manejo de las lesiones de tasc a a tasc d...outback® ltdtm re-entry catheter tuning the t marker...
TRANSCRIPT
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Manejo de las lesiones de
TASC A a TASC D
Fernando Cura, MD, PhD
Director, Cardiología Intervencionista
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Territorios tratados mediante ATP
Base de datos ICBA-Anchorena
40%
4,7%
55,3%
IliacaFemoralInfra-Patelar
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Rol de las imagenes: Angio TC y RMN
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Diagnóstico para evaluar estrategia ….
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Hacia procedimientos más seguros…
Base de datos ICBA
Angiografía diagnóstica
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TASC II Femoro - Poplíteo
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• Revascularización:
Tratamiento Endovascular Segmento Femoro-popliteo
Clase I C TASC A
Tratamiento endovascular como primera línea TASC B
TASC C Clase IIa A
TASC D Severas Comorbilidades Tratamiento
Endovascular
Clase IIbC
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Angioplastia poplitea TASC D
Tipo de Stent
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Centro de medicina vascular: Clinicos + Cirujanos Vasculares + Cardiologos Intervencionistas
Isquemia crìtica
Claudicación en tratamiento médico que limite las actividades normales
Respuesta parcial o inadecuada al tratamiento y ejercicio de rehabilitación Claudicación limitante en paciente con indicación de rehabilitación
Guías ICBA 2012
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Características clínicas y Morfología
Oclusión Estenosis
Longitud Extensión Diámetro Localización Run off Calcificación
Isquemia crítica Claudicación
Tiempo
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Accesos vasculares
Radial Humeral Femoral retrógrado Femoral anterógrado Poplíteo retrógrado Poplíteo anterógrado Infrapatelares TA y TP
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Punción femoral retrógrado
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Punción femoral retrógrado para acceso contralateral
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Punción femoral retrógrado para acceso contralateral
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Punción anterógrada de la arteria femoral
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Estrategias de acceso
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Angioplastia infrapatelar
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Punción retrógrada de la arteria poplitea
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Punción retrógrada de la arteria poplitea
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Outback por acceso popliteo
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Combinación de múltiples accesos
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Elección de estrategia de revascularización
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Oclusión crónica total
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32% 61% 6%
Oclusiones totales crónicas
Nau G, et sl. RAC 2014
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n (%)
Edad 64,8 ± 9,6
Sexo masculino (%) 87 (67,4)
HTA (%) 102 (79)
DLP (%) 94 (73)
TBQ (%) 35 (27,1)
DBT (%) TIPO 1
51 (39,5) 9 (6,98)
IRC (%) 14 (11)
Ruthelford 1-3 (%) 95 (73,6)
Ruthelford 4 (%) 16 (12,4%)
Ruthelford 5-6 (%) 18 (13,9%)
Tabla. 1 Características generales
HTA: hipertensión, DLP: dislipemia, TBQ tabaquismo, DBT diabetes, IRC: insuficiencia renal crónica
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Clasificación TASC
J Vasc Surg 2000;31:S1-296
TASC A 14 (10,8)
TASC B 67 (51,9)
TASC C 24 (18,6)
TASC D 24 (18,6)
Nau G, et sl. RAC 2014
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Éxito angiográfico según clasificación TASC
Nau G, et sl. RAC 2014 (en revision)
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0
500
1000
1500
2000
2500
3000
3500
Me
tro
s
Gráfico.3 Mejoría en distancia caminada
Post-ATP
Pre-ATP 126,5±108,5 metros
908,7±702 metros
ATP: angioplastia transluminal periférica
Nau G, Lamelas P, Cura F SAC 2014
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Nau G, Lamelas P, Cura F SAC 2014
Kaplan Meier: Re-intervención OTC
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Técnicas para oclusión crónica:
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Subintimal Angioplasty
• The objective is to create subintimal dissection plane proximal to occlusion, through the subintimal space, and then re-enter into the true lumen at the distal portion of lesion
• Subintimal channel is free from endothelium and atheroma which can invite thrombus and neo-intimal hyperplasia to accumulate
Internal Data, Cordis Corporation.
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FRONTRUNNER® XP CTO Catheter Device Specifications
• FRONTRUNNER® XP CTO Catheter – .039” distal tip & crossing profile when jaws closed – 2.3 mm maximum diameter when jaws open – 90cm & 140cm lengths – Braided, hydrophilic shaft with shapeable distal tip
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OUTBACK® LTDTM Re-Entry Catheter Overview
The OUTBACK® LTDTM Re-Entry Catheter is a single lumen catheter designed to facilitate placement and positioning of guidewires and catheters within the peripheral vasculature.
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OUTBACK® LTDTM Re-Entry Catheter Device Description
Deployment Slide Release Button
Deployment Handle Cannula
wire port Flush port
Rotating hemostasis valve (RHV)
Catheter shaft
Cannula tip emerging from lateral exit port
Catheter nosecone with lateral cannula exit port
Detail A (see below)
Catheter shaft
Cannula
Distal end port
Catheter “LT” Directional Marker Band & Nosecone
Distal Housing & Nosecone Assembly
Detail A
Cannula- Guide Tip Extended
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OUTBACK® LTDTM Re-Entry Catheter Tuning the T Marker
• Move image intensifier to (90 degree) orthogonal view.
• Ensure OUTBACK® LTDTM Re-Entry Catheter is „in line‟ with true lumen.
• Fine tune OUTBACK® LTDTM Re-Entry Catheter to display full “T” marker by rotating the proximal hub.
• If additional orientation adjustments are necessary, this can be achieved via rotation of the rotating hemostatic valve.
• A confirming orthogonal view should be considered after each new adjustment of the catheter towards the re-entry target.
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OUTBACK® LTDTM Re-Entry Catheter Tuning the L Marker
• Position image intensifier to show OUTBACK® LTDTM Re-Entry Catheter adjacent to true lumen.
• Point “L” marker toward the true lumen by turning the proximal rotating hub (rotating hemostasis valve - RHV).
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Riesgos asociados a la intervención
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Complicaciones del Acceso Vascular
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Alonso, M et. Rev Esp Cardiol. 2003;56:569-77
Complicaciones del Acceso Vascular
Factores de Riesgo: Edad (> 70 años), sexo femenino, sobrepeso, enfermedad vascular periférica, Insuficiencia Renal, anticoagulación, cateterización previa, múltiples catéteres en el mismo sitio, escasa experiencia.
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Nuestro mayor enemigo: Embolización distal
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Filtro Spider tipo Fogarty
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TROMBOLISIS FARMACO-MECANICA Heparina + ASA+ P2Y12 (+ GP2b3a o TL)
Catéter Pulse-Spray (AngioDynamics)
Guía oclusora
Segmento de Infusión (2, 5, 10….50 cm)
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Restenosis femoral superficial
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Fractura de stent
´Evaluación de fractura con reconstrucción 3 D Stentboost´
ICBA
0,8%
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• Formación de un grupo de trabajo
• Combinación de descripción de síntomas, examen físico,
estudios complementarios
• Selección del acceso (o accesos) a utilizar
• Selección de la estrategia acorde a la morfología de la
lesión y de la presentación clínica
• Conciencia de radiación, nefrotoxicidad y tiempo del
procedimiento asociado a trombosis
Conclusiones
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Sobrevida Pacientes con Enfermedad Vascular Periférica
TASC II. Eur J Vasc Endovasc Surg Vol 33, Suppl 1,2007