Management of distal peripheral vascular disease

Cheuk Kwan Yee, Queenie

Tuen Mun Hospital

In the past….

Below knee disease ---- >

Recently….

Our centre

• Perform endovascular procedures for infrapopliteal disease since Feb 2011

• 13 cases

• Post-op mortality : 7.7%

• Limb Salvage Rate : 84.6%

Infra-popliteal disease

• Endovascular tools

• Angiosome

CFA

SFA

Profundus

Popliteal a.

ATA Tibioperoneal trunk

ATA

Peroneal a.

PTA

ATA

R ATATibioperoneal trunk

Peroneal a.

PTA

0.018” cordis guidewire

Balloon Angioplasty

Completion

Angiogram

Pre-op Post-op

Post-op

Post-op

Endovascular• Studies for infrapopliteal disease

– Single center– Small patient size– Non randomized

• Comparable amputation free survival

• Isolated infrapopliteal revascularization : Endovascular -> better leg salvage

BASIL trial : what are its implications, Seminar in vascular surgery, Bradbury et al 2009

Tibial intervention for CLI, Wiechmann et al, Seminars in interventional radiology, vol26 no.4 2009

Treatment of lower extremity vessels disease, Annals of Surgery vol246, no.3, Sept 2007, DeRubertis et al

Endovascular approach

Global technical success= Direct flow to pedal arches

Residual stenosis <=25%

Preserve patency of treated lesion

Minimize risk of limb amputation

Limit extent of amputation

Long term clinical outcomes after endovascular therapy for patients with CLI due to isolated below the knee lesions, Lida et al, circulation vol 124 suppl, Nov 2011

Devices for infrainguinal endovascular therapy : Menu a la carte or table d’hotl, Zoccai et al, Journal of Endovascular therapy 2011;18:638-641

Endovascular approach

Restenosis :

– Immediate elastic recoil of vessel

– Myointimal hyperplasia

– Late vascular remodelling

Compromised runoff

=>early restenosis /reocclusion

Balloons

Plain Balloon Angioplasty

Peripheral Cutting Balloon– 4 atherotomes

Drug-Coated Balloon– More durable biological effect

(By small centre studies)Drug-coated balloons for the prevention of vascular restenosis. Gray et

al, Circulation June 2010

Bare Metal Stent

• Eliminate:– early abrupt vessel closure– elastic recoil– negative vessel remodelling

6m 24m Limb salvage 94 82 Amp free survival 80 62

• Problems may arise……

Stent-assisted below the ankle angioplasty for limb salvage, Kawarada et al, Journal of Endovascular therapy, 2011:18:32-42

Drug-eluting Stent

• inhibit restenosis

• Review of small scale studies :

– sup to balloon expandable bare metal• intervention free survival• patency rate

• Similar limb salvage rate

Infrapopliteal angioplasty with drug-eluting stents : from heart to toe , siablis et al, Journal of Endovascular therapy( 2010:17: 488-491)

Prime time for infrapopliteal drug eluting stents, Journal of Endovascular therapy, phoenix Apr 2002

Primary use of sirolimus-eluting stents in the infrapopliteal arteries, Rastan et al,Journal of Endovascular therapy 2010 : 17:480-487

• No sig diff in amputation free survival

• Stent : insignificant but higher limb salvage rate

Below the ankle angioplasty : to stent or not to stent, Journal of Endovascular therapy 2011: 18:43-45

Endovascular Mx as 1st therapy for chronic total occlusion of the lower extremity arteries : Comparison of balloon angioplasty, stenting and directional atherectomy ; Journal of Endovascular therapy 2011;18:624-637

VS

Other new endovascular tools

Nitinol stenting

Atherectomy

Cryotherapy

Long term outcomes and risk stratification of patency following nitinol stenting in the femoropopliteal seg :

retrospective multicenter analysis, lida et al, Journal of Endovascular therapy phoenix : Dec 2011 vol18 iss6 Cryoplasty for peripheral vascular disease , cochrane collaboration

Cryoplasty for PAD in an unselected patient population in a tertiary centre, Silva et al, Texas Heart Institute Journal

liquid nitrous oxide

Resist external compression forces

Where to attack ??

~~ANGIOSOME~~

Where to attack ??

3-D vascular territories

Supplied by specific source arteries

Drained by specific veins

Angiosomes of the leg;anatomic study and clinical implications, pleastic reconstruction surgery 1998 Sep 102(3) 599-616

ANGIOSOME

Angiosome Posterior tibial artery

Anterior tibial artery

Peroneal artery

Angiosome-oriented angioplasty

Clinical success of endovascular approach : – dilation of all critical inflow lesions with

residual stenosis < 30% – straight line outflow in at least one tibial

vessel to the pedal arch

Angiosome-oriented angioplasty : – Revascularize target vessels according to angiosome concept

Angiosome-oriented angioplasty

• Multiple single centre studies: – Angiosome-oriented angioplasty :

• improved overall limb salvage • 90 VS 84 at 1 year, 89 VS 79 at 3 year

• Limitation : – Variations of angiosomes – Non-randomized studies– Failure to cannulate target vessel

Revascularization of a specific angiosome for limb salvage : does the target artery matter?A reliable approach to diabetic neuroischemic foot wounds : below the knee angiosome-oriented angioplasty, Alexandescu et al; Journal of Endovascular therapy 2011;18: 376-387

Bring Home Messages

• New era for endovascular procedures

• Emerging new technologies

• Holistic and tailor made pre-op planning + post-op Mx

• Angiosome-oriented angioplasty

Thank You !!

THANK YOU !!!