • Management of distal peripheral vascular diseaseCheuk Kwan Yee, QueenieTuen Mun Hospital

  • In the past.Below knee disease ---- >

  • Recently.

  • Our centrePerform endovascular procedures for infrapopliteal disease since Feb 2011

    13 cases

    Post-op mortality : 7.7%Limb Salvage Rate : 84.6%

  • Infra-popliteal diseaseEndovascular tools

    Angiosome

  • CFASFAProfundus

  • Popliteal a.ATATibioperoneal trunk

  • ATAPeroneal a.PTA

  • ATA

  • R ATATibioperoneal trunkPeroneal a.PTA

  • 0.018 cordis guidewire

  • Balloon Angioplasty

  • CompletionAngiogram

  • Pre-opPost-op

  • Post-op

  • Post-op

  • EndovascularStudies for infrapopliteal disease Single centerSmall patient sizeNon randomized

    Comparable amputation free survival Isolated infrapopliteal revascularization : Endovascular -> better leg salvage

    BASIL trial : what are its implications, Seminar in vascular surgery, Bradbury et al 2009Tibial intervention for CLI, Wiechmann et al, Seminars in interventional radiology, vol26 no.4 2009Treatment of lower extremity vessels disease, Annals of Surgery vol246, no.3, Sept 2007, DeRubertis et al

  • Endovascular approachGlobal technical success= Direct flow to pedal arches Residual stenosis
  • Endovascular approachRestenosis :Immediate elastic recoil of vesselMyointimal hyperplasiaLate vascular remodelling

    Compromised runoff =>early restenosis /reocclusion

  • BalloonsPlain Balloon Angioplasty

    Peripheral Cutting Balloon4 atherotomes

    Drug-Coated BalloonMore durable biological effect (By small centre studies)

    Drug-coated balloons for the prevention of vascular restenosis. Gray et al, Circulation June 2010

  • Bare Metal StentEliminate:early abrupt vessel closureelastic recoilnegative vessel remodelling

    6m 24m Limb salvage 94 82 Amp free survival 80 62

    Problems may arise Stent-assisted below the ankle angioplasty for limb salvage, Kawarada et al, Journal of Endovascular therapy, 2011:18:32-42

  • Drug-eluting Stentinhibit restenosisReview of small scale studies : sup to balloon expandable bare metalintervention free survivalpatency rateSimilar limb salvage rate

    Infrapopliteal angioplasty with drug-eluting stents : from heart to toe , siablis et al, Journal of Endovascular therapy( 2010:17: 488-491)Prime time for infrapopliteal drug eluting stents, Journal of Endovascular therapy, phoenix Apr 2002Primary use of sirolimus-eluting stents in the infrapopliteal arteries, Rastan et al,Journal of Endovascular therapy 2010 : 17:480-487

  • No sig diff in amputation free survival

    Stent : insignificant but higher limb salvage rate

    Below the ankle angioplasty : to stent or not to stent, Journal of Endovascular therapy 2011: 18:43-45Endovascular Mx as 1st therapy for chronic total occlusion of the lower extremity arteries : Comparison of balloon angioplasty, stenting and directional atherectomy ; Journal of Endovascular therapy 2011;18:624-637VS

  • Other new endovascular toolsNitinol stenting

    Atherectomy

    Cryotherapy

    Long term outcomes and risk stratification of patency following nitinol stenting in the femoropopliteal seg : retrospective multicenter analysis, lida et al, Journal of Endovascular therapy phoenix : Dec 2011 vol18 iss6

    Cryoplasty for peripheral vascular disease , cochrane collaborationCryoplasty for PAD in an unselected patient population in a tertiary centre, Silva et al, Texas Heart Institute Journalliquid nitrous oxideResist external compression forces

  • Where to attack ??~~ANGIOSOME~~

  • Where to attack ??3-D vascular territories Supplied by specific source arteries Drained by specific veinsAngiosomes of the leg;anatomic study and clinical implications, pleastic reconstruction surgery 1998 Sep 102(3) 599-616ANGIOSOME

  • AngiosomePosterior tibial arteryAnterior tibial arteryPeroneal artery

  • Angiosome-oriented angioplastyClinical success of endovascular approach : dilation of all critical inflow lesions with residual stenosis < 30% straight line outflow in at least one tibial vessel to the pedal arch

    Angiosome-oriented angioplasty : Revascularize target vessels according to angiosome concept

  • Angiosome-oriented angioplastyMultiple single centre studies: Angiosome-oriented angioplasty : improved overall limb salvage 90 VS 84 at 1 year, 89 VS 79 at 3 year

    Limitation : Variations of angiosomes Non-randomized studiesFailure to cannulate target vessel

    Revascularization of a specific angiosome for limb salvage : does the target artery matter?A reliable approach to diabetic neuroischemic foot wounds : below the knee angiosome-oriented angioplasty, Alexandescu et al; Journal of Endovascular therapy 2011;18: 376-387

  • Bring Home MessagesNew era for endovascular proceduresEmerging new technologiesHolistic and tailor made pre-op planning + post-op MxAngiosome-oriented angioplasty

  • Thank You !!THANK YOU !!!

    *Paclitaxel : bind to beta subunit of tubulin -> arrest of microtuble function, prolonged tissue retention, sustainable structural modification of SM cells*partial/complete stent compression, stent #, subluxation stent #

    *Small single centre series, Non controlled cohorts, Linimted FU

    *Patients factor, comorbidity, estimated survival time