Xử trí bệnh động mạch ngoại vi phức tạp lựa chọn bệnh và mẹo để chọc mạch

VHA scientific meeting, 12°October 2014 Managementof Peripheral Artery Disease in the elderly: from patients selection to access tricks Gianluca Rigatelli, MD, PhD, EBIR, FACP, FACC, FESC, FSCAI Vice-Director, Cardiovascular Diagnosis and Endoluminal Interventions Unit Director, Congenital Heart Disease Interventions, Co-Director Peripheral Artery Disease Interventions, S.Maria della Misericordia Rovigo General Hospital, Rovigo, Italy Distrectual PAD • Femoral/popliteal: 80-90% • Tibial/peroneal: 4050% • Aorto-iliac: 30% Harrison’s Principles of Int Med Atherosclerotic artery disease AMI ANGINA ICTUS TIA Hypertension Renal failure Dibetic foot CLAUDICATIO ACUTE ISCHEMIA DISTRICT Clinical syndrome Subclavian Iliac-femoral Femoro-popliteal Below knee Subclavian steal Claudication Critical and acute limb ischemia Diabetic Foot PAD INCIDENCE Rotterdam (ABI Test >> fluoro or US guide  DIRECT ACCESS TO THE ARTERY  STRAIGHT ROUTE TO THE LESION  A 0.14-0.18 INCH WIRE CAN BE USED Drawbacks:  NEED OF A T LEAST 7F 23 CM SHEATH  SOMETIMES DIFFICULT TRACK IN OCCLUSIVE DISEASE  SOMETIMES NEED OF CONTROLATERAL ACCESS FOR INJECTING (OSTIAL DISEASE) Radio-brachial Technique Radio-brachial Technique Advantages: Drawbacks:  SIMPLE TO DO ( FOR CORONARY GUYS  AVOID MAJOR ACCESS SITE BLEEDING  SAFER ROUTE FROM ABOVE FOR OCCLUSIVE DISEASE  DIFFICULT ACCESS TO THE LESION SITE IF AORTICH ARCH TYPE OR  NEED OF 90 CM LONG TO 7F SHEATH (Shuttle or Flexor Cook, Biotronik, Terumo)  NEED OF HIGH SUPPORT WIRE (EASY ACCESS IN CASE OF VESSEL RUPTURE)>>> Look at the back up covered stent size Vassilev D,Rigatelli G et al Poland J Cardiol in PRESS Special case: carotid artery angioplasty and stenting Disadvantages: - spasm !!! -anatomical challenges Advantages: - Simple route for RCA and LCA if approach from right and left radial respectively - No manipulation of the arch - Virtually no bleeding -size matter! 1) 2) 3) 4) 5) 6) 7) radial access in the usual site as per PCI 5F short sheath Mammary artery + Terumo 035 inch to the RCA or Simmond/Amplatz +Terumo to the LCA Catheter in the external carotid artery Exchange wire for a Stiff ,035 inch (Amplatz , Supracor, etc) Advance a F 70 or 90 cm long guiding sheath (Cook, Terumo, Biotronik) Perform neuroprotection and stenting 1) Direct engagement 2) Looping technique 3) Multiple wire technique SOME SUGGESTIONS:  USE the right radial for the RCA and left radial for the LCA >>>to control the symptoms and to avoid arch manipulation  Give a good superficial sedation to the patient>>>to decrease spasm Bilateral CAS, Cardaioli P, Rigatelli G, et al Minerva Cardioangiologica 2013 CONCLUSIONS A) Aged patients are the typical patients you may face with managing peripheral artery disease B) You need to carefully select patients based upon: clinic, anatomy, global assessment, need of specific approach C) Good access site selection and technique is mandatory to succeed in peripheral angioplasty in aged patients D) Radio-brachial access is emerging as the preferred approach in PAD patients in the elderly Let’s keep our elderly pts alive! [...]... technique 1 Pedideal Puncture Technique 2 Advantages:  OPTIMAL VISUALIZATION OF THE ARTERY  Access to popliteal artery when other route are ineffective Drawbacks:  NEED FOR micropuncture set  ATTENTION when the pedideal is the unique artery of the foot Popliteal Puncture technique 1 Popliteal Puncture Technique 2 Advantages:  OPTIMAL VISUALIZATION OF THE ARTERY  Access to femoral or tibial artery... Tibial-pedideal occlusion Pedideal (ADVANCED) tibial peroneal occlusion Brachial ostial superficial femoral stenosis-occlusion Femoral Crossover Technique 1 Femoral Crossover Technique 2 Advantages:  OPTIMAL VISUALIZATION OF THE ARTERY  SIMPLE TO DO Drawbacks:  NEED FOR CROSSOVER SHEATH  DIFFICULT ADVANCEMENT OF MATERIALS  HUGE LIMITATION INTREATING DISTAL FEMORAL , POPLITEAL AND BTK DISEASE Antegrade... angioplasty and stenting Disadvantages: - spasm !!! -anatomical challenges Advantages: - Simple route for RCA and LCA if approach from right and left radial respectively - No manipulation of the arch - Virtually no bleeding -size matter! 1) 2) 3) 4) 5) 6) 7) radial access in the usual site as per PCI 5F short sheath Mammary artery + Terumo 035 inch to the RCA or Simmond/Amplatz +Terumo to the LCA Catheter