basic endovascular surgery
DESCRIPTION
TRANSCRIPT
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Dr Imran Javed MBBS, FCPS Surgery.
Ex-International Fellow Arizona Heart Institute / Hospital, Phoenix, AZ, USA.
Ex-Senior Registrar Cardiovascular Surgery
Allama Iqbal Medical College/ Jinnah Hospital Lahore, Pakistan.
Basic Endovascular Surgery
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Basic Endovascular Surgery
Basics Instruments
•Needles
•Wires
•Catheters
•Sheaths
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Basic Endovascular Surgery
• Balloons
• Stents
• Stent Grafts
• Filters
• Thrombolytics
• Closure Devices
• IVUS
Common Interventions
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Endoluminal Therapy Offers Less Invasive Approaches, Thereby Justifying Intervention at
Earlier Stages in the Symptom/Disease Complex
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Classical Surgical Indications to
Treat Intermittent Claudication Are
Obsolete in Many Cases
Endoluminal Treatment Has Liberalized Indications For Intervention
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Origin of Endovascular Therapies
Crude… with only large shafted balloons, inflexible wires, etc.
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Indications for Interventional Therapy Have Forever Changed
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This is the 21st Century!!!
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We Are A People On The Move...
Modern Treatment Methods Must Accommodate Our Life Style
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Intermittent Claudication
• Absence of pain at rest
• Commencement of pain, tension
weakness after walking has begun;
intensification of condition until
walking becomes impossible
• Disappearance of symptoms after
a period of rest
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Post-Op Pre-Op
ABI 0.56
“Cool” Laser
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Interventional
Treatment Should Be
Reserved For The Most
Symptomatic Patients”
William R. Hiatt, M.D.
from Perler & Becker 1998
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Laser Therapy Created Excitement
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Hot Tip Created Excitement
but failed.
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The Atherocath Turned out to be a Good Biopsy Instrument
But… Believe it or not, a new generation is forthcoming
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Single Most Important Breakthrough!
The Palmaz Stent for Iliacs
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The Palmaz Shatz Stent for Coronaries
A Second Most Important Breakthrough!
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Overnight, Endoluminal Approaches Became the Standard of Practice in
Many Arterial Distributions
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Subclavian
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Renal
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Iliac
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Aorta
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and…
SFA
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Below
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The Achilles heel of angioplasty, including stenting:
Restenosis and In-stent
Restenosis
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New stent designs have decreased profile for delivery, increased
flexibility, and provided numerous alternatives in sizing -- but all of these failed to solve the restenosis problem
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Researchers are Seeking Solutions
Cutting Balloon
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Heparin Coated Stents
Conclusion:
No angiographic or
clinically related benefit
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Antibiotic Coated Stents (Actinomycin-D)
Conclusion: Trial Halted
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Naturally occurring antibiotic
coated stent. Sirolimus
Conclusion:
210 day trial, 120 pts, Coronary
0 InStent Restenosis
24 month trail, 45 pts, Coronary
0 InStent Restenosis
Cordis Velocity Stent
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Balanced Effect -
Healing of
Stented Vessel Inhibition of Restenosis
The ideal drug has higher potency for smooth muscle cells
(SMCs) and lower potency for endothelial cells (ECs).
Benefit/Risk Relation
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Investigations are extending into the peripheral circulation
Mobile Peripheral
Radiation Trial Sponsored by:
Novoste
Radiation to
Treat Instent
Restenosis
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9 Years post-percutaneous deployment of endoluminal graft
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THE SILVER HAWK SYSTEM
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SilverHawk Atherectomy
Remote Endarterectomy
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Cryoplasty
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And Cool Laser (Spectranetics) has Returned
Laser Therapy Only
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Beyond Occlusive Disease
Endovascular Attack on Aneurysms
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• The current standard procedure, endoaneurysmorraphy with intraluminal graft placement was popularized by Creech, DeBakey and associates
Abdominal Aortic Aneurysms
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• Parodi JC, Palmaz JC, Barone, MD
– Transfemoral intraluminal graft implantation for
abdominal aortic aneurysms
Ann. Vasc. Surgery, 1991, Nov.
Endovascular Stent Grafting of Abdominal Aortic Aneurysms
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Commercially Available AAA Endografts
2002
Excluder
Gore
2005 PowerLink
Endologix
2003
Zenith
Cook
1999
AneuRx
Medtronic
April 15,
2008
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If you had this 6cm infrarenal AAA,
would you prefer a 30cm xyphoid to pubis slice,
accompanied by perforations into veins, arteries and
other vital structures with needles, tubes, sheaths,
conduits, urinary catheter, etc?
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• Completion angiogram shows aneurysm exclusion
• Groins repaired
• Follow-up CTA reveals thrombosis of AAA sac
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Endoluminal Grafts (ELG’s) to Correct Aneurysmal Disease
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Abdominal Aortic Aneurysm Rupture
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Current Conclusions:
Excellent results when indications are appropriate
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Deviations
Yield Failures
Current Conclusions:
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Aorfix: Angulated Neck
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The Aptus System
• Venture backed start-up
• Graft with fixation applied via
staples
• Smaller delivery system
• Locking modular limbs
• Unsupported body
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ELGs have multiple advantages and when applied properly, results are equal or superior
to classical procedure
Current Conclusions:
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8mm Graft
Splenic
Anastomosis
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Fenestrated and Branched Endografts:
Courtesy David Hartley
The Next Frontier
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Thoracic Endoluminal Grafts
Another Important Application
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Great Vessel Transposition for Antegrade Delivery of
the TAG Endoprosthesis in the Proximal Aortic Arch
Edward B. Diethrich, MD; Marwan Ghazoul, MD;
Grayson H. Wheatley III, MD; Jeffrey B. Alpern, DO;
Julio A. Rodriguez-Lopez, MD; and Venkatesh Ramaiah, MD
Department of Cardiovascular and Endovascular Surgery
Arizona Heart Institute and Hospital, Phoenix, Arizona, USA
J. Endovas Therapy 2005
Surgical graft for
debranching
Endoluminal
graft
exclusion
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The Future Is Now!
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Another Area of Major Investigation
Cervical
Carotid Artery
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Cervical
Carotid
Artery
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Do or Will Cerebral Protection Devices Make a Difference in CAS?
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Refocusing Attention on Congestive Heart Failure
Major cause for hospital
admission
Multiple Approaches
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-Medical
-Surgical “patch”, cup, etc
Multiple Approaches
Refocusing Attention on Congestive Heart Failure
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But where is all of this
leading us?
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Shortly the Entire Human Genome Will be Available for
Treatment Selection
Risk Assessment
Prognosis
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Can you imagine the power of gene
identification for the care of patients in the future?
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VEGEF for Peripheral Vascular Disease
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Basic Endovascular Surgery
ANATOMY
1. Femoral
2. Brachial
3. Radial
4. Axillary
5. Popliteal
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Imaging System
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ACIST Pressure Injector
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Basic Endovascular Techniques
CONTRAST MEDIA
1. Ionic
2. Nonionic
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Basic Endovascular Surgery
CONTRAST MEDIA Contrast Agents Anion Cation
Ionic Agents
Renografin Diatrizoate Sodium, meglumine, or
Angiovist mixture of both salts
Hypaque
Conray Iothalamate Meglumine, sodium, or both
Low Osmolar Agents
Iohexol (Omnipaque) Nonionic dimer
Iopamidol (Isovue) Nonionic dimer
Ioxaglate (Hexabrix) Ioxaglate Meglumine and sodium
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Access Related Accessories
• Steering/Torque
devices
• Needles 18/21 GA
• Stopcocks
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Basic Endovascular Surgery
Diameter Maximum Guidewire Common
Needles (gauge) Diameter (in.) Length
Seldinger 18 0.038 2 ¾ inch
19 0.025
20 0.021
21 0.018
Potts 18 0.038 2 ¾ inch
20 0.021
Amplatz (with 5 Fr Teflon 18 18-gauge 2 ½ inch
sheath over cannula) 20 sheath accepts
0.038
Butterfly 19 0.028 Various
venipuncture 21 0.021
Jelco IV (with Teflon sheath) 18 0.035 Various
20 0.025
NEEDLES
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Basic Endovascular Surgery
Diameter Maximum Guidewire Common
Needles (gauge) Diameter (in.) Length
Syringe Needles 18 0.025 Various
20 0.021
21 0.018
Percutaneous Transhepatic 22 (black hub) 0.018 20 cm
Cholangiography 23 (green hub)
Sheath Needle 16G sheath 0.038 24 cm
(19-gauge
stylet)
NEEDLES
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Basic Endovascular Surgery
ACCESS
1. Femoral
2. Brachial
3. Axillary
4. Popliteal
5. Radial
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Basic Endovascular Surgery
ACCESS
1. Retrograde
2. Antegrade
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Basic Endovascular Surgery
ACCESS
1. Single Puncture
2. Double Puncture
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Guidewire Anatomy &
Construction • Composite construction
• Materials
– Stainless Steel
– Nitinol
– Jacketed Composite
• Tapered grinds
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• Core
• Stainless Steel
– Used for support
– Stiffness varies based on taper / diameter of core
• Nitinol
– Used for it’s flexibility, memory and kink resistance
• Tip
• Platinum / Gold
– Provides radiopacity
– Atraumatic
– Ribbon formed for shaping tip
Core Material
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• Core
• Stainless Steel
– Used for support
– Stiffness varies based on taper / diameter of core
• Nitinol
– Used for it’s flexibility, memory and kink resistance
• Tip
• Platinum / Gold
– Provides radiopacity
– Atraumatic
– Ribbon formed for shaping tip
Core Material
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• Core
• Stainless Steel
– Used for support
– Stiffness varies based on taper / diameter of core
• Nitinol
– Used for it’s flexibility, memory and kink resistance
• Tip
• Platinum / Gold
– Provides radiopacity
– Atraumatic
– Ribbon formed for shaping tip
Core Material
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Grind & Tip Performance
• Stiff
• Intermediate
• Floppy
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Variable Tip Grinds & Visibility
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Variable Grinds & Tip Stiffness
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Tip Shaping
• Shapeable tips
• Pre-shaped tips
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Dilators
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Sheaths
• Sheaths are hemostatic conduits inserted into the
vessel. They allow passage of guidewires, catheters
and interventional devices. The allows these to be
passed in and out of the body without damaging the
vessel and reducing the blood loss.
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Sheath Construction
Hemostatic Valve
3-Way Stopcock
Sheath Conduit
Dilator (obturator)
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Sheaths
• Peripheral and coronary sheaths have a universal color code
• Universal color coding
4 Fr = red
5 Fr = gray
6 Fr = green
7 Fr = orange
8 Fr = blue
9 Fr = black
10 Fr = violet
11 Fr = yellow
• Sheaths are measured inner diameter in french size (1fr =
.33mm)
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Basic Endovascular Surgery
CATHETERS
1. Straight - End holed
- Flush
2. Rim
3. JB2
4. IMA
5. Pig
6. Omni
7. Head Hunter
8. Simmons/VTEK
9. Cobra 2
10. Berenstein
11. Grollman
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Thoracic Endografting
The Future
Is Now !!!