Management of distal peripheral vascular disease

1. Management of distal peripheral vascular disease Cheuk Kwan Yee, Queenie Tuen Mun Hospital

2. In the past…. Below knee disease ---- >

4. Recently….

5. Our centre • Perform endovascular procedures for infrapopliteal disease since Feb 2011 • 13 cases • Post-op mortality : 7.7% • Limb Salvage Rate : 84.6%

6. Infra-popliteal disease • Endovascular tools • Angiosome

8. CFA SFA Profundus

9. Popliteal a. Tibioperoneal trunk ATA

10. ATA PTA Peroneal a.

11. ATA

12. Tibioperoneal trunk R ATA PTA Peroneal a.

13. 0.018” cordis guidewire

15. Balloon Angioplasty

16. Completion Angiogram

17. Pre-op Post-op

18. Post-op

19. Post-op

20. 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

21. 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

22. Endovascular approach Restenosis: • Immediate elastic recoil of vessel • Myointimal hyperplasia • Late vascular remodelling Compromised runoff =>early restenosis /reocclusion

23. 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

24. 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

25. 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

26. VS • 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

27. Other new endovascular tools Nitinol stenting Atherectomy Cryotherapy Resist external compression forces liquid nitrous oxide 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

28. Where to attack ?? ~~ANGIOSOME~~

29. Where to attack ?? ANGIOSOME 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

30. Angiosome Posterior tibial artery Anterior tibial artery Peroneal artery

31. 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

32. 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

33. Bring Home Messages • New era for endovascular procedures • Emerging new technologies • Holistic and tailor made pre-op planning + post-op Mx • Angiosome-oriented angioplasty

34. Thank You !! THANK YOU !!!