pad, agiography & angioplasty

1. Peripheral Vascular Disease,
Angiography - Angioplasty and
Surgical Techniques
Dr. Rajdeep Agrawal,Dr. Rajdeep Agrawal, MD,MD,
DMDM
Interventional Cardiologist &Interventional Cardiologist &
Vascular InterventionistVascular Interventionist ,,
Sir H N Hospital,MumbaiSir H N Hospital,Mumbai
Breach Candy HospitalBreach Candy Hospital
Cumballa Hill HospitalCumballa Hill Hospital

2. Dr. Rajdeep Agrawal
Indications of Angiography in
PVD
 Life style limiting claudicationLife style limiting claudication
 Critical ischemia / limbCritical ischemia / limb
threatening ischemia (rest pain,threatening ischemia (rest pain,
nocturnal pain, non healing ulcer,nocturnal pain, non healing ulcer,
gangrenegangrene
 Graft stenosisGraft stenosis
 High surgical riskHigh surgical risk
 Acute ischemia of lower limbAcute ischemia of lower limb

3. Dr. Rajdeep Agrawal
Arteriogram
 Remains the ‘Gold standard’ for vascularRemains the ‘Gold standard’ for vascular
evaluation.evaluation.
 Should be done only in patients who haveShould be done only in patients who have
clinical indications for vascularclinical indications for vascular
interventions (surgery or angioplasty)interventions (surgery or angioplasty)
 Complications are less than 5% andComplications are less than 5% and
mortality about 0.025%.mortality about 0.025%.
 Patients should be well hydraded beforePatients should be well hydraded before
and after angiograms, especiallyand after angiograms, especially
diabetics.diabetics.

4. Dr. Rajdeep Agrawal
Angioplasty -- History
 Charles Dotter (1964)Charles Dotter (1964)
 First angioplasty using co-axialFirst angioplasty using co-axial
cathetercatheter
 Andreas Gruentzig (1977)Andreas Gruentzig (1977)
 First PTCA using double lumenFirst PTCA using double lumen
cathetercatheter

5. Dr. Rajdeep Agrawal
Percutaneous Transluminal
Angioplasty (PTA) in Peripheral
Vascular Disease
An over view of the arterialAn over view of the arterial
pathologies of the lower limbspathologies of the lower limbs
and their percutaneousand their percutaneous treatmenttreatment
modalitiesmodalities

6. Dr. Rajdeep Agrawal
Percutaneous Transluminal
Angioplasty
 A non-surgical technique designed toA non-surgical technique designed to
increase the lumen of the vessel &increase the lumen of the vessel &
thus prevent ischemia & itsthus prevent ischemia & its
complicationscomplications
 MechanismMechanism
Inflated balloon exertsInflated balloon exerts
circumferentialcircumferential
pressure on the plaquepressure on the plaque
1. Plaque splitting & disruption1. Plaque splitting & disruption
2. Stretching of the vessel wall2. Stretching of the vessel wall

7. Dr. Rajdeep Agrawal
Rutherford – Becker classification of PVD
GradGrad
ee
CategorCategor
yy
SymptomsSymptoms
OO OO NoneNone
II 11 Mild claudicationsMild claudications
II 22 Moderate claudicationsModerate claudications
II 33 Severe (life style limiting)Severe (life style limiting)
claudicationsclaudications
IIII 44 Rest painRest pain
IIIIII 55 Nonhealing ulcers focalNonhealing ulcers focal
gangrenegangrene
IIIIII 66 Major tissue lossMajor tissue loss

8. Dr. Rajdeep Agrawal
Rutherford – Becker classification of PVDRutherford – Becker classification of PVD
Ankle Brachial Index -Ankle Brachial Index -
> 0.90 – No significant obstructive> 0.90 – No significant obstructive
diseasedisease
0.50 to 0.90 – Claudications (Grade I)0.50 to 0.90 – Claudications (Grade I)
<0.50 – Limb threatening ischemia<0.50 – Limb threatening ischemia
(Grade II or III)(Grade II or III)

9. Dr. Rajdeep Agrawal
Ideal settings for PTA
LesionsLesions
CharacteristicsCharacteristics
PatientPatient
CharacteristicsCharacteristics
ShortShort Non diabeticNon diabetic
ConcentricConcentric ClaudicationClaudication
Non calcifiedNon calcified
SolitarySolitary
Non occlusiveNon occlusive
Large vesselLarge vessel
Continuous run offContinuous run off

10. Dr. Rajdeep Agrawal
Percutaneous Transluminal
Angioplasty (PTA) in Peripheral
Vascular Disease
Modalities will include –Modalities will include –
Angioplasty,Angioplasty,
Stents,Stents,
Lasers,Lasers,
Rotablaters,Rotablaters,
And ThrombolysisAnd Thrombolysis

11. Dr. Rajdeep Agrawal
Percutaneous Transluminal
Angioplasty (PTA) in Peripheral
Vascular Disease
Modalities will be treated together or separatelyModalities will be treated together or separately
in the territories commonly affected byin the territories commonly affected by
vascular diseasevascular disease
Acute arterial obstruction will be treated as aAcute arterial obstruction will be treated as a
separate issue, where multimodal treatmentsseparate issue, where multimodal treatments
may come togethermay come together

12. Dr. Rajdeep Agrawal
Lower Limb Ischemia -
Vascular involvement in Diabetic
 Aorto illiac relatively spared.Aorto illiac relatively spared.
 Most of the diseases involvesMost of the diseases involves
infrainguinal arteries (femoral - popliteal -infrainguinal arteries (femoral - popliteal -
tibial)tibial)
 About 60% have involvement of plantarAbout 60% have involvement of plantar
arch and digital arteries.arch and digital arteries.
 About 80% have microangiopathyAbout 80% have microangiopathy
Does not adversely affect the outcome ofDoes not adversely affect the outcome of
vascular reconstructionvascular reconstruction..

13. Dr. Rajdeep Agrawal
Angiography -- Technique
 ApproachApproach
 Femoral / BrachialFemoral / Brachial
 Vascular accessVascular access using Seldinger’susing Seldinger’s
techniquetechnique
 Material / HardwareMaterial / Hardware
 0.035 guide wire0.035 guide wire
 Renal catheter, Simmon’s cathRenal catheter, Simmon’s cath

14. Dr. Rajdeep Agrawal
Seldinger needle & guide wire for
introducing an arterial catheter

15. Dr. Rajdeep Agrawal
 Arterial OcclusionArterial Occlusion
just above thejust above the
knee causingknee causing
claudication of theclaudication of the
calf; goodcalf; good
collateralcollateral
circulationcirculation

16. Dr. Rajdeep Agrawal
Balloon Catheter for PTA

17. Dr. Rajdeep Agrawal
Contraindications to
percutaneous revascularization
PTA C/I - Medically unstablePTA C/I - Medically unstable
(Absolute) - Stenosis adjacent to aneurysm(Absolute) - Stenosis adjacent to aneurysm
or near an ulcerated plaqueor near an ulcerated plaque
(Relative) - (Unfavourable anatomy)(Relative) - (Unfavourable anatomy)
Long segment & multi-focalLong segment & multi-focal
stenosisstenosis
Long segment OcclusionsLong segment Occlusions
(thrombolysis)(thrombolysis)

18. Dr. Rajdeep Agrawal
PTA Contra-indicationsPTA Contra-indications
(Relative) - If large vessel at ankle is available(Relative) - If large vessel at ankle is available
for bypassfor bypass
- Heavy eccentric calcification- Heavy eccentric calcification
- Lesion in essential collateral vessel- Lesion in essential collateral vessel
- Stenosis with thrombus- Stenosis with thrombus
Percutaneous
revascularization

19. Dr. Rajdeep Agrawal
Post PTA recurrence are seldom worse thanPost PTA recurrence are seldom worse than
before, does not interfere with the originalbefore, does not interfere with the original
planned surgery.planned surgery.
In 25% Femoro - popliteal PTFE Graft,In 25% Femoro - popliteal PTFE Graft,
Popliteal gets occluded when bypassPopliteal gets occluded when bypass
closescloses
Adar etalAdar etal
Percutaneous
revascularization

20. Dr. Rajdeep Agrawal
THROMBOLYSISTHROMBOLYSIS is an alternateis an alternate
attemptable modality of treatment inattemptable modality of treatment in
PVDPVD
Safe if cases are selected properlySafe if cases are selected properly
Cannot be used in all cases.Cannot be used in all cases.
Various methods are used to administerVarious methods are used to administer
thrombolysisthrombolysis
Acute ischemia of lower limb is one areaAcute ischemia of lower limb is one area
Percutaneous revascularization

21. Dr. Rajdeep Agrawal
Intra-arterial ThrombolysisIntra-arterial Thrombolysis
Restores blood flowRestores blood flow
Identifies underlying lesionIdentifies underlying lesion
Thrombotic or embolic occlusionThrombotic or embolic occlusion
Native artery or bypass graftNative artery or bypass graft
Percutaneous revascularization

22. Dr. Rajdeep Agrawal
THROMBOLYSIS - CONTRAINDICATIONSTHROMBOLYSIS - CONTRAINDICATIONS
Absolute -Absolute - Active internal bleedingActive internal bleeding
Irreversible limb ischaemiaIrreversible limb ischaemia
Recent stroke, craniotomyRecent stroke, craniotomy
Mobile L-V thrombusMobile L-V thrombus
Percutaneous
revascularization

23. Dr. Rajdeep Agrawal
THROMBOLYSIS CONTRAINDICATIONSTHROMBOLYSIS CONTRAINDICATIONS
Relative - H/o GI bleedRelative - H/o GI bleed
- Recent major- Recent major
surgery/CPR/Traumasurgery/CPR/Trauma
- Diastolic BP- Diastolic BP >>125 mm125 mm
- DM – Proliferative Retinopathy- DM – Proliferative Retinopathy
- Sub acute bacterial endocarditis- Sub acute bacterial endocarditis
- Coagulopathy- Coagulopathy
- Post partum state- Post partum state
Percutaneous revascularization

24. Dr. Rajdeep Agrawal
Stents: Contra indicationsStents: Contra indications
-- Diffuse aortic diseaseDiffuse aortic disease
-- Extravasation of contrast after PTAExtravasation of contrast after PTA
-- Non compliant lesion on angioplastyNon compliant lesion on angioplasty
-- Diffuse iliac diseaseDiffuse iliac disease
-- Aortic tortuosity & aneurysmAortic tortuosity & aneurysm
-- Diffuse long segment small caliber externalDiffuse long segment small caliber external
iliac or femoral arteryiliac or femoral artery
Percutaneous
revascularization

25. Dr. Rajdeep Agrawal
Stent Complications (10%)Stent Complications (10%)
- Almost all are minorAlmost all are minor
- Puncture site injuryPuncture site injury
- Distal embolizationDistal embolization
- Stent dislodgementStent dislodgement
- Pseudo anemysm formationPseudo anemysm formation
- Vessel ruptureVessel rupture
Percutaneous
revascularization

26. Dr. Rajdeep Agrawal
Percutaneous Transluminal
Angioplasty (PTA) in Peripheral
Vascular Disease
AORTO – ILIAC PercutaneousAORTO – ILIAC Percutaneous
Transluminal AngioplastyTransluminal Angioplasty
-- Optimizes inflow for bypassOptimizes inflow for bypass
- Excellent patient tolerance- Excellent patient tolerance
-- Short recovery periodShort recovery period
-- No worsening of vascular status – if failsNo worsening of vascular status – if fails

27. Dr. Rajdeep Agrawal
AORTIC OCCLUSSIONSAORTIC OCCLUSSIONS
- Relatively uncommonRelatively uncommon
- Younger population who smokeYounger population who smoke
- Claudication and impotencyClaudication and impotency
- Risk of propagation of clot to renalRisk of propagation of clot to renal
and mesenteric arteryand mesenteric artery
Percutaneous revascularization

28. Dr. Rajdeep Agrawal
ABDOMINAL AORTIC STENOSISABDOMINAL AORTIC STENOSIS
- Isolated - relatively uncommonIsolated - relatively uncommon
- More frequent in women with hypoplasticMore frequent in women with hypoplastic
aortasaortas
- PTA and Stent can be tried and are useful ifPTA and Stent can be tried and are useful if
the lesions are amenablethe lesions are amenable
- Otherwise Grafts can be placedOtherwise Grafts can be placed
- Even thrombolysis could be attempted withEven thrombolysis could be attempted with
angioplastyangioplasty
- Large thick atherosclerotic lesions could beLarge thick atherosclerotic lesions could be
commoncommon
Percutaneous
revascularization

29. Dr. Rajdeep Agrawal
Percutaneous
revascularization
AORTO – ILIAC STENTINGAORTO – ILIAC STENTING
Indications - Residual stenosis > 30% afterIndications - Residual stenosis > 30% after
percutaneous revascularizationpercutaneous revascularization
Or if a gradient >10mm persistsOr if a gradient >10mm persists
DissectionDissection
Highly eccentric stenosisHighly eccentric stenosis
Recurrent Stenosis post PTARecurrent Stenosis post PTA
Iliac artery occlusionIliac artery occlusion

30. Dr. Rajdeep Agrawal
ILIAC ARTERY STENOSISILIAC ARTERY STENOSIS
PTAPTA
- PTA with/without stentPTA with/without stent
- Focal, uncalufied sterosis <5 cm longFocal, uncalufied sterosis <5 cm long
- Eccentric or calufied sterosis < 3cm longEccentric or calufied sterosis < 3cm long
Long segment (Long segment (>>10cm)10cm) respond less favorablyrespond less favorably
STENTSSTENTS
- Residual pressure gradient (<5mmHg) orResidual pressure gradient (<5mmHg) or
residual stenosis(>30%)residual stenosis(>30%)
- Flow limiting dissection flapFlow limiting dissection flap
- Restenosis (acute or subaiute)Restenosis (acute or subaiute)
Percutaneous revascularization

31. Dr. Rajdeep Agrawal
ILIAC ARTERY OCCLUSIONSILIAC ARTERY OCCLUSIONS
- Bilateral – Surgery treatmentBilateral – Surgery treatment
- Primary stent placementPrimary stent placement
- PTA followed by stentPTA followed by stent
- Thrombolysis followed by stentThrombolysis followed by stent
Percutaneous
revascularization

32. Dr. Rajdeep Agrawal
INTERNAL ILIAC STEONSISINTERNAL ILIAC STEONSIS
- Isolated buttock claudicationIsolated buttock claudication
- ImpotenceImpotence
- PTA is the choicePTA is the choice
Percutaneous
revascularization

33. Dr. Rajdeep Agrawal
CFA STENOSISCFA STENOSIS
- Isolated is uncommon without history of injuryIsolated is uncommon without history of injury
(eg. Catheterization)(eg. Catheterization)
- Endarterectomy – choice simple, LA andEndarterectomy – choice simple, LA and
conscious sedationsconscious sedations
- Durable than PTADurable than PTA
Percutaneous
revascularization

34. Dr. Rajdeep Agrawal
Ext. Iliac Artery stenosis - before,
after dilatation, after stent

35. Dr. Rajdeep Agrawal
Femoro poplitealFemoro popliteal
- Lesion 3 times commoner than iliac- Lesion 3 times commoner than iliac
- Occlusions 3 times commoner than- Occlusions 3 times commoner than
stenosisstenosis
- 80% of the stenosis- 80% of the stenosis areare <<10cm10cm
- 20% occlussions- 20% occlussions << 10cm10cm
Percutaneous
revascularization

36. Dr. Rajdeep Agrawal
Femoro poplitealFemoro popliteal
- 10 cm upper limit to select cases- 10 cm upper limit to select cases
- Stents disappointing beyond that- Stents disappointing beyond that
length of stenosislength of stenosis
- Covered (PTFF) grafts have a promise- Covered (PTFF) grafts have a promise
- Over 5 years 15-20% new Femoro- Over 5 years 15-20% new Femoro
popliteal occlussions developpopliteal occlussions develop
Percutaneous
revascularization

37. Dr. Rajdeep Agrawal
Narrowed superficial femoral artery
before & after dilatation

38. Dr. Rajdeep Agrawal
Femoropopliteal stenosis:Femoropopliteal stenosis:
- PTA is less durable than bypass.PTA is less durable than bypass.
- Bypass 5 year patency rate is about 80%Bypass 5 year patency rate is about 80%
-- Complication of PTA is 10%, surgical repairComplication of PTA is 10%, surgical repair
required in 2% casesrequired in 2% cases
Percutaneous revascularization

39. Dr. Rajdeep Agrawal
Femoropopliteal stenosisFemoropopliteal stenosis
-- Stents useful in proximal Superficial FemoralStents useful in proximal Superficial Femoral
ArteryArtery
-- Stents – restenosis in distal SFA or poplitealStents – restenosis in distal SFA or popliteal
artery due to extrinsic compressions (eg.artery due to extrinsic compressions (eg.
Addutor canal) is possibleAddutor canal) is possible
-- Long term consequences of placing flexibleLong term consequences of placing flexible
stents across joints is unknown.stents across joints is unknown.
Percutaneous revascularization

40. Dr. Rajdeep Agrawal
Femoropopliteal occlussions:Femoropopliteal occlussions:
- Long segment or complete SFA occlusionsLong segment or complete SFA occlusions
does not respond well to any widelydoes not respond well to any widely
available endovascular techniqueavailable endovascular technique
- Amplatz thrombectomy catheter – excellentAmplatz thrombectomy catheter – excellent
technical access, but long term patency istechnical access, but long term patency is
modest or unknownmodest or unknown
- Covered stents - results disappointingCovered stents - results disappointing
- Endovascular stent grafts show mostEndovascular stent grafts show most
promisepromise
Percutaneous
revascularization

41. Dr. Rajdeep Agrawal
Femoropopliteal occlusions:Femoropopliteal occlusions:
- PTA is effective for short solitary occlusions,PTA is effective for short solitary occlusions,
< 10cm long, not involving SFA origins or< 10cm long, not involving SFA origins or
distal popliteal arterydistal popliteal artery
and tenders occlusions <3cm longand tenders occlusions <3cm long
- Focal occlussions (<2 to 3cm)Focal occlussions (<2 to 3cm) PTA alonePTA alone
- Long occlussions – Thrombolysis prior to PTALong occlussions – Thrombolysis prior to PTA
Percutaneous revascularization

42. Dr. Rajdeep Agrawal
Femoropopliteal occlusions:Femoropopliteal occlusions:
- Upper SFA occlusions – stent if PTA is sub-Upper SFA occlusions – stent if PTA is sub-
optimaloptimal
- PTA long term patency rates may bePTA long term patency rates may be
substantially less than clinical patency ratessubstantially less than clinical patency rates
- Technical failure almost always results fromTechnical failure almost always results from
inability to cross the lesion with guide wire.inability to cross the lesion with guide wire.
Percutaneous revascularization

43. Dr. Rajdeep Agrawal
Infra-popliteal revascularization -Infra-popliteal revascularization -
IndicationsIndications
Absence of pedal pulses – minimal orAbsence of pedal pulses – minimal or
asymptomaticasymptomatic
If collaterals are not well developed orIf collaterals are not well developed or
limitation of activity resultslimitation of activity results
Focal lesionsFocal lesions
Limited in diffuse disease,Limited in diffuse disease,
If short term patency is desired sufficient toIf short term patency is desired sufficient to
heal superficial ulcerations or amputationheal superficial ulcerations or amputation
sitessites
Percutaneous
revascularization

44. Dr. Rajdeep Agrawal
Infra popliteal revascularization –Infra popliteal revascularization –
Early results - Not impressiveEarly results - Not impressive
Manipulations - Easier with DSAManipulations - Easier with DSA
& road mapping& road mapping
Increased popularity - Safe & SuccessfulIncreased popularity - Safe & Successful
Decision with surgeonDecision with surgeon
Inflow lesions Treatment firstInflow lesions Treatment first
Percutaneous
revascularization

45. Dr. Rajdeep Agrawal
Tibial Artery Obstructions:Tibial Artery Obstructions:
–– Infra popliteal PTA is almost always performed forInfra popliteal PTA is almost always performed for
limb salvagelimb salvage
- Short term patency may be sufficient to allow healingShort term patency may be sufficient to allow healing
of an ischemic ulcer or amputation site or to avoidof an ischemic ulcer or amputation site or to avoid
amputationamputation
- PTA is not particularly effective if run-off vessels arePTA is not particularly effective if run-off vessels are
not visualized. Liberal Heparin use must to maintainnot visualized. Liberal Heparin use must to maintain
patencypatency
Percutaneous revascularization

46. Dr. Rajdeep Agrawal
STENTS RESULTSSTENTS RESULTS
-- Technical success rate – 90-100%Technical success rate – 90-100%
-- Cumulative 5 year vessel patency – 94%Cumulative 5 year vessel patency – 94%
-- Clinical success – 93%Clinical success – 93%
-- (PTA 65% & 70%)(PTA 65% & 70%)
Percutaneous revascularization

47. Dr. Rajdeep Agrawal
Infra-popliteal revascularizationInfra-popliteal revascularization
IndicationsIndications
-- Limb threatening IshcemiaLimb threatening Ishcemia
(Disabling claudication, Rest pain, Ulcer, Gangrene)(Disabling claudication, Rest pain, Ulcer, Gangrene)
-- ABI < 0.5 Ischemic rest pain or ankle pressure <60ABI < 0.5 Ischemic rest pain or ankle pressure <60
mm, with or without a non healing ulcermm, with or without a non healing ulcer
-- DM – ABI not useful - calcificationDM – ABI not useful - calcification
Percutaneous
revascularization

48. Dr. Rajdeep Agrawal
Stent
 An expandable metallic helicalAn expandable metallic helical
device which is permanentlydevice which is permanently
implanted in the arteryimplanted in the artery ..
 MechanismMechanism
 The prosthesis acts as aThe prosthesis acts as a
scaffold to hold the artery openscaffold to hold the artery open
 Prevents recoil of the vesselPrevents recoil of the vessel
 Reduces RestenosisReduces Restenosis

49. Dr. Rajdeep Agrawal
Newer Techniques Of
Angioplasty
 AtherectomyAtherectomy
 DirectionalDirectional
 Percutaneous RotationalPercutaneous Rotational
 TECTEC
 LASERLASER
 StentStent

50. Dr. Rajdeep Agrawal
Directional Atherectomy
 It excises the atheromatousIt excises the atheromatous
plaque material into very fineplaque material into very fine
slices which can be retrievedslices which can be retrieved
outside bodyoutside body

51. Dr. Rajdeep Agrawal
Percutaneous Rotational
Atherectomy (Rotablator)

52. Dr. Rajdeep Agrawal
LASER
 A LASER produces an intenseA LASER produces an intense
beam of light in uniformbeam of light in uniform
wavelength that can be preciselywavelength that can be precisely
focused to deliver high energyfocused to deliver high energy
levels to a small arealevels to a small area
 It converts solid plaque to gasIt converts solid plaque to gas
which is soluble in bloodwhich is soluble in blood

53. Dr. Rajdeep Agrawal
Stent Complications (5-10%)Stent Complications (5-10%)
Groin hematomaGroin hematoma
Pseudo AneurysmPseudo Aneurysm
Embolization of thrombusEmbolization of thrombus
Acute stent thrombosisAcute stent thrombosis
DissectionDissection
Vessel perforationVessel perforation
Percutaneous
revascularization

54. Dr. Rajdeep Agrawal
IDDM – Reduce insulinIDDM – Reduce insulin
First caseFirst case
5% Dextrose, Blood sugar,5% Dextrose, Blood sugar,
Insulin (1-3 units/ hr) or more for higherInsulin (1-3 units/ hr) or more for higher
blood glucose levelsblood glucose levels
No protamine zinc insulin should be usedNo protamine zinc insulin should be used
Protamine antagonizes the heparinProtamine antagonizes the heparin
anticoagulationanticoagulation
Hybration to prevent aute tubular necrosisHybration to prevent aute tubular necrosis
Percutaneous
revascularization

55. Dr. Rajdeep Agrawal
Cost effectiveness of PTA compared toCost effectiveness of PTA compared to
surgical reconstructionsurgical reconstruction
PTA - Bypass - 53% in Disabling ClaudicationPTA - Bypass - 53% in Disabling Claudication
75% in critical ischemia75% in critical ischemia
A cost effective analysis demonstrated that performingA cost effective analysis demonstrated that performing
PTA as a initial procedure is more desirablePTA as a initial procedure is more desirable
technically feasible cases and reserving bypasstechnically feasible cases and reserving bypass
surgery for those PTS in whom PTA fails, or recurssurgery for those PTS in whom PTA fails, or recurs
would save more lives, limbs and money.would save more lives, limbs and money.
Percutaneous revascularization

56. Dr. Rajdeep Agrawal
Cost effectiveness of PTA compared toCost effectiveness of PTA compared to
surgical reconstructionsurgical reconstruction
In technically feasible cases PTA would be theIn technically feasible cases PTA would be the
preferred optionpreferred option
Reserve bypass surgery for those PTAs inReserve bypass surgery for those PTAs in
whom it fails, or recurswhom it fails, or recurs
It would save more lives, limbs and money.It would save more lives, limbs and money.
Percutaneous revascularization

57. Dr. Rajdeep Agrawal
Complications:Complications:
Vasospasm - Nifedipine start well beforeVasospasm - Nifedipine start well before
procedureprocedure
- Intra-arterial Nitroglycerins,- Intra-arterial Nitroglycerins,
in the vessel to be treated –in the vessel to be treated –
(100 to 200 mg) before(100 to 200 mg) before
dilationdilation
Flow limiting dissection flap – Employ StentFlow limiting dissection flap – Employ Stent
Percutaneous revascularization

58. Dr. Rajdeep Agrawal
Complications:Complications:
Post PTA occlusion –Post PTA occlusion –
Repeat PTA & thrombolytic therapyRepeat PTA & thrombolytic therapy
OR Repeat PTA – StentOR Repeat PTA – Stent
Arterial rupture – Reinflation of baloon acrossArterial rupture – Reinflation of baloon across
rupturerupture ,, followed by surgical repairfollowed by surgical repair
Percutaneous revascularization

59. Dr. Rajdeep Agrawal
Medical Therapy
Exercise programExercise program
Risk factor modificationsRisk factor modifications

60. Dr. Rajdeep Agrawal
Results of percutaneous therapy
Site &Site &
DiseaseDisease
Of arterialOf arterial
stenosisstenosis
TherapTherap
yy
SuccessSuccess
% of% of
TechnicTechnic
1 year1 year
patencypatency
(%)(%)
3 year3 year
patencpatenc
y (%)y (%)
AbdominalAbdominal
AortaAorta
PTAPTA 9595 ?? ??
IliacIliac PTAPTA 9595 8080 7070
IliacIliac StentStent 9595 9090 8585
Iliac occlusionIliac occlusion StentStent 8080 7070 6565
Two year limb salvage of 60 to 80%Two year limb salvage of 60 to 80%

61. Dr. Rajdeep Agrawal
Results of percutaneous therapy
Site & DiseaseSite & Disease
Of arterialOf arterial
stenosis /stenosis /
occlusionocclusion
TherapyTherapy SuccesSucces
s % ofs % of
TechnicTechnic
OneOne
yearyear
patencypatency
(%)(%)
ThreeThree
yearyear
patencypatency
(%)(%)
ProximalProximal
femoralfemoral
StentStent 9595 8585 7575
FemoroFemoro
poplitealpopliteal
OcclusionOcclusion
Lysis,Lysis,
PTAPTA
8080 5050 4040
Tibial stenosisTibial stenosis PTAPTA 9090 -- --
Two year limb salvage of 60 to 80%Two year limb salvage of 60 to 80%

62. Dr. Rajdeep Agrawal
Aorto-iliac Occlusions:Aorto-iliac Occlusions:
Aorto bifemoral bypassAorto bifemoral bypass
- Extra anatomic- Extra anatomic
- Endarterctomy- Endarterctomy
- 5 year patency - 85 to 95%- 5 year patency - 85 to 95%
Surgical revascularization - 1

63. Dr. Rajdeep Agrawal
Infra – inguinal occlusions:Infra – inguinal occlusions:
- Autologous veins or PTFE grafts are usedAutologous veins or PTFE grafts are used
PTEF above Hunter’s canal for SFAPTEF above Hunter’s canal for SFA
- Saphenous Vein – below knee, for tibial or peronealSaphenous Vein – below knee, for tibial or peroneal
occlusionocclusion
- 5 yr patency – 60% - above5 yr patency – 60% - above
- Below knee – 3 yr patency and limb salvage 58 toBelow knee – 3 yr patency and limb salvage 58 to
92% respectively92% respectively
Surgical revascularization - 1

64. Dr. Rajdeep Agrawal
AORTIC OCCLUSSIONSAORTIC OCCLUSSIONS
- Aorto bifemoral graft with endarterectomyAorto bifemoral graft with endarterectomy
axillo bifemoral graft or thorarofemoral graftaxillo bifemoral graft or thorarofemoral graft
- Re-construction with endovascular stent graftRe-construction with endovascular stent graft
is feasible – long term results unknownis feasible – long term results unknown
Surgical revascularization - 2

65. Dr. Rajdeep Agrawal
Lower Limb Ischemia -
Approach to Therapy
Direct arterial reconstruction.Direct arterial reconstruction.
 EndarterectomyEndarterectomy
 Vascular bypassVascular bypass
 Endovascular (minimally invasive)Endovascular (minimally invasive)
interventionintervention
 Lumbar sympathectomyLumbar sympathectomy

66. Dr. Rajdeep Agrawal
Lower Limb Ischemia -
Results of Direct Reconstruction
 Aorto illiac reconstruction - early graft patency ofAorto illiac reconstruction - early graft patency of
about 98%, operative mortality 3%:5years graftabout 98%, operative mortality 3%:5years graft
patency of 85-90%.patency of 85-90%.
 Femoro popliteal bypass - early graft patency ofFemoro popliteal bypass - early graft patency of
over 90%, with mortality of 2-5% : 5 year patencyover 90%, with mortality of 2-5% : 5 year patency
of about 75%.of about 75%.
 Infrapopliteal/ paramalleolar bypass - earlyInfrapopliteal/ paramalleolar bypass - early
patency of about 90% with 2% mortality. 5 yearpatency of about 90% with 2% mortality. 5 year
patency of 55%patency of 55%
LIMB SALVAGE about 90%LIMB SALVAGE about 90%

67. Dr. Rajdeep Agrawal
OPERATIONS
Depends on the site of occlusion andDepends on the site of occlusion and
the physical state of the patientthe physical state of the patient..

68. Dr. Rajdeep Agrawal
Aorto-iliac occlusion
 Limited involvement : Iliac EndartectomyLimited involvement : Iliac Endartectomy
 Marked involvement : Aorto-femoral bypassMarked involvement : Aorto-femoral bypass
Aorto-iliac occlusion patient unable to undergoAorto-iliac occlusion patient unable to undergo
surgerysurgery;;
 1 iliac artery involved : femoro-femoral or ileo-1 iliac artery involved : femoro-femoral or ileo-
femoral bypassfemoral bypass
 Both iliac arteries involved : Axillo-bifemoralBoth iliac arteries involved : Axillo-bifemoral
bypassbypass

69. Dr. Rajdeep Agrawal
 AtheroscleroticAtherosclerotic
narrowing ofnarrowing of
aortic bifurcationaortic bifurcation
 AortobifemoralAortobifemoral
graft to bypassgraft to bypass
stenosisstenosis

70. Dr. Rajdeep Agrawal
Femoral & Profunda Femoris
Occlusion
 If conservative measures not suitable,If conservative measures not suitable,
PTA may be possiblePTA may be possible
 For more severe disease, angioplastyFor more severe disease, angioplasty
or bypass maybe usedor bypass maybe used
 Femoropopliteal bypass graft is theFemoropopliteal bypass graft is the
most usual operationmost usual operation
 Saphenous vein graft gives the bestSaphenous vein graft gives the best
resultsresults

71. Dr. Rajdeep Agrawal
 SuperficialSuperficial
femoral arteryfemoral artery
occlusion withocclusion with
profunda femorisprofunda femoris
stenosis providingstenosis providing
poor collateralpoor collateral
circulationcirculation
 FemoropoplitealFemoropopliteal
graft used tograft used to
bypass thebypass the
occluded areaoccluded area

72. Dr. Rajdeep Agrawal
Occlusion below popliteal
 Bypass to tibial vessels, even down toBypass to tibial vessels, even down to
the ankle can be met with reasonablethe ankle can be met with reasonable
success.success.
 Most successful is with long saphenousMost successful is with long saphenous
vein in thevein in the in situin situ fashion.fashion.
 If saphenous not available, can useIf saphenous not available, can use
PTFE (Polytetrafluoroethylene) graft.PTFE (Polytetrafluoroethylene) graft.

73. Dr. Rajdeep Agrawal
PROSTHETIC MATERIALS
 Aortoiliac bypass - DacronAortoiliac bypass - Dacron
 Femoropopliteal - Autogenous veinsFemoropopliteal - Autogenous veins
(Long saphenous best)(Long saphenous best)
If not available - PTFE orIf not available - PTFE or
glutaraldehyde-tanned, Dacronglutaraldehyde-tanned, Dacron
supported, human umbilical veinsupported, human umbilical vein
 Profundoplasty - Vein/PTFE/DacronProfundoplasty - Vein/PTFE/Dacron

74. Dr. Rajdeep Agrawal
Treatment of A/C Occlusion
 Embolectomy - Using Fogarty’s catheter ->Embolectomy - Using Fogarty’s catheter ->
Catheter passed beyond emblous, balloonCatheter passed beyond emblous, balloon
inflated & pulled back till blood comesinflated & pulled back till blood comes
 Direct Embolectomy - Artery exposed,Direct Embolectomy - Artery exposed,
transverse incision, clot removed.transverse incision, clot removed.
 Intra-arterial Thrombolysis - TPA preferred.Intra-arterial Thrombolysis - TPA preferred.
Arteriography done and a catheter embeddedArteriography done and a catheter embedded
in clot - Thrombolytic agent infused overin clot - Thrombolytic agent infused over
several hrsseveral hrs

75. Dr. Rajdeep Agrawal
Surgical Embolectomy
 Relatively simple procedureRelatively simple procedure
 Done under LA, small incision in theDone under LA, small incision in the
groin, using Fogarty’s cath.groin, using Fogarty’s cath.
 ProblemsProblems
1. Blind procedure, can be traumatic1. Blind procedure, can be traumatic
2. Not successful in 10 – 30% cases2. Not successful in 10 – 30% cases
3. Inefficient in multistenosed artery3. Inefficient in multistenosed artery
4. Complete removal of thrombus4. Complete removal of thrombus
difficult in leg arteriesdifficult in leg arteries

76. Dr. Rajdeep Agrawal
Post PTA MX
 Antiplatelet agentsAntiplatelet agents
 LMW Heparin X 7 – 10 DLMW Heparin X 7 – 10 D
 IV / oral TrentalIV / oral Trental
 StatinsStatins
 Aggressive control of riskAggressive control of risk
factorsfactors

77. Dr. Rajdeep Agrawal
Conclusion
 In Diabetic foot, PVD contributes toIn Diabetic foot, PVD contributes to
amputation by impeding the delivery ofamputation by impeding the delivery of
antibiotics, Oxygen, nutrients & byantibiotics, Oxygen, nutrients & by
delaying wound healing & the ability todelaying wound healing & the ability to
fight infection.fight infection.
 Aggressive therapy with debridement,Aggressive therapy with debridement,
antibiotics,good control of Diabetes &antibiotics,good control of Diabetes &
when indicated revascularisationwhen indicated revascularisation
results in salvage of > 90% ofresults in salvage of > 90% of
threatened limbs even in high riskthreatened limbs even in high risk
patientspatients