Aorto-Iliac Interventions GOTHI Training

Aorto-Iliac Interventions : 

Aorto-Iliac Interventions GOTHI Endovascular Training Course

Surgical revascularization : 

Surgical revascularization Good patency Operative mortality 3.3 % Systemic morbidity 8.3% Ref:Metanalysis Devries JVS ,1997,26:558-69

Advantage of Endovascular over Vascular surgery in Aorto-Iliac segment : 

Advantage of Endovascular over Vascular surgery in Aorto-Iliac segment No General anaesthesia Less access trauma Lower mortality and morbidity Less infection Recurrent treatment is easy, not like surgery. No affection to male sexual dysfunction The option of surgery is still valid if failed More attractive opption to patient than surgery

Indications : : 

Indications : Nearly all manifestations of Atheosclerotic aorto-iliac dissease can be considered as potentially suitable for endoluminal treatment . Claudication Rest pain Gangrene and tissue loss Blue toe syndrome . Vasculogenic empotence.

Classification : : 

Classification : TASK Classification Task A Task B Task C Task D

Equipements : 

Equipements Hight resolution parrallel panning fluoroscopy , with surgical operating facility Patient monitoring facility IVUS Operative Duplex facility Wires ,Balloons , stents , sheath’s,and embolization devices different shapes and sizes .

Technique : (1) Medication : 

Technique : (1) Medication Aspirin Plavix Heparin Cardiac medication

Technique : (2) Thrombolysis : 

Technique : (2) Thrombolysis Streptikinase Urokinase r.TPA Has to be catheter directed Can be used from 1-6 months old occlusions

Technique : (3) Recanalization : 

Technique : (3) Recanalization Wire Catheter combination Intentional Intraluminal or subintimal

Technique : (4) Balloon dilatation : 

Technique : (4) Balloon dilatation Kissing technique versus hugging technique . Usually for 1 min intervals at high pressure if using high pressure balloon Always use inflation device In subintimal use rapid inflation deflation device

Technique (5) Stent deployment : 

Technique (5) Stent deployment Balloon expandable stent to osteal lesion , Self expandable to other lesions , Stent must cover the whole lesion . Accurate placement is a must Use hugging stent instead of kissing ones

Post-intervention : : 

Post-intervention : Aspirin Ticlopedin or plavix Heparin or LMWH

Complications : : 

Complications : Dissection Embolization Perforation Conversion to occlusion Wound haematoma Pseudoaneurysm

Technical tips : 

Technical tips Increased complexity will increase the risk of complications. You need to understand each complication associated with each lesion type. Anneurysmal dissease and diffuse dissease will increase risk of embolization Chronic occlusion will increase the risk or perforation or rupture .

Tools for complications : 

Tools for complications Snare. Covered stents. Occlusion balloon Long Sheaths Detachable balloon Coils

Technical tips : 

Technical tips Plan access and intervention rather than Ad hoc dilatation to a complex lesions. Consider alternative access or additional access in ball out strategy Smaller system may avoid obstructive or thrombotic complications Avoid stent CFA or across profunda .Know your landing zone .

Technical tips : 

Technical tips Intervene on proximal aortic segment first Use bilateral iliac access approach

Cases : 

Cases

What we do for aorto-iliac dissease : 

What we do for aorto-iliac dissease Percutaneous , surgery for extensive dissease which is declining Iliac occlusion =iliac stent Thrombolysis unnecessay Bilateral iliac access Transbrachial for subintimal route Ipsilateral 80% or contra, transbrachial

What we do for aorto-iliac dissease : 

What we do for aorto-iliac dissease 6 F.sheath 0.035 system Ninitinol stent 90% Unersiziing balloon dilatation

Conclusion : 

Conclusion There is multiple ways of approaching lesion ,they can be correct ,one is better Technical improvements in stents , balloons devices allowed treating more complex lesions Always be ready with the bailout plan.

Slide 37: 

Thank You