Catheter Based Intervention and Surgical Management of Peripheral Arterial Occlusive Disease: Technique and Results

CATHETER BASED INTERVENTION AND SURGICAL MANAGEMENT OF PERIPHERAL ARTERIAL OCCLUSIVE DISEASE: TECHNIQUE AND RESULTSDr Omar P. Haqqani, MD

Chief, Vascular and Endovascular SurgeryAssociate Professor of Surgery, Central Michigan University

DISCLOSURE

Author does not have any disclosures

IMPACT OF PAD ON MARTALITY

Lifestyle modification•Smoking cessation•Regular exercise training•Diet

Pharmacological treatment•Antiplatelet therapy•Control risk factors (e.g. hypertension, blood glucose)•Vasodilators for symptomatic relief

MANAGEMENT OF PAD PATIENTS

• Lifestyle limiting claudication• Rest Pain• Non-healing wounds

INDICATION FOR INTERVENTION

Endovascular•Revascularization (Angioplasty)•Stent Placement•Atherectomy (Directional or Laser)•Intravascular Ultrasound (IVUS)

Surgical•Endarterectomy•Peripheral Bypass Graft•Amputation

INDICATION FOR INTERVENTION

Endovascular•Revascularization (Angioplasty)•Stent Placement•Atherectomy (Directional or Laser)•Intravascular Ultrasound (IVUS)

Surgical•Endarterectomy•Peripheral Bypass Graft•Amputation

INDICATION FOR INTERVENTION

Plain Balloon•modifies obstructions through a disruptive stretching process

Drug-coated Balloon (DCB)•modifies obstructions through a disruptive stretching process with high-concentration, rapid local release of an antirestenotic drug

PLAIN BALLOON ANGIOPLASTY

DRUG COATED BALLOON (DCB) ANGIOPLASTY

Endovascular•Revascularization (Angioplasty)•Stent Placement•Atherectomy (Directional or Laser)•Intravascular Ultrasound (IVUS)

Surgical•Endarterectomy•Peripheral Bypass Graft•Amputation

INDICATION FOR INTERVENTION

Bare Metal Stent•modifies obstructions using a metallic scaffolding

Drug-eluting Stent (DES)•modifies obstructions using a metallic scaffolding with a slowly releasing drug to block cell proliferation

BARE METAL STENT PLACEMENT

DRUG ELUTING STENT (DES) PLACEMENT

Endovascular•Revascularization (Angioplasty)•Stent Placement•Atherectomy (Directional or Laser)•Intravascular Ultrasound (IVUS)

Surgical•Endarterectomy•Peripheral Bypass Graft•Amputation

INDICATION FOR INTERVENTION

LASER Atherectomy•Pulverizes obstructions using ultraviolet pulsed light

Directional Atherectomy•Excises obstructions using mechanical cutting devices

EXCIMER LASER ATHERECTOMY

DIRECTIONAL ATHERECTOMY

Endovascular•Revascularization (Angioplasty)•Stent Placement•Atherectomy (Directional or Laser)•Intravascular Ultrasound (IVUS)

Surgical•Endarterectomy•Peripheral Bypass Graft•Amputation

INDICATION FOR INTERVENTION

Intravascular Ultrasound (IVUS)•Intra-vessel ultrasonography to delineate composition and extent of obstructions

INTRAVASCULAR ULTRASOUND (IVUS)

RESULTS OF ARTERIAL RECONSTRUCTION

RESULTS OF ARTERIAL RECONSTRUCTION

RESULTS OF ARTERIAL RECONSTRUCTION

RESULTS OF ABOVE-KNEE INTERVENTION

POBA

DCB DES DAth LASER

BMS

RESULTS OF BELOW-KNEE INTERVENTION

POBA DCB

Endovascular•Revascularization (Angioplasty)•Stent Placement•Atherectomy (Directional or Laser)•Intravascular Ultrasound (IVUS)

Surgical•Endarterectomy•Peripheral Bypass Graft•Amputation

INDICATION FOR INTERVENTION

RESULTS OF ARTERIAL RECONSTRUCTION

RESULTS OF ABOVE-KNEE BYPASS

RESULTS OF BELOW-KNEE BYPASS

37 YO DM WITH ESRD

WET GANGRENE

37 YO DM WITH ESRD

37 YO DM WITH ESRD

ENDO VS OPEN OUTCOMES

BASIL (Bypass versus angioplasty in severe ischemia of the leg)– Angioplasty is recommended only for high risk patients with a projected survival of less than 2 years

Among patients undergoing repeat interventions 1 year patency 22 %

BENEFITS OF AN ENDO-FIRST APPROACH

• Remarkably safe even in high-risk patients

• Emergency operative bailout a rare event

• Endovascular re-intervention as successful as initial intervention

• Repeat interventions allows limb salvage to be prolonged in some cases indefinitely

• Preservation of distal targets

THANK YOU

Thank You