strategies for management of acute thrombosis in patients
TRANSCRIPT
Strategies for Management of Acute
Thrombosis in Patients With PAD
Zhihui Dong, Gang Fang, Weiguo Fu
Dept. Vascular Surg.
Zhongshan Hospital, Fudan University
Shanghai, China
2018
Disclosure
Speaker name:
............................ Zhihui Dong .......................................
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
I do not have any potential conflict of interest
Strategies for Management of Acute
Thrombosis in Patients With PAD
Challenges
• urgent: limb salvage; nerve function preservation
• mixed: chronic lesion covered by acute thrombi
• comorbidities: open surg. /thrombolysis contraindicated
an early case, year 2009 (PMT devices not available)
58Yrs, male
: 5P, dysuria, tissue loss at perineal region & hip
hybrid under GA：open thrombectomy＋CDT＋Stent
Pre D1 Post @4 Yr
Chronic
lesion
Chronic
lesion
1st stent
2nd stent
acute & chronic
diffusely
acute removed
chronic discovered
Urgency
mixed
minimized
stenting
@ 4Wks
plastic surgery
@4Yrs
Thrombectomy incision
hip ulcer
skin
transplantation
skin graft
donor area
Current Tx Algorithm
critical comorbidities
Not limb-threatening
Medical Tx
Operation
Otherwise
AmputationLimb salvage
EndovascularOpen surgery Hybrid
PMT
(Rotarex / Angiojet)
CDT
Stent
(1/ 2 stages)
CFA involvedclose to renal A
coexistent AAA
Representative Case 1
high-risk for open surg.
Strategy：CDT+2nd-stage stenting
• 71 Yr, male
• HT, DM, AMI & PCI
• Rest pain for 1M; paralysis for 2 D
• Referred from Dept. Neurology
• CTA: aorta-iliac occlusion
Lt Brachial Approach
Pass the easier side (Lt.)
just to place a cath
gentle Pre-dilation
(Pacific, 3*120mm)CDT (Unifuse)
Chronic
stenosisUnifuse
Occlusive
segment
@36h
significantly thrombolyzed
chronic lesion @ bifur revealed@1M
Kissing (bare)
Rt Femoral+Lt Brachial @8M
Representative Case 2
challenge: contraindication for CDT
Strategy: single-stage PMT (Angiojet) + stenting
• 47Yr, male
• Progressive rest pain & ED for 3 days
after use of Reptilase for hemoptysis
• Absent bilateral femoral artery pulses
• PAH for over 20 Yr, recurrent hemoptysis,
CTA： aorta-iliac occlusion
Lt brachial
approachAngiojet RCIA Angiojet LCIA
thrombi removed markedly
Kissing
(complete)Bare stents
Preserve ICA and lumber A
stent
Occlusive
segment
@1M
ED relieved
@6M
Representative CASE 3
challenge: whole popliteal A (PA) involved
Strategy: recanalization without stent @ PA, esp. @P2-3
• 62 Yr, male
• Claudication for 1 Yr
• Lt leg rest pain for 1M, progression over 1 Wk
• DM & HT
• CTA：Total occlusions of the Lt SFA & PA
• ABI：Lt 0.25，Rt 0.48
to realize PMT, stay in true lumen, at least in PA
Pre-dilation
(Pacific ø3mm)Rotarex
On-table
250,000 u
urokinase
@PA
Clear prox. thrombi as much as possible
Leave more time & urokinase for PA
Unifuse
HOPE😊
Unifuse
Left @ PAStent @ SFA prior to CDT
Ensure adequate inflow to
optimize the distal thrombolysis
@36h 1 additional Stent @ completion
Chronic
lesion
Stent
end
@1M@3M
300-m claudication
@1Yr
Pain-free walking
>1-2Km
exercise
collaterals
reocclusion
Representative case 4
➢ 83Yr, female
➢ acute pain, paresthesia for 1w
➢ HT, DM, but without Af
➢ CTA: total SFA – PA involved
Lesson: CDT failed without adequate inflow
D0
D1
Proximal stenting
(Everflex)
Only PMT, without proximal stenting Prior to CDT
CDT for another
24Hr
Pre Post-PMT
Post-CDT
D2
Stent
end
@3M: 800-m claudication
ABI
L R
Pre 1.08 0.33
@ 1W 1.14 1.07
@3 M 1.02 0.89
Summary
• Systemically & locally balanced
• Remove the acute, reveal and fix the chronic
• Ensure an adequate inflow during distal thrombolysis
• Hopefully, leave nothing @ PA
• Even if reoccluded, limb salvage could be kept
www.zs-hospital.sh.cn [email protected]
Strategies for Management of Acute
Thrombosis in Patients With PAD
Zhihui Dong, Gang Fang, Weiguo Fu
Dept. Vascular Surg.
Zhongshan Hospital, Fudan University
Shanghai, China
2018