Technical Pearls and Results of Technical Pearls and Results of Endovascular Therapy for Critical Limb Endovascular Therapy for Critical Limb Dorros-Feuer Interventional Ischemia Ischemia Cardiovascular Disease Foundation, Ltd Gerald Dorros MD, ScD (Yeshiva) , MA (ex officio Colby ’02) , ScD (Colby), Gerald Dorros MD, ScD (Yeshiva) , MA (ex officio Colby ’02) , ScD (Colby), FACC, FESC, FASCI, FACP, FSVMB, FCCP, FACA FACC, FESC, FASCI, FACP, FSVMB, FCCP, FACA Clinical Professor of Medicine, Columbia University, NYC Clinical Professor of Medicine, Columbia University, NYC Adjunct Professor of Medicine, State University of New York, Buffalo (NY) Adjunct Professor of Medicine, State University of New York, Buffalo (NY) Dorros-Feuer Interventional Cardiovascular Disease Foundation Dorros-Feuer Interventional Cardiovascular Disease Foundation Jackson Hole ( WY), Grafton (WI), and Phoenix (AZ) Jackson Hole ( WY), Grafton (WI), and Phoenix (AZ) Jan-04 TCT Washington D.C. 8.2003
TPV-PTA: Classification Dorros-Feuer Interventional Cardiovascular Claudicants Disease Limb Salvage Foundation, Ltd Class I-II Class III-IV Ulcers/non--healing Rest Pain wound/gangrene Class III Class IV Jan-04
Technical Pearls: Preferred approaches Technical Pearls: Preferred approaches 1. Contralateral with sheath: 6F coronary multipurpose guide, coronary wires, balloons, and stents Dorros-Feuer 2. Antegrade puncture Interventional Cardiovascular 3. Staged procedure for SFA flush occlusion: popliteal, then Disease Foundation, Ltd contralateral or even antegrade 4. Left brachial with long sheath (125cm) and coronary equipment (150cm) for situations with fem-fem graft. 5. DP/AT cutdown for flush occlusions of the TPV. 6. AVOID Complications: COMPARTMENT SYNDROME (carefully open occlusions and avoid bleeding), stents for tears, distal embolization, prolonged balloon inflation for tears, avoid compressing ipsilateral side to maintain antegrade flow. Jan-04
CLI 80M CLI 80M [L.subclavian [L.subclavian Dorros-Feuer Interventional occl. (80M)] : L. occl. (80M)] : L. Cardiovascular Disease brachial brachial Foundation, Ltd approach approach stent stent recanalization recanalization Jan-04
Ischemic petechia: recognition and Ischemic petechia: recognition and recanalization (RA 80M) recanalization (RA 80M) Dorros-Feuer Interventional Cardiovascular Disease Foundation, Ltd Jan-04
Popliteal Approach used for Popliteal Approach used for recanalization of SFA recanalization of SFA occlusion for CLI, was occlusion for CLI, was complication by popliteal complication by popliteal Dorros-Feuer Interventional fossa hemorrhage 1 (6/92 MC 60F) fossa hemorrhage 1 (6/92 MC 60F) Cardiovascular Disease Foundation, Ltd Jan-04
Healing of right foot occurs 2 (6/93) Healing of right foot occurs 2 (6/93) Dorros-Feuer Interventional Cardiovascular Disease Foundation, Ltd Jan-04
Patient returns with right leg claudication 3 (5/94) Patient returns with right leg claudication 3 (5/94) Dorros-Feuer Interventional Cardiovascular Disease Foundation, Ltd Jan-04
Bilateral popliteal occlusions 1 Bilateral popliteal occlusions 1 (78F with severe COPD, Class IV angina; 8/90) (78F with severe COPD, Class IV angina; 8/90) Dorros-Feuer Interventional Cardiovascular Disease Foundation, Ltd Bilateral balloon PTA, 8/80 Jan-04
Bilateral popliteal occlusions 1 : 2.5 yrs. latter Bilateral popliteal occlusions 1 : 2.5 yrs. latter (81F with severe COPD, Class IV angina; 1st PTA in 8/90) (81F with severe COPD, Class IV angina; 1st PTA in 8/90) Dorros-Feuer Interventional Cardiovascular Disease Foundation, Ltd Jan-04
CLI: Resolution of long standing ischemic ulcer CLI: Resolution of long standing ischemic ulcer with TPV PTA with TPV PTA Dorros-Feuer Interventional Cardiovascular Disease Foundation, Ltd Jan-04
Dorros-Feuer Interventional Cardiovascular Disease Foundation, Ltd Jan-04
Dorros-Feuer Interventional Cardiovascular Disease Foundation, Ltd Jan-04
CLI: using coronary techniques CLI: using coronary techniques to solve a peripheral problem of to solve a peripheral problem of left posterior tibial artery (66M) left posterior tibial artery (66M) Dorros-Feuer Interventional Cardiovascular Disease Foundation, Ltd Jan-04
Dorsalis pedis cannulation: cutdown to expose Dorsalis pedis cannulation: cutdown to expose artery; similarly can be done for posterior tibial artery; similarly can be done for posterior tibial artery artery Dorros-Feuer Interventional Cardiovascular Disease Foundation, Ltd Jan-04
Results and Resource Implications of Results and Resource Implications of Treating End-stage Limb Ischemia: Treating End-stage Limb Ischemia: Holdsworth* Holdsworth* Dorros-Feuer Interventional 228 Pts Cardiovascular Disease 275 severely ischemic limbs Foundation, Ltd 235 limbs (86%) 19 limbs (7%) 21 limbs (8%) procedure to improve primary amputation treated conservatively blood supply Jan-04 Holdsworth et al. Eur J Vasc Endovasc Surg 1997; 13:164-173
Results and Resource Implications of Results and Resource Implications of Treating End-stage Limb Ischemia Treating End-stage Limb Ischemia 284 grafts Dorros-Feuer Interventional Cardiovascular Disease Foundation, Ltd Individual grafts Additional Procedure 216 (76%) 51(18%) 17(6%) 31 (10%) 28 (10%) primary secondary supplemental revisions thrombectomy Holdsworth et al. Eur J Vasc Endovasc Surg 1997; 13:164-173 Jan-04
Results and Resource Implications of Results and Resource Implications of Treating End-stage Limb Ischemia Treating End-stage Limb Ischemia 1 Dorros-Feuer Interventional 0.8 Cardiovascular Disease percent 0.6 Foundation, Ltd 0.4 0.2 0 0 1yr 2yr 3yr 4yr 1 0.83 0.73 0.68 0.65 limb salvage 1 0.69 0.58 0.48 0.41 survival Jan-04 Holdsworth et al. Eur J Vasc Endovasc Surg 1997; 13:164-173
Results and Resource Implications of Results and Resource Implications of Treating End-stage Limb Ischemia Treating End-stage Limb Ischemia Dorros-Feuer Interventional “ An acceptable limb-salvage rate can be Cardiovascular Disease Foundation, Ltd achieved although there is a high initial mortality . In view of the poor overall survival, any benefit for these patients should be viewed as relatively short-term objectives.” Holdsworth, vascular surgeon, Stirling Royal Infirmary, Stirling, UK Holdsworth et al. Eur J Vasc Endovasc Surg 1997; 13:164-173 Jan-04
TPV-PTA: Demographics Dorros-Feuer Class I-III Class IV Class V Interventional Cardiovascular PTS. 77 134 101 Disease Foundation, Ltd Male 22 (29%) 39 (29%) 34 (34%) Female 55 (71%) 95 (71%) 67 (66%) Cases 133 166 118 Age 65 + 11 (32-88) 67 + 8 (46-83) 67 + 10 (40-86) #Dilation Sites 359 450 319 TPV 208 258 191 Other 151 192 128 Jan-04
TPV: Demographics Class I-III Class IV Class V NYHA CI 3-4 4 (3%) 17 (10%) 1 (1%) Dorros-Feuer Interventional CHF, prior 12 (9%) 7 (4%) 28 (24%) Cardiovascular Prior MI 41 (31%) 36 (22%) 43 (36%) Disease Foundation, Ltd Prior CABG 44 (33%) 57 (35%) 38 (32%) Prior PV Surg 52 (39%) 63 (38%) 48 (41%) Diabetes 55 (41%) 63 (38%) 83 (70%) CRF 30 (23%) 29 (17%) 48 (41%) Hypertension 72 (54%) 103 (62%) 77 (65%) CVA 12 (9%) 14 (8%) 14 (12%) TIA 5 (4%) 13 (8%) 7 (6%) Jan-04
TPV-PTA: Success 2 Dorros-Feuer Interventional Cardiovascular Class I-III Class IV Class V Disease Stents 1/ 1 1/ 1 5/ 5 Foundation, Ltd Other Sites Femoral 75/ 75 97/ 99 46/ 46 Iliac 9/ 10 5/ 5 6/ 6 Popliteal 59/ 59 81/ 83 68/ 71 Renal 5/ 5 4/ 4 4/ 4 Subclavian 1/ 1 1/ 1 --- Jan-04
TPV-PTA: Success 1 100 Dorros-Feuer Interventional 80 Cardiovascular Disease Foundation, Ltd 60 TPV % Success Stenosis 40 Occlusion 197 148 49 240 197 43 168 116 52 - - - - - - - - - 208 151 57 258 198 60 191 120 71 20 0 Class I-III Class IV Class V Jan-04
TPV-PTA: Complications 1 Class I-II Class III Class IV Dorros-Feuer Interventional Death Related -- -- 1 (1%) Cardiovascular Spasm 7 (5%) 2 (1%) 4 (4%) Disease Foundation, Ltd Distal Emboli 2 (1%) 5 (3%) 1 (1%) Dissection 11 (8%) 2 (1%) 9 (8%) Occlusion 2 (1%) -- 1 (1%) Em Vasc Surg 2 (1%) 2 (1 %) 1 (1%) Fem./Brach. Repair 2 (1%) 2 (1%) -- Bypass -- -- --* Amputation -- -- 1 (1%) * bypass followed by amputation Jan-04
TPV-PTA: Complications 2 Dorros-Feuer Interventional Cardiovascular Disease Foundation, Ltd Class I-II Class III Class IV Compartment Syndrome -- -- 1 (1%) ARF 3 (2%) 5 (3%) 15 (13%) Transfusion -- 6 (4%) 8 (5%) Major Infection -- 1 (1%) -- Jan-04
TPV-PTA: Discharge Data (no outliers > 30 days) Dorros-Feuer Interventional Class I-II Class III Class IV Cardiovascular Disease Hospital Days 5.6 + 5.0 (2-30) 4.8 + 3.9 (2-26) 8.1 + 6.5 (1-29) Foundation, Ltd Proc-dischg 4.1 + 3.9 (1-25) 3.5 + 3.5 (1-25) 5.9 + 5.0 (1-25) Clinical Status Improved 130 (98%) 165 (99%) 105 (89%) Unchanged 1 (<1%) 1 8 (7%) Worse 1 (<1%) -- 3 (3%) Deceased 1 (<1%) -- 2 (2%) Related -- -- 1 (1%) Jan-04
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