SCAI CHAP 34 Aorta and PVD Flashcards
What is the prevalence of obstructive disease of the major aortic arch vessels supplying the upper extremities?
It affects up to 7% of individuals in select populations.
What are the common causes of subclavian and brachiocephalic disease?
Atherosclerotic disease, fibromuscular dysplasia, medium- and large-vessel vasculitides, thoracic outlet syndrome, or radiation-induced disease. Non-atherosclerotic disease usually cause more distal lesions than atherosclerotic disease. The latter cause predominantly ostial or proximal lesions.
Where is subclavian and brachiocephalic atherosclerotic disease predominantly located?
It is predominantly ostial or proximal in location.
What are the symptoms of subclavian obstruction?
Arm claudication, which manifests as fatigue, paresthesia, or pain during exertion.
What additional symptoms may arise from proximal left subclavian artery stenosis?
Symptoms of vertebrobasilar insufficiency when the left vertebral artery flow is affected or angina when the left internal mammary artery (LIMA) has been used for CABG.
When is revascularization of the brachiocephalic or subclavian arteries indicated?
In the presence of significant symptoms like arm claudication, vertebrobasilar insufficiency, or angina.
Is subclavian artery revascularization appropriate when the LIMA is required for CABG surgery?
Yes, empiric revascularization of left subclavian artery stenosis is appropriate even in the absence of symptoms.
Should isolated identification of flow reversal in the vertebral artery ( common finding on Doppler ultrasound), prompt revascularization in asymptomatic patients?
No, it should not prompt revascularization unless the internal mammary is needed for arterial bypass.
What is the success rate of percutaneous revascularization of the subclavian and brachiocephalic arteries?
> 95% of cases
Mostly used for atherosclerotic lesions.
What do the American College of Rheumatology guidelines recommend in the presence of vasculitis of subclavian artery or brachiocephalic artery?
Recommend against invasive therapy and favor medical management and escalation of immunosuppression unless there is risk to life or organ function, refractory hypertension, or significant impact on activities.
Elevated surgical risk due to the nature of the disease.
What did single-center data report about endovascular treatment of Takayasu arteritis?
Subclavian lesions had lower late success rates and required more interventions compared to other lesions ( aortic, axillary, mesenteric, renal, iliac )
Likely due to the usually long and diffuse nature of the disease , in the subclavian artery. So even if it’s feasible, you have to exercise caution before considering intervention.
What is the most common approach for subclavian or brachiocephalic revascularization??
There are no randomized trials comparing stent to open revascularization.
The femoral approach is most often utilized.
Brachial or radial access may facilitate treatment of chronic total occlusions (CTOs) also when it is difficult to localize origin of the subclavian from the aortic arch. Also, when it is difficult to maintain catheter support from femoral access.
What type of stents are generally used for ostial and proximal lesions?
Balloon-expandable stents (BESs) are generally used.
Because Radial ((radius) force is desirable in these regions , also ostial and proximal subclavian segments are not subject to external compression.
What type of stents may be preferred for distal subclavian lesions?
Self-expanding stents (SESs) may be preferred.
It accommodates for the increased mobility of the subclavian vessel in the distal segments .
What should be considered if a lesion is just distal to the origin of the mammary or vertebral arteries?
Brachial or radial access should be considered to avoid covering the origins of these vessels.
What should be considered a devastating complication of subclavian artery revascularization?
Atheroembolization ! It can occur due to the direct route to the cerebral circulation through the vertebral artery.
What do some operators advocate during treatment of bulky or angiographically ‘worrisome’ lesions?
The use of cerebral embolic protection.
No convincing data are available to validate this strategy.
What is the success rate of percutaneous revascularization of the subclavian and brachiocephalic arteries?
Successful in >95% of cases and mostly used for atherosclerotic lesions.
What do the American College of Rheumatology guidelines recommend for vasculitis?
Recommend against invasive therapy and favor medical management and escalation of immunosuppression unless there is risk to life or organ function, refractory hypertension, or significant impact on patient activities.
What is noted about the success rate of endovascular treatment of Takayasu arteritis?
Subclavian lesions had lower late success rates and required more interventions compared to other lesions.
What is the most common approach for revascularization?
The femoral approach is most often utilized.
What types of stents are generally used for ostial and proximal lesions?
Balloon-expandable stents (BESs) are generally used because radial force is desirable.
What type of stents may be preferred for distal lesions?
Self-expanding stents (SESs) may be preferred to accommodate increased mobility of the vessels.
What complication can occur due to atheroembolization?
Atheroembolization represents a devastating potential complication and can occur due to the direct route to the cerebral circulation through the vertebral artery.
What do some operators advocate for during treatment of bulky subclavian or brachiocephalic lesions?
Advocate the use of cerebral embolic protection, but no convincing data are available to validate this strategy.
Draw a motif for right subclavian stenosis before and after stent.
What is aortic coarctation?
A discrete narrowing of the thoracic aorta that occurs near the ligamentum arteriosum.
How common is aortic coarctation?
It is the sixth most common form of congenital heart disease.
What are common associations with aortic coarctation?
It commonly occurs with other congenital lesions, especially bicuspid aortic valves.
What are the manifestations of coarctation in children and adults?
Most commonly manifested as hypertension and brachial-femoral artery pulse delay.
What risks are associated with unrepaired coarctation?
Increased risk of cardiovascular events, including stroke, heart failure, and death.
When is repair recommended for coarctation?
When there is a gradient of >20 mm Hg across the segment of coarctation. it is usually performed either endovascular or surgical repair.
What should be considered if collateral flow is significant across the segment of coarctation?
Intervention may be considered in lower gradient states (lower than 20 mmHg)
What are the acceptable modes of therapy for coarctation?
Surgical repair and endovascular angioplasty.
When is surgical repair preferred for coarctation?
For those with compelling anatomical indications such as branch artery involvement or large aneurysmal dilatation.
What is a significant concern with angioplasty with coarctation?
It is associated with significant recurrence rates; primary stenting is therefore preferred(not balloon only).
What follow-up is recommended after coarctation repair?
Annual follow-up with thoracic aortic imaging at regular intervals.
There is usually high risk of aneurysm formation following surgical repair or endovascular treatment of coarctation. The risk is usually significant.
What are acute aortic syndromes?
Acute aortic syndromes include aortic dissection, intramural hematoma, aortic pseudoaneurysm, and penetrating aortic ulcer.
How are aortic dissections classified?
Aortic dissections are classified as type A (proximal tear in the ascending aorta or arch) or type B (distal to the left subclavian artery).
What does intramural hematoma represent?
Intramural hematoma represents the presence of an aortic wall hematoma in the absence of an intimal tear.
What causes most aortic pseudoaneurysms?
Most aortic pseudoaneurysms occur as a result of blunt trauma, such as following a motor vehicle accident.
When do penetrating aortic ulcers typically occur?
Penetrating aortic ulcers tend to occur among patients with advanced atherosclerotic disease.
What represents a surgical emergency in aortic dissection?
The presence of a type A aortic dissection represents a surgical emergency.
How is type B aortic dissection managed?
The management of type B dissection depends on the presence of distal organ malperfusion, such as renal dysfunction, mesenteric ischemia, or limb ischemia.
What is the focus of medical management for descending thoracic acute aortic syndromes?
The focus is on meticulous control of blood pressure to minimize subsequent extension of the dissection flap.
What may be considered for type B aortic dissection with malperfusion?
Thoracic endovascular aortic repair (TEVAR) with a covered stent graft may be considered to cover the site of the tear.
What percentage of patients with type B aortic dissection managed conservatively develop complications?
Approximately 25% to 30% develop aneurysmal degeneration of the aorta or extension of the dissection during the ensuing 5 years, requiring endovascular repair.
What percentage of all aortic aneurysms do thoracic aortic aneurysms (TAAs) comprise?
Approximately one-third of all aortic aneurysms.
What are some etiologies of thoracic aortic aneurysms (TAAs)?
Atherosclerotic disease, aneurysmal progression at a site of prior dissection, and predisposing genetic disease states such as Marfan syndrome.
How are the majority of thoracic aortic aneurysms (TAAs) detected?
They are usually asymptomatic and detected on ultrasound or by computed tomography (CT) scan.
What are the indications for repair of a thoracic aortic aneurysm (TAA)?
A symptomatic TAA, an asymptomatic ascending TAA of 5 to 6 cm, or an asymptomatic descending TAA of 6 to 7 cm diameter.
Why might patients with genetic etiologies benefit from earlier repair of TAAs?
Due to the natural history of continued progression. They are saying once you reach the threshold above, consider earlier repair in patients with genetic etiology .
How are the majority of !! ascending !! thoracic aortic aneurysms (TAAs) repaired?
They are repaired surgically.
What devices are being developed for future endovascular approaches to repair TAAs?
Branched and fenestrated stent graft devices.
How may the majority of !!descending!! thoracic aortic aneurysms (TAAs) be repaired?
They may be repaired with TEVAR stent grafts.
What is the prevalence of abdominal aortic aneurysm (AAA)?
AAA is a prevalent condition that poses a significant risk of death from rupture.
What are the classic associated risk factors for AAA?
Tobacco use, Caucasian race, and male gender.
How is diabetes related to AAA?
Diabetes is associated with a reduced rate of AAA.
What are the current recommendations for AAA screening in males?
A one-time ❗️ultrasound screening for AAA is recommended in males ❗️aged 65 to 74 ❗️with a history of smoking❗️.
Who else should be screened for AAA according to societal guidelines?
Patients with a family history of AAA, regardless of gender or smoking history.
What do the most recent guidelines from the Society of Vascular Medicine suggest?
Screening for AAA in first-degree relatives of patients who present with an AAA.
What is the age range for first-degree relatives to be screened for AAA?
Screening should be performed in first-degree relatives who are between 65 and 75 years of age or if older than 75 years and in good health.
What was historically considered the standard of care for AAA?
Open surgical repair.
What is the current preferred method for AAA repair?
Endovascular aneurysm repair (EVAR) has been utilized in the majority of cases due to its lower periprocedural risk.
When should repair be considered for AAA?
For AAA larger than 5.5 cm, AAA that are expanding rapidly (>0.5 cm over 6 months), or for those of any size that are symptomatic.
What imaging modality is recommended for abdominal aortic aneurysm screening and surveillance?
Ultrasound is recommended as the preferred imaging modality when feasible.
What do the most recent guidelines from the Society of Vascular Surgery suggest for abdominal aortic aneurysm repair decision making?
The guidelines suggest using the Vascular Quality Initiative (VQI) mortality risk score (class IIC) in conjunction with mutual decision making with patients.
What are the requirements for elective EVAR for abdominal aortic aneurysm, according to the guidelines?
Elective EVAR should be limited to hospitals with a documented mortality and conversion rate to open surgical repair of <2% and that perform at least 10 EVAR cases each year.
What are the requirements for open elective abdominal aortic aneurysm repair according to the guidelines?
Open elective aneurysm repair should be limited to hospitals with a mortality of <5% and that perform at least 10 open aortic operations every year.
What is EVAR and who is it a reasonable option for?
EVAR is a reasonable option for those at high risk for open repair of abdominal aortic aneurysm with suitable anatomy.
What do the guidelines recommend for other patients (not at high risk for open repair ) regarding abdominal aortic aneurysm repair?
For other patients, the guidelines recommend making decisions based on the VQI score.
What do the major randomized trials indicate about EVAR compared to surgical revascularization?
The trials indicate that EVAR is associated with lower short-term mortality than surgical revascularization, but long-term mortality is similar between treatment groups.
What is the rate of reintervention associated with EVAR at 5-year follow-up?
EVAR is associated with a higher rate of reintervention , compared to surgical repair, approaching 25% at 5-year follow-up. this is based on many trials utilizing older STENT graft devices.
What may improve technical success and lower rates of long-term reintervention in EVAR?
Newer-generation stent graft devices may improve technical success and are likely associated with lower rates of long-term reintervention.
What percentage of AAA patients in the US are treated with EVAR?
Approximately 80% of patients with AAA in the United States are treated with EVAR.
What factors may favor open surgery over EVAR in AAA ?
Factors include complex anatomy not amenable to endovascular repair, young age, and patients less willing to maintain close follow-up.
What are the components of devices used for endovascular treatment of AAA?
Devices are comprised of SESs with interwoven fabric to exclude the aneurysmal segment and suprarenal fixation to prevent device migration.
How have sheath sizes for EVAR devices changed over time?
The sheath sizes of these devices have decreased over time, allowing for a fully percutaneous approach.
What is the purpose of ‘preclosure’ in EVAR?
‘Preclosure’ involves a large suture-mediated closure device technique for management of the arteriotomy.
What is required for patients who undergo EVAR?
Patients require long-term surveillance to monitor for device failure.
Is long-term surveillance necessary for surgical repair of AAA?
Surveillance is generally not necessary for patients who undergo surgical repair.
What are the major long-term complications associated with EVAR?
Complications include type 1 endoleak and aneurysm expansion due to lack of an effective seal between the endograft and the aorta,
and type II endoleak and aneurysm expansion from persistent communication of collateral arteries with the aneurysm sack.
What is the preferred mechanism of repair for rupture aneurysms?
Endovascular repair is the preferred mechanism of repair according to current guidelines.
What is the recommended door to intervention time for rupture aneurysms?
A door to intervention time of less than 90 minutes is recommended.
What is the estimated prevalence of lower extremity PAD worldwide?
Lower extremity PAD is estimated to affect ≈236 million adults (5.6%) worldwide.
How much has the prevalence of PAD increased from 2000 to 2015?
The prevalence of PAD has increased by ≈45% globally from 2000 to 2015.
What percentage of patients with PAD are asymptomatic?
The majority of patients with PAD are asymptomatic.
What is the likelihood of requiring amputation for symptomatic PAD patients?
Fortunately, <4% of symptomatic patients will require amputation during long-term follow-up.
About 70 to 80% of symptomatic patients will have stable claudication symptoms otherwise.
What is the 1-year cumulative incidence for mortality and amputation in patients with chronic limb-threatening ischemia (CLTI)?
The 1-year cumulative incidence for mortality and amputation in CLTI patients is ~20%.
What is the 5-year cumulative incidence for mortality and amputation in patients with chronic limb-threatening ischemia (CLTI)?
The 5-year cumulative incidence for mortality and amputation in CLTI patients is ~50%.
What is the mainstay of therapy for PAD?
The mainstay of therapy for PAD includes risk factor modification: smoking cessation, cholesterol reduction, treatment of diabetes, antihypertensive therapy, and antiplatelet therapy.
What does conservative management for PAD include?
Conservative management includes hygienic and supportive measures, exercise conditioning, and pharmacotherapy for claudication.
Is endovascular therapy indicated for asymptomatic PAD patients?
Endovascular therapy is not indicated in patients with asymptomatic PAD. There is no evidence that symptomatic clinical outcome can be improved or prevented by prophylactic revascularization (endovascular surgical) and is not recommended in asymptomatic patients.
When is percutaneous revascularization of the lower extremities typically reserved?
Percutaneous revascularization is reserved for lifestyle-limiting symptoms that persist despite conservative measures or for limb-threatening ischemia (rest pain or tissue loss)
What segments should be treated first in patients with claudication?
Inflow disease (the more proximal segments) should be treated first for patients with claudication.
What is often necessary in cases of critical limb ischemia (CLI)?
In cases of CLI, multilevel intervention is often necessary to establish straight-line flow to the affected limb.
What is the purpose of the TransAtlantic Inter-Society Consensus (TASC) document?
To categorize “aortoiliac “ lesions and guide therapy.
What therapy is recommended for TASC A and B aortoilliac lesions?
Endovascular therapy.
What therapy is recommended for TASC D lesions?
Surgery.
What is recommended for TASC C lesions?
Individually tailored decisions.
How has the TASC classification system’s relevance changed?
It has become less relevant due to the evolution of endovascular technology and techniques for aortoilliac vessels .
What is the current approach for most lesion subsets in most aortoilliac patients?
Endovascular approaches are considered.
What is the patency rate for iliac artery when proceeding with stenting versus surgery?
Patency rates similar to that of surgery.
What should iliac artery stenting be used in conjunction with?
Exercise therapy.
I think PATENCY rates are similar to surgery when in conjunction with exercise.
What are the characteristics of TASC Category A ( A means endovascular therapy is recommended usually not surgery.) aortoilliac lesions?
Unilateral or bilateral stenosis of CIA ( common iliac artery )
unilateral or bilateral stenoses of EIA or external iliac artery (<3 cm)
What are the characteristics of TASC Category B ( endovascular preferred ) lesions?
Stenosis of infrarenal aorta (<3 cm),
unilateral CIA occlusion,
stenoses of EIA 3-10 cm in length not involving CFA,
unilateral EIA occlusion not involving IIA or CFA
What are the characteristics of TASC Category aortoilliac C lesions?
Bilateral CIA occlusions, bilateral EIA stenoses 3-10 cm in length, unilateral EIA stenosis extending into CFA, unilateral EIA occlusion involving IIA or CFA, heavily calcified unilateral EIA occlusion
What are the characteristics of TASC Category D aortoilliac lesions?
Infrarenal aortoiliac occlusion, diffuse aortic and bilateral CIA disease requiring treatment, multiple stenoses involving CIA, EIA, and CFA, unilateral occlusion of CIA and EIA, bilateral EIA occlusions, iliac stenoses with AAA that are not amenable to endograft placement
Draw a schematic map about treatment of aortoilliac stenosis based on TASC approach
Stenosis and Occlusion Classification]
|
+—> [A] endovascular treatment recommended
| |
| +—> [Unilateral/Bilateral CIA Stenosis]
| +—> [Unilateral/Bilateral EIA Stenoses <3 cm]
|
+—> [B] endovascular recommended
| |
| +—> [Stenosis of Infrarenal Aorta <3 cm]
| +—> [Unilateral CIA Occlusion]
| +—> [EIA Stenoses 3-10 cm (not involving CFA)]
| +—> [Unilateral EIA Occlusion (not involving IIA or CFA)]
|
+—> [C] endovascular or surgery
| |
| +—> [Bilateral CIA Occlusions]
| +—> [Bilateral EIA Stenoses 3-10 cm]
| +—> [Unilateral EIA Stenosis (extending into CFA)]
| +—> [Unilateral EIA Occlusion (involving IIA or CFA)]
| +—> [Heavily Calcified Unilateral EIA Occlusion]
|
+—> [D] surgery recommended
|
+—> [Infrarenal Aortoiliac Occlusion]
+—> [Diffuse Aortic and Bilateral CIA Disease]
+—> [Multiple Stenoses (CIA, EIA, CFA)]
+—> [Unilateral Occlusion (CIA and EIA)]
+—> [Bilateral EIA Occlusions]
+—> [Iliac Stenoses with AAA (not amenable to endograft)]
Draw the anatomy of the POPLITEAL and TIBIAL ARTERIES WITH BIFURCATIONS
Draw the anatomy of iliac arteries down to the tibial arteries
What is TASC Category A for Femoropopliteal?
Single stenosis <10 cm, occlusion <5 cm
What is TASC Category B for Femoropopliteal?
Multiple stenoses each <5 cm,
stenosis or occlusion <15 cm not involving infrageniculate popliteal artery (genicular artery supplies blood to the knee joint),
single or multiple lesions in the absence of continuous tibial vessel with an attempt to improve distal (distal to the stenosis) bypass inflow,
heavily calcified occlusion <5 cm,
single popliteal stenosis
What is TASC Category C for Femoropopliteal?
Multiple stenoses or occlusions >15 cm,
recurrent disease needing treatment
What is TASC Category D for Femoropopliteal?
Occlusions >20 cm of CFA or SFA involving popliteal artery,
occlusion of popliteal and proximal trifurcation vessels
What is TASC Category A for Infrapopliteal?
Single stenosis <5 cm in the target tibial artery
What is TASC Category B for Infrapopliteal?
Multiple stenoses, each <5 cm in length, or total length <10 cm or single occlusion <3 cm in length in the target tibial artery
What is TASC Category C for Infrapopliteal?
Multiple stenoses in the target tibial artery and/or single occlusion with total lesion length >10 cm
What is TASC Category D for Infrapopliteal?
Multiple occlusions involving the target tibial artery with total lesion length >10 cm or dense lesion calcification or nonvisualization of collaterals. The other tibial arteries are occluded or have dense calcification
What was the primary endpoint of the CLEVER trial?
Improvement in peak walking time at 6 months. The trial randomized 100 patients with symptomatic AORTOILIAC stenosis to medical therapy or with supervised exercise program or STENT.
What were the results of the peak walking time improvement in the CLEVER trial?
Supervised exercise program: 5.8 ± 4.6 minutes greater than baseline;
Stenting: 3.7 ± 4.9 minutes;
Optimal medical therapy: 1.2 ± 2.6 minutes.
Which treatment showed the highest improvement in peak walking time in the CLEVER trial?
Supervised exercise program.
Which treatment had a greater number of patients achieving improvement in quality of life in the CLEVER trial?
Stenting.
What was the primary finding of the ERASE trial? The trial randomize 200 patients with AORTOILIAC or FP disease and symptomatic claudication to exercise therapy alone or exercise therapy plus ENDOVASCULAR revascularization.
Combination therapy (exercise therapy plus endovascular revascularization) significantly improved maximum walking distance compared to exercise therapy alone. it also improves pain-free walking distance.
What were the maximum walking distances in the ERASE trial for combination therapy versus exercise therapy alone?
Combination therapy: 264-1501 m;
Exercise therapy alone: 285-1240 m.
The two trials above suggest that revascularization and supervised exercise therapy are complementary among patients with lifestyle limiting CLAUDICATION .
What is the optimal strategy for arterial access in aortoiliac disease interventions?
It depends on the characteristics and location of the lesion.
What access method is used for entire reconstruction of the aortoiliac bifurcation?
❗️Bilateral femoral access. This will allow simultaneous bilateral iliac stent placement and kissing, balloon post dilation.
What access is desired when treating unilateral disease within the proximal iliac system? for example , common iliac.
Ipsilateral access. Ipsilateral access will allow retrograde delivery of the balloon and STENT.
Contralateral approach is difficult because of the acute band of the aortoiliac bifurcation and the challenge in establishing adequate coaxial support to deliver a balloon and stent to a lesion that is proximal in the common iliac artery. ❗️
When is contralateral access preferred in aortoiliac interventions?
When the target lesion is in the distal common or external iliac artery.
Contralateral access is also very helpful in particular when external iliac disease extends distal to the common femoral artery which usually compromises ipsilateral sheath placement.
What should be considered when using radial or pedal access for management of aortoiliac lesions?
Limited bail out and covered stent options with adequate length to reach radial to peripheral.
In summary, here is the text and please fill in the blank:
The optimal strategy for arterial access in patients undergoing intervention for aortoiliac disease depends on the __________ and location of the lesion to be addressed.
If entire reconstruction of the aortoiliac bifurcation is required, __________ femoral access is employed to permit simultaneous bilateral iliac stent placement and “kissing” balloon postdilation.
When treating unilateral disease within the proximal iliac system, such as the common iliac, __________ access is desired to permit retrograde delivery of balloons and stents.
The contralateral approach may be more difficult because of the acute bend of the aortoiliac bifurcation and the associated challenges in establishing adequate __________ support.
If the target lesion is in the distal common or external iliac artery, __________ access may be preferred, especially when external iliac disease extends distally to the common femoral region.
With the advent of radial and pedal devices, in select cases, __________ access can be sufficient for management of these lesions.
One should be mindful of the limited bail out and covered stent options with adequate length to reach __________ to peripheral.
The optimal strategy for arterial access in patients undergoing intervention for aortoiliac disease depends on the characteristics and location of the lesion to be addressed.
If entire reconstruction of the aortoiliac bifurcation is required, bilateral femoral access is employed to permit simultaneous bilateral iliac stent placement and “kissing” balloon postdilation.
When treating unilateral disease within the proximal iliac system, such as the common iliac, ipsilateral access is desired to permit retrograde delivery of balloons and stents.
The contralateral approach may be more difficult because of the acute bend of the aortoiliac bifurcation and the associated challenges in establishing adequate coaxial support.
If the target lesion is in the distal common or external iliac artery, contralateral access may be preferred, especially when external iliac disease extends distally to the common femoral region.
With the advent of radial and pedal devices, in select cases, radial access can be sufficient for management of these lesions. One should be mindful of the limited bail out and covered stent options with adequate length to reach radial to peripheral.
What is the primary treatment for the majority of iliac lesions?
The majority of iliac lesions are treated with stent placement.
What alternative treatment may be used for shorter and anatomically simple iliac lesions?
Shorter and anatomically simple lesions may be treated with balloon angioplasty alone.
What are the outcomes of PTA with provisional stenting versus primary stenting in simple TASC A and B lesions?
PTA with provisional stenting versus primary stenting has similar technical success, symptomatic improvement, quality of life, and long-term patency.
What did a meta-analysis involving over 2000 patients reveal about stenting in the treatment of iliac lesions
Stenting resulted in a 43% decrease in failure rates over a period of 4 years compared to using PTA alone, hence primary stenting strategy is preferred.
What type of stents are preferred for treating common iliac and proximal external iliac lesions?
Ballon expandable stents (BESs) are preferred due to their superior radial strength and more predictable delivery.
In which vascular segments might the flexibility of SESs outweigh their inferior radial strength?
In vascular segments near the femoral region, which are prone to flexion and extrinsic compression. The superior flexibility of self expendable stent, outweighs the slightly inferior regional strength compared with balloon expendable stent.
What were the findings of the ICE trial comparing BES to SES?
SES had lower restenosis (6.1% vs 14.9%, P = .006) and target lesion revascularization (6.9% vs 3%, P = .041) at 12 months compared to BES, except in patients with heavy calcification.
What are the two types of peripheral stents?
Stents can be classified as covered versus uncovered stents.
What materials line covered stents?
Covered stents comprise a metallic scaffold lined with polytetrafluoroethylene or Dacron material.
Why are covered stents preferred in calcific disease?
Covered stents are preferred in calcific disease as they offer an added safety measure against arterial rupture from expansion of calcified segments.
What is the potential benefit of covered stents?
Covered stents have a decreased potential for restenosis by preventing intrusion of underlying plaque in the lumen.
What are the risks associated with covered stents?
Covered stents carry a higher risk of thrombosis, edge restenosis, and obliterating side branches.
Have drug-coated balloons (DCBs) and drug-eluting stents (DESs) been evaluated for iliac lesions?
DCBs and DESs have not yet been evaluated systematically for iliac lesions.
What are the size limitations of DCBs and DESs for iliac lesion?
The largest available DCB is 7.0 mm and the largest DES is 8.0 mm in diameter. This could be a limiting factor for iliac STENTING.
This is a patient who presented with bilateral leg pain refractory to medical therapy and exercise. The picture shows severe stenosis in bilateral external iliac arteries. Patient had post dilation followed by SES stent placement measuring 8×40 mm on the right and the left. The procedure was performed using a left radial approach.
What is the nature of the FP arterial segment?
The FP arterial segment is long and relatively straight but is subjected to extrinsic compression from the thigh musculature and to flexion and torsion due to movement at the hip and knee joints.
What are common characteristics of disease within the FP arterial segment?
Disease within this segment is often calcific, diffuse, and frequently occlusive.
What classification system is used for FP lesions?
The TASC classification system describes FP lesions as type A, B, C, or D, corresponding to increasing anatomic complexity based on length, presence of occlusion, and territory involved.
What is the historical perception of TASC C and D lesions?
TASC C and D lesions have historically been regarded as ‘surgical disease’ due to the demanding technical approach required for complex stenoses and occlusions.
Why is endovascular therapy often avoided in the common femoral artery?
Endovascular therapy is often avoided because the common femoral artery is a valuable target for future peripheral bypass surgery, and placing a stent could ‘burn a bridge’ to important subsequent revascularization efforts.
What risks are associated with stenting in the common femoral artery?
The proximity of the hip joint and constant exposure to flexion increase the risk of stent fracture. on the other side, balloon angioplasty has very limited data for the treatment of common femoral artery.
Therefore open surgical interventions, including endarterectomy and bypass grafting have been traditionally used for the segment.
What is the traditional approach for treating common femoral disease?
Open surgical interventions, including endarterectomy and bypass grafting, have been traditionally used for this segment.
What is the first-line approach for the FP segment?
Endovascular therapy is generally the first-line approach ( excluding common femoral artery as discussed )
What is a major limitation of endovascular intervention in FP lesions?
Restenosis remains the major limitation.
What are the reported restenosis rates with balloon angioplasty alone for FP SEGMENTS ?
Restenosis rates as high as 63% at 1 year have been reported.
What were the outcomes with the use of BESs in FP lesions?
Poor outcomes were noted, likely due to extrinsic compressive forces.
What newer devices have been developed to improve long-term patency in FP segments?
Newer devices include DCBs (drug-coated balloons) and DES (drug-eluting stents).
How do DCBs work?
DCBs deliver lipophilic paclitaxel to the vessel wall during balloon inflation, exerting an antirestenotic effect.
What are the benefits of DCBs compared to primary angioplasty?
DCBs have demonstrated superior primary patency that is similar to nitinol SES and superior primary patency with lower target lesion revascularization, and need for repeat interventions, as compared to primary angioplasty, alone.
What may be necessary after DCB angioplasty for FP lesions ?
Focal stent placement may be necessary in cases of significant flow-limiting dissection or recoil.
What are the rates of bailout stenting in real-world studies for FP SEGMENTS after DCB angioplasty ?
The rates of bailout stenting are 10% to 20% and depend on the length of the lesion being treated.
What advantages do paclitaxel-eluting nitinol stents have over balloon angioplasty in FP lesions ?
They demonstrate superior patency and a long-term reduction in the need for reintervention.
What is the significance of nitinol-based SESs in treating nonfocal FP disease?
Multiple randomized trials have shown their superiority compared to balloon angioplasty with provisional stenting and superiority to BMS.
Head TO HEAD ANALYSIS OF DES AND DCB for FP lesions ARE LACKING. ❗️
What is a major reason for failure in FP endovascular therapy?
Failure to cross chronic total occlusions (CTOs), which occurs in approximately 30% of cases.
What is crucial for effective planning of CTO FP interventions?
Preintervention imaging and a comprehensive evaluation of the occlusion’s morphology.
What factors should be determined for a successful CTO intervention?
Location, lesion morphology, inflow and outflow vessels, and arterial supply to ischemic tissue.
What does the CTOP classification system categorize?
Proximal CTO cap morphology into four types: type I, II, III, and IV.
Type one has concave, proximal, and distal caps. ()
Type two has concave proximal and convex distal caps.((
Type three has convex proximal and concave distal caps.))
Type four has convex proximal and distal caps.)(
There are also other factors besides cap Morphology such as occluded segment length, proximal cap ambiguity, vessel course, and target vessel quality. They all impact the initial crossing strategy.
How are short or intermediate PCTOs with type I caps typically crossed? ()
They are usually crossed antegrade.
What approach is often used for long PCTOs with type IV caps? )(
They are often approached in a retrograde fashion.
What advanced methods may be required in challenging CTO cases?
Re-entry devices, controlled dissection re-entry, and rendezvous techniques. These techniques are helpful to access the true lumen.
What is the role of atherectomy in endovascular therapy ?
It is useful for debulking plaque in regions where stent placement is undesirable.
What is a drawback of surgical bypass in treating CTOs?
It has marginally better durability but poses a higher risk of cardiovascular risk and local adverse events , like local surgical wound infection.
What is the best approach for tapered CTO caps?
Initial antegrade approach is preferred for tapered caps while retrograde crossing can be considered if antegrade dissection reentry is unsuccessful, provided adequate distal access vessels, or interventional collaterals, are present.
Where is this lesion located and how was it treated?
Superficial femoral artery stenosis, CVA, sapphire, treated with lithotripsy and DCB.
What arteries are formed by the bifurcation of the popliteal artery BTK?
The popliteal artery bifurcates into the anterior tibial (AT) and tibioperoneal trunk, which gives rise to the posterior tibial (PT) and peroneal arteries.
What is the major blood supply to the foot?
The AT, PT, and peroneal arteries form the major blood supply to the foot.
What is CLTI? Chronic limb threatening ischemia
CLTI is defined as ischemic REST pain, tissue loss, or gangrene in the presence of PAD and hypoperfusion of the lower extremity for more than 2 weeks.
When is infrapopliteal revascularization typically performed?
Infrapopliteal revascularization is typically reserved for cases of CLTI. In contrast to iliac artery and FP arteries, were majority of interventions are performed for claudication, interventions on infra pop arteries are reserved to cases of CLTI.
perfusion requirements for wound healing greater than those for tissue integrity? True or false
Perfusion requirements for wound healing are much greater than those necessary to maintain tissue integrity.
Long-term tibial artery patency after intervention is not this important as long as patency has been durable enough to allow for ischemic ulcerations to heal.
Why is CLTI an important concept?
Long-term tibial vessel patency is less important as long as it has been durable enough to allow for ischemic ulcerations to heal. Perfusion requirements for wound healing are much greater than those required to maintain integrity of tissues.
What is recommended prior to amputation for a patient with CLTI?
It is imperative to consider a consultation with a multidisciplinary care team and comprehensive imaging prior to amputation.
What do the CLI Global Society guidelines recommend for limb salvage in the context of CLTI ?
The guidelines recommend optimizing limb salvage through endovascular therapy for CLI.
What was the limb salvage rate in a study of patients undergoing angioplasty for tibioperoneal stenosis in the context of CLI ?
The limb salvage rate was 91% among survivors at a mean follow-up of 34 months.
What is a central principle in the treatment of CLTI?
To re-establish a patent, straight line of blood flow from the heart to the foot, including at least one of the infrapopliteal vessels.
What is an angiosome?
A 3-dimensional anatomic block of tissue fed by a source artery, including skin, subcutaneous tissue, fascia, muscle, and bone.
How can revascularization strategies enhance wound healing for infrapopliteal arteries ?
By favoring the infrapopliteal artery correlated with the angiosome of tissue loss.
What should be the goal when direct flow to the angiosome is not possible?
To provide indirect flow via collaterals and optimize strategy for maximum pedal reconstruction. It is not clear if either strategies i.e. direct to the angiosome or via collaterals, lead to change in limb salvage rate.
What is the preferred access for infrapopliteal intervention?
Ipsilateral antegrade common femoral arterial access.
Infra Popliteal arteries are similar in caliber to coronaries so equipments and wires are similar.
What advantages does ipsilateral antegrade access offer?
Ipsilateral CFA access offers significant technical advantages for wire and catheter manipulation due to the short distance and straight access from groin to knee.
What is ‘pedal’ access?
Access through the dorsalis pedis or PT, important for treating FP or proximal infrapopliteal total occlusions.
What is the benefit of ipsilateral retrograde access through pedal access ?
It may offer an advantage to cross recalcitrant occlusions difficult to penetrate using antegrade CFA technique.
What is the risk associated with pedal access?
It may compromise flow in the accessed vessel, which may represent the only outflow to the foot.
What recent data supports the use of pedal access?
Recent multicenter data have supported the overall safety of this approach.
What equipment is commonly used for infrapopliteal interventions?
Narrow-caliber equipment, including 0.014-in wires, angioplasty balloons, and stent systems.
What is superior in infrapopliteal intervention for angiographic results and wound healing? DCB OR PTA ?
DCBs are superior to PTA alone.
When are stents used in infrapopliteal intervention?
Stents are reserved for rare cases of severely suboptimal angioplasty results or flow-limiting dissections.
What type of stents are preferred for infrapopliteal stenosis when implanted?
DESs are preferred.
What are the treatment options for patients with CLTI?
Patients with CLTI may be treated with surgical bypass or endovascular techniques.
What factors influence the individual patient approach for CLTI treatment?
The approach is based on anatomic feasibility of revascularization, presence of adequate vein for bypass, and patient comorbidities.
What did the BASIL trial compare?
The BASIL trial was a randomized study of surgical bypass versus balloon angioplasty for patients with CLI and FP disease.
What were the findings of the BASIL trial regarding amputation-free survival?
There was no significant difference in amputation-free survival or overall survival between surgical bypass and balloon angioplasty for the first 2 years.
What trend was observed in the BASIL trial after 2 years?
The curves started to separate in favor of bypass after 2 years.
Are the BASIL trial results generalizable to current endovascular techniques?
No, the results are not generalizable to current endovascular techniques.
What did the BEST CLI trial report?
The BEST CLI trial reported that surgical revascularization with a great saphenous venous conduit was superior to endovascular intervention in reducing major adverse limb events.
What factor influenced the superiority of surgical revascularization in the BEST CLI trial?
The superiority was mainly driven by the need for repeat procedures in the endovascular group.
What is the outcome for patients without a suitable vein for bypass in BEST CLI ?
In patients without a suitable vein for bypass, endovascular revascularization is similar if not better.
What did the BASIL-2 trial evaluate?
The BASIL-2 trial evaluated vein bypass compared with endovascular treatment among patients with CLTI due to infrapopliteal disease.
What was the result of the BASIL-2 trial?
The BASIL-2 trial reported superiority of endovascular treatment for infrapopliteal .
