ischemia critica degli arti inferiori trattamenti endovascolari · 2017-11-17 · strategy for...
TRANSCRIPT
Ischemia critica degli arti inferiori
Trattamenti endovascolari
Claudio Bianchini Massoni
Chirurgia Vascolare
DPT di Medicina e Chirurgia
Università Parma
AORTO-ILIACO
FEMORO-POPLITEO
SOTTOGENICOLARE
Vascular Surgery - University of Parma
Agenda
Quando trattamento endovascolare?
Linee guida
Casi clinici
Risultati
AORTO-ILIACO
FEMORO-POPLITEO
SOTTOGENICOLARE
Vascular Surgery - University of Parma
Agenda
Quando trattamento endovascolare?
• ESVS 2011
Eur J Vasc Endovasc Surg. 2011;42 Suppl 2:S43-59.
• SICVE 2015
It J Vasc Endovasc Surg. 2015;22(3 Suppl 2):25-68
• SVS 2016
J Vasc Surg 2016;63:3S-21S
AORTO-ILIACO
FEMORO-POPLITEO
SOTTOGENICOLARE
ESVS 2011
• Endovascular treatment can be considered a successful primary
strategy for patients with aorto-iliac lesions… Its major advantage
is its less invasiveness, characterized by a lower operative
morbidity-mortality. (Level 3; Grade C)
• …re-interventions may be performed percutaneously. (Level 5;
Grade D)
Vascular Surgery - University of Parma
Linee guida – Aorto-iliache
AORTO-ILIACO
FEMORO-POPLITEO
SOTTOGENICOLARE
SICVE 2015
• Nel paziente con ischemia critica cronica, arteriopatia obliterante
aorto-iliaca… il trattamento endovascolare è preferibile in caso di
lesioni non estese ed anatomia favorevole. Tuttavia in pazienti
con lesioni trofiche avanzate, anche in lesioni aorto-iliache
estese, un primo approccio endovascolare può essere indicato ai
fini di salvataggio d’arto immediato.
Vascular Surgery - University of Parma
Linee guida – Aorto-iliache
AORTO-ILIACO
FEMORO-POPLITEO
SOTTOGENICOLARE
Self-expandable stent
8x80mm
+ post-dilation (7x60mm)
TASC II: B
Vascular Surgery - University of Parma
Caso clinico - #1
AORTO-ILIACO
FEMORO-POPLITEO
SOTTOGENICOLARE
Kissing stent
(self-expandable 9x60mm)
+ kissing ballon
TASC II: C
Vascular Surgery - University of Parma
Caso clinico - #2
AORTO-ILIACO
FEMORO-POPLITEO
SOTTOGENICOLARE
ESVS 2011
• Endovascular treatment of aorto-iliac occlusive disease in a hybrid
fashion offers an acceptable alternative treatment in patients with
aorto-iliac disease and concomitant common femoral artery
disease that requires open surgery. (Level 3b; Grade C).
Vascular Surgery - University of Parma
Linee guida – Aorto-iliache
AORTO-ILIACO
FEMORO-POPLITEO
SOTTOGENICOLARE
Stent
EV3 Protege
10x40mm
8x60mm
8x40mm
Vascular Surgery - University of Parma
Caso clinico - #3
AORTO-ILIACO
FEMORO-POPLITEO
SOTTOGENICOLARE
A comparison between aortobifemoral bypass and aortoiliac
kissing stents in patients with complex aortoiliac obstructive
diseaseDorigo W et al. J Vasc Surg 2017;65:99-107
• Multicenter, retrospective study
• TASC II C and D lesion
• Group 1 (G1): ao-bif bypass; Group 2 (G2): endovascular
G1 open
N=82
G2 endo
N=128P
Technical failure - 2 (1.5%) .3
Intraoperative complication - 2 (1.5%) .3
Local complication 7 (8.5%) 6 (5%) .03
Major morbidity 10 3 .006
Mortality 1 (1%) -
Vascular Surgery - University of Parma
Aorto-iliaco - Risultati
AORTO-ILIACO
FEMORO-POPLITEO
SOTTOGENICOLARE
P=.07 P=.1
P=.6 P=.3
Dorigo W et al. J Vasc Surg 2017;65:99-107
Mean follow-up: 38.1 months (range 1-96)
A comparison between aortobifemoral bypass and aortoiliac
kissing stents in patients with complex aortoiliac obstructive
disease
Vascular Surgery - University of Parma
Aorto-iliaco - Risultati
FEMORO-POPLITEO
SOTTOGENICOLARE
AORTO-ILIACO
SICVE 2015
Vascular Surgery - University of Parma
Linee guida – Femoro-poplitee-tibiali
Chirurgia
• complessità anatomica
• lesioni steno-occlusive lunghe,
specie calcifiche
• paziente non ad alto rischio
chirurgico(Classe I, Livello B)
Endovascolare
• stenosi o occlusioni
segmentarie (no AFC
e ostio della AFS e
AFP)
• … è indicata la rivascolarizzazione secondo il modello angiosomico
con tecnica endovascolare o chirurgica o ibrida scelta in base alla
valutazione del rischio operatorio, dell’aspettativa di vita, della
topografia della malattia steno-ostruttiva, della qualità delle
lesioni steno-ostruttive, dello stadio delle lesioni trofiche, del
patrimonio venoso autologo. … (Classe I, Livello A)
• … L’orientamento più accreditato è quello di scegliere, nei pazienti in
cui possono essere proponibili sia la tecnica endovascolare che quella
chirurgica, la terapia endovascolare nei pazienti con elevato
rischio chirurgico e ridotta aspettativa di vita.
FEMORO-POPLITEO
SOTTOGENICOLARE
AORTO-ILIACO
SVS 2016
• It is presently unclear for which patients EVT is preferable to open
bypass. There are data suggesting that the outcomes of EVT for
TransAtlantic Inter-Society Consensus type D femoropopliteal
lesions are poor in patients with diabetes.
• …the choice of intervention likely depends on the degree of
ischemia, the extent of arterial disease, the extent of the wound,
the presence or absence of infection, and the available
expertise.
Vascular Surgery - University of Parma
Linee guida – Femoro-poplitee-tibiali
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
ESVS 2011
• Short SFA lesions (<5cm) are preferably treated with angioplasty.
Stenting of short lesions should only be performed when suboptimal
results are obtained with PTA alone (Level 1a; Grade B).
• The preferred treatment of intermediate SFA lesions (5-15 cm) is
PTA with primary bare nitinol stenting (Level 1b; Grade B)
• In long SFA lesions (>15 cm) endovascular treatment (intraluminal
or subintimal) with a stent graft seems acceptable when the
patient’s condition precludes an open procedure. … (Level 3b;
Grade C)
Vascular Surgery - University of Parma
Linee guida – Femoro-poplitee
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
Vascular Surgery - University of Parma
Caso clinico - #1
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
Vascular Surgery - University of Parma
Caso clinico - #2
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
Vascular Surgery - University of Parma
Caso clinico - #3
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
PTA6x60mm
Vascular Surgery - University of Parma
Caso clinico - #4
7-8 cm
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
OUTBACK® LTD™
Re-Entry Catheter
Vascular Surgery - University of Parma
Caso clinico - #5
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO Stent Protege
6x150mm
Gore Viabahn
6x50mm
Vascular Surgery - University of Parma
Caso clinico - #5
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
Rutherford 4
Vascular Surgery - University of Parma
Caso clinico - #6
FEMORO-POPLITEO
AORTO-ILIACO
SOTTOGENICOLARE
Vascular Surgery - University of Parma
Infrainguinal multilevel TASC D
Open surgery as first-line treatment of infrainguinal multilevel
TASC D arterial disease with critical limb ischemia Abualhin M, et al.
Oral Presentation at European Society for Vascular Surgery 31st Annual Meeting
62 patients (mean age: 72years, male: 76%)
Revascularization Technique N (%)
CFA Endarterectomy +
Fem-pop Bypass (BTK)10 (16)
Femoro-Tibial/Pedal Bypass 48 (77)
CFA Endarterectomy +
Femoro-Tibial/Pedal Bypass4 (7)
Survival Limb salvage
77%
. .82%
Mean follow-up: 24.6 months
2-y primary p: 55%
2-y assisted p: 69.2%
2-y secondary p: 78%
Patencies
Technical success: 98%
+
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
ESVS 2011
• Hybrid procedures are the preferred treatment modality
irrespective of lesion length in high-risk patients not suitable for
open bypass surgery or when no suitable vein is available if
minimally open revascularization is mandated, such as CFE (Level
2b; Grade B).
Vascular Surgery - University of Parma
Linee guida – Femoro-poplitee
AORTO-ILIACO
FEMORO-POPLITEO
Vascular Surgery - University of Parma
Caso clinico - #7
SOTTOGENICOLARE
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
A meta-analysis of endovascular versus surgical reconstruction
of femoropopliteal arterial disease.
Antoniou GA et al. J Vasc Surg 2013;57:242
• 4 randomized trials; 6 observational studies
• 2817 patients CLI: 74%
Endovascular
Endovascular: 1430 Surgery: 1387
30-d morbidityTechnical failure
SurgeryEndovascular Surgery
Vascular Surgery - University of Parma
Femoro-popliteo - Risultati
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
A meta-analysis of endovascular versus surgical reconstruction
of femoropopliteal arterial disease.
Antoniou GA et al. J Vasc Surg 2013;57:242
Vascular Surgery - University of Parma
Femoro-popliteo - Risultati
AORTO-ILIACO
FEMORO-POPLITEO
SOTTOGENICOLARE
ESVS 2011
• Endovascular treatment of infrapopliteal arteries has the potential to
achieve similar limb salvage rates with less procedural
morbidity and mortality than surgical bypass. Angioplasty as the
first-line therapeutic modality for patients with CLI and
infrapopliteal lesion is reasonable in the majority of cases,
considering that the interventional procedure should not
preclude future surgical intervention. (Level 4; Grade C).
Vascular Surgery - University of Parma
Linee guida –Tibiali
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
Vascular Surgery - University of Parma
Caso clinico - #1
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
POBA 2.5mm in diameter
Vascular Surgery - University of Parma
Caso clinico - #2
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
Vascular Surgery - University of Parma
Caso clinico - #3
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
Vascular Surgery - University of Parma
Caso clinico - #4
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
Vascular Surgery - University of Parma
Tibiali - Risultati
What’s next after optimal infrapopliteal angioplasty ?
Clinical and ultrasonografic results of a prospective single-center study.
Gargiulo M e t al. J Endovasc Ther 2008;15:363-369
37.9%
87 limbs
Months
Primary patency
1-y restenosis rate
62.1%
Endovascular Surgery
AORTO-ILIACO
Percutaneous Transluminal Angioplasty in Patients With
Infrapopliteal Arterial Disease: Systematic Review and Meta-
Analysis. Mustapha JA et al. Circ Cardiovasc Interv. 2016 May;9(5):e003468.
• 52 studies (65% retrospective; 35% prospective)
• 6769 patients; 9399 lesions
CLI: 97%
SOTTOGENICOLARE
FEMORO-POPLITEO 1-y primary patency:
63.1% 1-y repeated
revascularization:
18.2%
1-y major amputation:
14.9%
Vascular Surgery - University of Parma
Tibiali - Risultati
1 year
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
Wu R et al. J Vasc Surg. 2014;59(6):1711.
Limb salvage
6 months 6 months
1 year
Primary patency
Percutaneous transluminal angioplasty versus primary
stenting in infrapopliteal arterial disease: a meta-analysis of
randomized trials.
Vascular Surgery - University of Parma
Tibiali - Risultati
AORTO-ILIACO
SOTTOGENICOLARE
FEMORO-POPLITEO
Wu R et al. Int J Surg. 2016;35:88
1-y target lesion
revascularization1-y binary restenosis
Drug-eluting balloon versus standard percutaneous
transluminal angioplasty in infrapopliteal arterial disease: A
meta-analysis of randomized trials.
1-y late lumen loss
Vascular Surgery - University of Parma
Tibiali - Risultati
AORTO-ILIACO
FEMORO-POPLITEO
SOTTOGENICOLARE
Endovascolare >>> chirurgia
• Stenosi, occlusioni corte o di media lunghezza
• Non calcificazione
• Elevato rischio operatorio, ridotta aspettativa di vita,
lesioni trofiche poco estese, assenza di patrimonio
venoso autologo
• Trattamento endovascolare come primo approccio
nella maggior parte dei casi, purché non precluda
un successivo trattamento chirurgico
Vascular Surgery - University of Parma
CLI – Trattamento endovascolare
Quando trattamento endovascolare?