CORIDS ALEXANDRIA 2011

Cordis Alexandria 2011 : 

Cordis Alexandria 2011 Mr. Mohamed Omar Elfarok ,M.Sc, FRCSENG, FRCSED

Conventional Subintimal angioplasty : 

Conventional Subintimal angioplasty

Leg Medical session : 

Leg Medical session Step by Step Procedure Product Selection Procedural  Challenges & Complications Access strategies Learning objectives of this session

Step by Step Procedure : 

Step by Step Procedure

Basic structure of intervention: : 

Basic structure of intervention: Initialization Main interventional cycle termination

Initialization: : 

Initialization: Assess the patient , indication and clinical condition Assess the access site , previous scar , pulse quality Assess images to inflow , ouflow , lesion and access site Have plane A and B Prepare tools and run a mental senario

Main interventional cycle : 

Main interventional cycle It is three steps , Assess , Intervene , Repeat You can use telescopic system , 0.014 wire or 0.035 platform Cross over technique is preferred to ipsi-lateral approach in most cases

Steps: : 

Steps: 8F Sheath to contralateral CFA at zone 2 Cross the aortic bifurcation with RIM,or SOS-OMNI-HOOK , HOCKY STICK or even PIGTAIL Pass Terumo or normal wire to the other side Put cross over GC 8 F and park on the CFA Assess with angiogram

Steps: : 

Steps: Try to cross the lesion with 0.035 or 0.014 wire platform You can reinforce the wire with Balloon or Catheter or the GC or telescopic system The nearer to the lesion the more success you will get Gentle maneuvers is advisable and study the wire behavior After crossing the lesion either put a catheter or Balloon to make sure that you are intra-luminal

Steps: : 

Steps: Park the wire to politeal artery and always be ware of the distal end of your wire The guidewire tip should not pass distal to part II of the popliteal artery to avoid distal injury Balloon dilatation with different techniques Assess with angiogram or duplex and repeat the cycle

Steps: : 

Steps: Always try to be intraluminal and subintimal if every thing failed SFA dissease usually starts with adductor canal region and extends in both directions If you want to go inside a stent make the wire in a form of a loop Injection of Hep-Saline may facilitate micro-chanels

Termination : 

Termination Success when you have residual stenosis of <30% following plain balloon angioplasty and of <20% following stenting has been achieved The termination criteria may be modified in patients undergoing palliative interventions (improvement of collateral circulation) as opposed to curative interventions (reconstitution of the vascular anatomy). Retraction of tools should be done safely

After care and follow up : 

After care and follow up Continue double antiplatelet therapy Sheath removed from 2-4 hours Mobilization after 4-6 hours Follow-up with clinical and duplex monitoring

SFA : 

SFA The most common cause of claudication Adductor canal area is unique Always treat upstream lesion first Focal stenosis does not necessarly means focal dissease. 14 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Best results in : 

Best results in Male Non diabetic Non smocker Large vessel diameter Short lesion Tasc A 15 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Access sites : 

Access sites Contralateral Ipsilateral Popliteal Transbrachial

Potential difficulties : 

Potential difficulties Huge habitus Subcutaneous scarring Vascular calcifications Atherosclerotic occlusion Tortuosity Aneurysmal changes Bypass graft

Questions to ask before you start ? : 

Questions to ask before you start ? Access site possible What target size vessel State of collateral Durtion of occlusion Bleeding risk Distal vessel situation Any proximal lesion 18 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Access : 

Access Nearly always contralateral Safer for the patient Much easier than antegrade No post-procedure compression Does not impede flow in the SFA

Wire choices : 

Wire choices Terumo 0.035 260 cm stiff looks for braches , good for subintimal 0.035 PTFE J shaped tip 260 cm wire travels in the main artery 0.035 Amplatz wire for calcified artery 0.018 V 18 wire as stiff as 0.035 20 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Antegrade puncture : 

Antegrade puncture Higher risk of complications Improve wire control Difficult in Obese patients Can cause retroperitoneal haematoma Few tricks

Popliteal approach : 

Popliteal approach The backdoor to SFA Very deep , vein posterolateral Has risk of bleeding and compartement syndrome Use duplex mapping , or angio with road map

“May I please be excused? My brain is full!” : 

“May I please be excused? My brain is full!”

Go Back : 

Go Back

Product selection : 

Product selection

Basis of tools selection : 

Basis of tools selection What plat form to use Which access to use Which technique to use Tools for CTO Tools for re-entery Tools for complications

Technical tips : 

Technical tips Iliac platform is 0.035 SFA platform changed from 0.035 to 0.014 Tibial platform is 0.014 Telescopic system is helpful Frontrunner is one of the best CTO devices Outback is difficult to use but better than pioner catheter

Slide 30: 

Consider consultant preferences Check tools of Sinario A , B and failure of A and B Give any tools around 15 min to try before changing to another tool

Examples : 

Examples SFA intervention from cross over what tools? SFA intervention from ipsilateral what tools? Tibial intervention from cross over what tools? Iliac intervemtion from cross over what tools

Go Back : 

Go Back

Procedural  Challenges & Complications : 

Procedural  Challenges & Complications

Common pitfalls are : : 

Common pitfalls are : Wrong indications Wrong timing Wrong imaging Wrong place of intervention Wrong access Wrong tools Wrong procedure

Wrong indications ? : 

Wrong indications ? Try to stick to TASC indications of A, and B in the first 20 cases Avoid high risk lesions in Stable Claudicant patient . He might get worse Tibial artery interventions only in CLI and or rest pain

Wrong imaging ? : 

Wrong imaging ? Correlate duplex and angiography with clinical data Do not intervene on images older than one month even with this you get surprises MRI angiogram is not accurate in below the knee arteries Iliac and SFA lesions will not give good data on tibial arteries Angiogram is only two dimensional images

Standard imaging protocol for peripheral DSA : 

Standard imaging protocol for peripheral DSA 38

Standard imaging protocol for peripheral DSA : 

Standard imaging protocol for peripheral DSA

Standard imaging protocol for peripheral DSA : 

Standard imaging protocol for peripheral DSA Adapted from Pattynama PMT. X-ray peripheral and visceral angiography. In Lanzer P, Topol EJ, eds. PanVasular Medicine: Integrated Clinical Management. New York: Springer-Verlag, 2002:636-658.

Wrong place of intervention ? : 

Wrong place of intervention ? Every angio-suit has certain capabilities. Do not do major procedure in a small unit . Always try to be near to surgical , coronary and intensive care unit . Do not do Carotid and Renal interventions in a new Angiosuit with new staff

Wrong tools ? : 

Wrong tools ? Always be ready with a strategy A, and B Prepare the tools yourself before you start Check the compatibility of sheath, GC and Stent systems Have more than one type of catheter for cross over or other maneuvers Prepare for the worse and hope for the best Have tools of complications ready as snairs , covered stent ,embolization devices

Wrong timing : 

Wrong timing Avoid acute arterial lesions less than 12 weeks history Every patient have the best timing Be away from any cardiac or renal or pulmonary insult Make sure that there is nothing that can be done to improve patient pre-intervention

Wrong access ? : 

Wrong access ? Difficult access try to have duplex mapping or intelligent needle or cross over technique Convert retrograde to ante grade access is a useful tool Transbrachial access is good for iliacs and SFA zone one only but nothing further down Cross over is good till middle third tibials and not further down Ipsilateral is good for technique for tibials and paedal interventions Popliteal and tibial access is a very useful tool

Wrong procedure ? : 

Wrong procedure ? Iliac occlusion = iliac stenting Always be ready with stenting even in the most innocent looking lesion Correct proximal lesion first Try to get a direct flow to the foot with at least one tibial vessel

If you can not see it well you can not treat it well : 

If you can not see it well you can not treat it well There are many images that are below diagnositc quality Always ask yourself is this enough images Iliac plaque to known to be in the posterior plan and needs lateral veiws

Definition of Complications in Peripheral Arterial Interventions : 

Definition of Complications in Peripheral Arterial Interventions Minor: A. No therapy, no consequence,    B. Nominal therapy, no consequence; includes overnight admission for observation only Major: C. Require therapy, minor hospitalization (<48 h)     D. Require major therapy, unplanned increase in level of care, prolonged hospitalization      F. Result in death Reproduced with permission from Sacks D, Marinelli DL, Martin LG, et al. Reporting standards for clinical evaluation of new peripheral arterial revascularization devices. J Vasc Intervent Radiol. 1997;8:137-149.

Incidence of Complications of Peripheral Arterial Interventions, Data Based on Early Evidence : 

Incidence of Complications of Peripheral Arterial Interventions, Data Based on Early Evidence PUNCTURE SITE (TOTAL) 4.0 Bleeding 3.4 False aneurysm 0.5 Arteriovenous fistula 0.1 ANGIOPLASTY SITE (TOTAL) 3.5 Thrombus 3.2 Rupture 0.3 DISTAL VESSEL (TOTAL) 2.7 Dissection 0.4 Embolization 2.3 SYSTEMIC (TOTAL) 0.4 Renal failure 0.2 Myocardial infarction (fatal) 0.2 Cerebrovascular accident (fatal) 0.55 CONSEQUENCES   Surgical repair 2.0 Limb loss 0.2 Mortality 0.2 Reproduced with permission from Pentecoast MJ, Criqui MH, Dorros G, et al. Guidelines for peripheral percutaneous transluminal angio-plasty of the abdominal aorta and lower extremity vessels. A statement for health professionals from a Special Writing Group of the Councils on Cardiovascular Radiology, Arteriosclerosis, Cardio-thoracic and Vascular Surgery, Clinical Cardiology, and Epidemiology and Prevention, American Heart Association. Circulation. 1994;89:511-531. 48

Conclusion : 

Conclusion There are three types of interventionist . Always be ready for complications before they start Always inform the patient during consent about possible complications Ask for help early rather than late .

Go Back : 

Go Back

Access strategies : 

Access strategies

Types of Access in peripheral : 

Types of Access in peripheral Transfemoral retrogrde Transfemoral antegrade Transbrachial Transradial Transaxillary Transpopliteal Trans Tibials Trans SFA

The best access : 

The best access There is always more than one access There is always one access better than the other SFA intervention we shifted from transfemoral ipsilateral to contralateral due to excellent new tools

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Conventional Subintimal angioplasty : 

Conventional Subintimal angioplasty

CTO : 

CTO

Slide 59: 

Prevalence, Symptoms & Pathophysiology Conventional Subintimal angioplasty New devices

CTOPrevalence , symptoms and pathophysiology : 

CTOPrevalence , symptoms and pathophysiology

Definitions : 

Definitions What is CTO IS it the correct name

Circulatory System Disease : 

Circulatory System Disease The single major cause of artery disease is the thickening and hardening of arterial walls by deposits of fatty materials, known as arteriosclerosis.

Arteriosclerosis : 

Arteriosclerosis Vascular disease, which affects the brain, heart, kidneys, other vital organs, and extremities, is the leading cause of morbidity and mortality in the USA and in most Western countries. There were almost 1 million deaths due to vascular disease in the USA in 1994 (twice as many as from cancer and 10 times as many as from accidents). CAD and ischemic stroke combined are the number one killer in industrialized Western countries and are of increasing prevalence in the rest of the world. The death rate from CAD among white men aged 25 to 34 is about 1/10,000; at age 55 to 64, it is nearly 1/100. The death rate from CAD among white men aged 35 to 44 is 6.1 times that among age-matched white women.

Arteriosclerosis : 

Arteriosclerosis Atherosclerosis is a disease of the arteries in which fatty material is deposited in the vessel wall, resulting in narrowing and eventual impairment of blood flow. Severely restricted blood flow in the arteries to the heart muscle leads to symptoms such as chest pain. Atherosclerosis shows no symptoms until a complication occurs.

Arteriosclerosis : 

Arteriosclerosis

“May I please be excused? My brain is full!” : 

“May I please be excused? My brain is full!”

Go Back : 

Go Back

New Endovascular tools 2010 : 

New Endovascular tools 2010

Topics to be covered : 

Topics to be covered - Advancing fields in vascular surgery - Recent developments in new equipments - How to chose new tools . - Conclusion .

Advances are in the following fields : : 

Advances are in the following fields :

Better Tools : : 

Better Tools : Surgery have reached a standardization of tools and techniques with a very predictable results Endovascular Surgery did not , it is rapidly evolving

EVOLVING TECHNOLOGY AND STRATEGY : 

EVOLVING TECHNOLOGY AND STRATEGY

Guide wire Technology : 

Guide wire Technology

There is microchanels in any occlusion : 

There is microchanels in any occlusion

1-Cross -IT XT Wire: Tapering Tip : 

1-Cross -IT XT Wire: Tapering Tip

2-Miracle series : 

2-Miracle series

Confienza Wire (Conquest) : 

Confienza Wire (Conquest)

3-Steerable GW STEER-IT CORDIS : 

3-Steerable GW STEER-IT CORDIS

4-OCR Waveform display : 

4-OCR Waveform display

PT2 coronary GW : 

PT2 coronary GW

NEXT GENERATION GW : 

NEXT GENERATION GW

What is inside : 

What is inside

Success of different GW : 

Success of different GW

Ablative technology : 

Ablative technology 1-Excimer Laser 2-Ultrasoud (therapeutic) 3-Radiofrequency ablation

2-Omniwave Technology : 

2-Omniwave Technology OmniWaveTechnology is the first technology that delivers controlled acoustic energy along the active section of a flexible 0.004section of a flexible .0025”wire

2-Omniwave technology : 

2-Omniwave technology

Mechanical technology : 

Mechanical technology 1-Blunt microdissection Fruntrunner catheter 2-Flowcardia crosser 3-Fibrinolysis Trellis 4-Demineralization collagenase Mechanical Tech.

1-Frontrunner : 

1-Frontrunner Controlled Blunt Micro-Dissection Technique

Fruntrunner Catheter : : 

Fruntrunner Catheter :

2-Flow cardia crosser system : 

2-Flow cardia crosser system High frequency mechanical revascularization Monorail and OTW, 0.0140.014””wire and 6 Fr guide compatible wire Straight and angled tip configurations

Re-Entry technology : 

Re-Entry technology 1-Percutaneous bypass 2-Re-Entry devices Re-Entry Technology

Pioneer Catheter : : 

Pioneer Catheter : This 6 Fr 130 cm long catheter has a tapered tip which integrates a nitinol curved needle with a phased array intravascular transducer.

Outback catheter : : 

Outback catheter :

Conclusion : 

Conclusion 1- In new technology do not be the first and also do not wait too long 2-No center can buy everything but a wise surgeon gets what he needs 3-30% of these devices will end in the museum and history of medicine do not do not buy these 30% 4- GW technology is easy to apply

Slide 96: 

Science advances, not by the accumulation of new facts, but by the continuous development of new concepts. - Dr. James Bryant Conant (1893–1978) American chemist, diplomat, & educator

Go Back : 

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Cordis venous session : 

Cordis venous session

Slide 100: 

VTE disease state Venous procedure Indications / Contraindications

I.V.C. Filter : 

I.V.C. Filter

History : 

History John Hunter Ligated femoral vein 1784 . Bottini IVC ligation 1893. IVC suture , Stappling were developed 1930 . Mobin-Uddin umbrella was developed 1951 .

Absolute Indications : 

Absolute Indications DVT ,PE in a patient with contraindication to anticoagulation . Recurrent DVT, PE despite adequate anticoagulation . Complication of anticoagulation . After pulmonary embolectomy . Failure of another form of caval interruption with recurrent PE .

Relative Indication : 

Relative Indication A large free floating ilio-femoral thrombus . Propagation of ilio-femoral DVT despite adequate anticoagulation . Chronic PE in patient with cor pulmonale or pulmonary hypertension . More than 50 % occlusion of pulmonary vascular bed . Recurrent septic embolism .

Pulmonary Embolism : 

Pulmonary Embolism Is a common dissease . Is a lethal dissease . Is a preventable dissease .

Shapes : 

Shapes Cone shaped Bird’s Nest Coils Double barrel With or without hooks 70% filled with clot only 50% cross diameter reduction . 80% filled with clot to have pressure difference.

Technical Considerations : 

Technical Considerations Venous access under local anesthesia . Passing a guide wire and venography to IVC (less than 30mm , patent ) Inf-rarenal positioning The right way (femoral – Jugular ) Filter deployment . Check venography .

Access : 

Access Femoral Jugular Cephalic

Filter Placement : 

Filter Placement Infrarenal Suprarenal Superior Vena Caval filter

Durability : 

Durability Permanent Filter Temporary Filter Filter retrieval System

Problems : 

Problems Mal-alignment . Filter Migration . Filter occlusion . Filter perforation . Infection . Incomplete opening . Upside down configuration

Aim : 

Aim Prevent fatal pulmonary emboli not all PE There is a recurrent PE rate with each type .

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TECHNIQUES OF I.V.C FILTER DEPLOYMENT & PITFALLS : 

TECHNIQUES OF I.V.C FILTER DEPLOYMENT & PITFALLS Mr.Mohamed Omar El-Farok M.Scm FRCS

Topics to be covered: : 

Topics to be covered: Techniques of IVC filter placement . Difficulties in venous access Difficulties in size of IVC Difficulties in tortuous iliac vein Difficulties in upside down deployment Difficulties in Misalignment Difficulties in deployment mechanism 117 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Technique of IVC filter placement: : 

Technique of IVC filter placement: Pre-operative workup Venous access puncture Pass GW to IVC then IVC filter sheath Check venogram Filter deployment Completiong venogram Followup-plan Mr.Mohamed Omar El-Farok M.Sc, FRCS 118

Difficulties in venous access : 

Difficulties in venous access Always do venous duplex scan to both femoral veins and internal jugular veins Some filters can be deployed through femoral , jugular and cephalic route One can use occluded vein as an access for IVC filter placement if you have to First use femoral pulse as a landmark and then bone landmark if failed then duplex guided if all failed 119 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Steps in Ultrasound Guided Venous Puncture (Access) : 

Steps in Ultrasound Guided Venous Puncture (Access) Examine planned access vein with ultrasound If one cannot work through thrombosed/occluded vein, consider another access site Prep and drape site of access vein Localize skin entry point over vein access point Anesthetize skin and make incision large for tools to pass through and blunt dissect soft tissues tract Enter vein with access needle under ultrasound Can use syringe with suction to look for blood flashback to confirm vein entry It may be helpful to use a Valsalva maneuver to distend the vein Pass guidewire via needle into vein Troubleshoot as needed 120 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Duplex guided vein puncture: : 

Duplex guided vein puncture: 121 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Troubleshooting Guidewire Difficulties : 

Troubleshooting Guidewire Difficulties If the guidewire does not pass easily : Double wall puncture (bevel beyond back wall). Ultrasound may show this. Pull wire back into needle. Pull needle back into lumen. Readvance guidewire Single puncture of front wall. Ultrasound may show this (bevel indenting front wall) Advance needle until it penetrate into lumen and advance guidewire Bevel partially in lumen. This can give blood return. Advance needle marginally and try readvancing guidewire 122 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Resistance after advancing guidewire a short distance : 

Resistance after advancing guidewire a short distance Guidewire in side branch (Fluoroscopy reveals unexpected course of guidewire) Pull back guidewire and redirect under fluoroscopy Guidewire against unexpected stenosis/occlusion (Fluoroscopy shows guide looping back on itself/deflected into unexpected course) Advance sheath or catheter over wire and perform venogram to define anatomy/pathology 123 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Some IVC filters permanent : 

Some IVC filters permanent 124 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Some IVC filters temporary : 

Some IVC filters temporary 125 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Preoperative Workup and Planning : 

Preoperative Workup and Planning Review the clinical data to determine which group of filters to use (see the later section on filters) and examine the patient to determine what access site is available for use. It is good to match the access site to the filter required. Any available imaging should be reviewed, such as an abdominal CT scan, to get some information relating to possible variant IVC anatomy. In a morbidly obese patient, where the fluoroscopy table weight limit is exceeded, plan to use IVUS guidance for placement. 126 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Different Scenarios of IVC placement : 

Different Scenarios of IVC placement If thrombus in IVC What to do ? Suprarenal filter (if no room in infrarenal IVC), or infrarenal filter above the clot 127 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Duplicate IVC what to do ? : 

Duplicate IVC what to do ? 1. One infrarenal filter in each IVC, or   2. Suprarenal filter. 128 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Accessory IVC (small IVC forming venous ring from level of iliac veins to renal veins) : 

Accessory IVC (small IVC forming venous ring from level of iliac veins to renal veins) 1. Place filter in main IVC and embolize the accessory IVC with coils. 129 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Circumaortic left renal vein (forming venous ring from normal renal vein via hilum into inferior aspect of infrarenal IVC) : 

Circumaortic left renal vein (forming venous ring from normal renal vein via hilum into inferior aspect of infrarenal IVC) 1. If room permits place filter below IVC opening of circumaortic vein, or   2. Suprarenal filter. 130 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Retro aortic renal vein (single left renal vein that empties lower in IVC) : 

Retro aortic renal vein (single left renal vein that empties lower in IVC) 1. Infrarenal IVC filter below vein orifice if there is room, or   2. Filter in each iliac vein. 131 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Mega-Cava (IVC diameter >28 mm) : 

Mega-Cava (IVC diameter >28 mm) 1. Place a bird's nest filter in infrarenal IVC, or   2. One filter in each common iliac vein. 132 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Pregnant woman : 

Pregnant woman 1. Suprarenal filter 133 Mr.Mohamed Omar El-Farok M.Sc, FRCS

SVC filter needed (points to keep in mind) : 

SVC filter needed (points to keep in mind) Keep apex of filter out of RA Position legs of filter above azygos if possible Avoid bird's nest filter (components will prolapse into RA) 134 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Occluded filter what to do? : 

Occluded filter what to do? Filter occlusion (no intervention in asymptomatic patient) 135 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Symptomatic IVC filter thrombosis : 

Symptomatic IVC filter thrombosis Pharmacologic thrombolysis/anticoagulation Mechanical thrombolysis (especially if AC contraindicated) to restore flow Suprarenal IVC filter 136 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Filter migration inferiorly into iliac veins : 

Filter migration inferiorly into iliac veins Place second filter above in IVC 137 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Filter migration superiorly into RA/PA : 

Filter migration superiorly into RA/PA If possible attempt percutaneous filter retrieval/repositioning or Consult cardiac surgery for removal 138 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Filter failure : 

Filter failure Place second filter below 1st if there is room, or Suprarenal IVC filter, or SVC filter (if upper extremity source) 139 Mr.Mohamed Omar El-Farok M.Sc, FRCS

Thank You : 

Thank You 140 Mr.Mohamed Omar El-Farok M.Sc, FRCS

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