basic endovascular surgery

Dr Imran Javed MBBS, FCPS Surgery.

Ex-International Fellow Arizona Heart Institute / Hospital, Phoenix, AZ, USA.

Ex-Senior Registrar Cardiovascular Surgery

Allama Iqbal Medical College/ Jinnah Hospital Lahore, Pakistan.

Basic Endovascular Surgery

Basic Endovascular Surgery

Basics Instruments

•Needles

•Wires

•Catheters

•Sheaths

Basic Endovascular Surgery

• Balloons

• Stents

• Stent Grafts

• Filters

• Thrombolytics

• Closure Devices

• IVUS

Common Interventions

Endoluminal Therapy Offers Less Invasive Approaches, Thereby Justifying Intervention at

Earlier Stages in the Symptom/Disease Complex

Classical Surgical Indications to

Treat Intermittent Claudication Are

Obsolete in Many Cases

Endoluminal Treatment Has Liberalized Indications For Intervention

Origin of Endovascular Therapies

Crude… with only large shafted balloons, inflexible wires, etc.

Indications for Interventional Therapy Have Forever Changed

This is the 21st Century!!!

We Are A People On The Move...

Modern Treatment Methods Must Accommodate Our Life Style

Intermittent Claudication

• Absence of pain at rest

• Commencement of pain, tension

weakness after walking has begun;

intensification of condition until

walking becomes impossible

• Disappearance of symptoms after

a period of rest

Post-Op Pre-Op

ABI 0.56

“Cool” Laser

Interventional

Treatment Should Be

Reserved For The Most

Symptomatic Patients”

William R. Hiatt, M.D.

from Perler & Becker 1998

Laser Therapy Created Excitement

Hot Tip Created Excitement

but failed.

The Atherocath Turned out to be a Good Biopsy Instrument

But… Believe it or not, a new generation is forthcoming

Single Most Important Breakthrough!

The Palmaz Stent for Iliacs

The Palmaz Shatz Stent for Coronaries

A Second Most Important Breakthrough!

Overnight, Endoluminal Approaches Became the Standard of Practice in

Many Arterial Distributions

Subclavian

Renal

Iliac

Aorta

and…

SFA

Below

The Achilles heel of angioplasty, including stenting:

Restenosis and In-stent

Restenosis

New stent designs have decreased profile for delivery, increased

flexibility, and provided numerous alternatives in sizing -- but all of these failed to solve the restenosis problem

Researchers are Seeking Solutions

Cutting Balloon

Heparin Coated Stents

Conclusion:

No angiographic or

clinically related benefit

Antibiotic Coated Stents (Actinomycin-D)

Conclusion: Trial Halted

Naturally occurring antibiotic

coated stent. Sirolimus

Conclusion:

210 day trial, 120 pts, Coronary

0 InStent Restenosis

24 month trail, 45 pts, Coronary

0 InStent Restenosis

Cordis Velocity Stent

Balanced Effect -

Healing of

Stented Vessel Inhibition of Restenosis

The ideal drug has higher potency for smooth muscle cells

(SMCs) and lower potency for endothelial cells (ECs).

Benefit/Risk Relation

Investigations are extending into the peripheral circulation

Mobile Peripheral

Radiation Trial Sponsored by:

Novoste

Radiation to

Treat Instent

Restenosis

9 Years post-percutaneous deployment of endoluminal graft

THE SILVER HAWK SYSTEM

SilverHawk Atherectomy

Remote Endarterectomy

Cryoplasty

And Cool Laser (Spectranetics) has Returned

Laser Therapy Only

Beyond Occlusive Disease

Endovascular Attack on Aneurysms

• The current standard procedure, endoaneurysmorraphy with intraluminal graft placement was popularized by Creech, DeBakey and associates

Abdominal Aortic Aneurysms

• Parodi JC, Palmaz JC, Barone, MD

– Transfemoral intraluminal graft implantation for

abdominal aortic aneurysms

Ann. Vasc. Surgery, 1991, Nov.

Endovascular Stent Grafting of Abdominal Aortic Aneurysms

Commercially Available AAA Endografts

2002

Excluder

Gore

2005 PowerLink

Endologix

2003

Zenith

Cook

1999

AneuRx

Medtronic

April 15,

2008

If you had this 6cm infrarenal AAA,

would you prefer a 30cm xyphoid to pubis slice,

accompanied by perforations into veins, arteries and

other vital structures with needles, tubes, sheaths,

conduits, urinary catheter, etc?

• Completion angiogram shows aneurysm exclusion

• Groins repaired

• Follow-up CTA reveals thrombosis of AAA sac

Endoluminal Grafts (ELG’s) to Correct Aneurysmal Disease

Abdominal Aortic Aneurysm Rupture

Current Conclusions:

Excellent results when indications are appropriate

Deviations

Yield Failures

Current Conclusions:

Aorfix: Angulated Neck

The Aptus System

• Venture backed start-up

• Graft with fixation applied via

staples

• Smaller delivery system

• Locking modular limbs

• Unsupported body

ELGs have multiple advantages and when applied properly, results are equal or superior

to classical procedure

Current Conclusions:

8mm Graft

Splenic

Anastomosis

Fenestrated and Branched Endografts:

Courtesy David Hartley

The Next Frontier

Thoracic Endoluminal Grafts

Another Important Application

Great Vessel Transposition for Antegrade Delivery of

the TAG Endoprosthesis in the Proximal Aortic Arch

Edward B. Diethrich, MD; Marwan Ghazoul, MD;

Grayson H. Wheatley III, MD; Jeffrey B. Alpern, DO;

Julio A. Rodriguez-Lopez, MD; and Venkatesh Ramaiah, MD

Department of Cardiovascular and Endovascular Surgery

Arizona Heart Institute and Hospital, Phoenix, Arizona, USA

J. Endovas Therapy 2005

Surgical graft for

debranching

Endoluminal

graft

exclusion

The Future Is Now!

Another Area of Major Investigation

Cervical

Carotid Artery

Cervical

Carotid

Artery

Do or Will Cerebral Protection Devices Make a Difference in CAS?

Refocusing Attention on Congestive Heart Failure

Major cause for hospital

admission

Multiple Approaches

-Medical

-Surgical “patch”, cup, etc

Multiple Approaches

Refocusing Attention on Congestive Heart Failure

But where is all of this

leading us?

Shortly the Entire Human Genome Will be Available for

Treatment Selection

Risk Assessment

Prognosis

Can you imagine the power of gene

identification for the care of patients in the future?

VEGEF for Peripheral Vascular Disease

Basic Endovascular Surgery

ANATOMY

1. Femoral

2. Brachial

3. Radial

4. Axillary

5. Popliteal

Imaging System

ACIST Pressure Injector

Basic Endovascular Techniques

CONTRAST MEDIA

1. Ionic

2. Nonionic

Basic Endovascular Surgery

CONTRAST MEDIA Contrast Agents Anion Cation

Ionic Agents

Renografin Diatrizoate Sodium, meglumine, or

Angiovist mixture of both salts

Hypaque

Conray Iothalamate Meglumine, sodium, or both

Low Osmolar Agents

Iohexol (Omnipaque) Nonionic dimer

Iopamidol (Isovue) Nonionic dimer

Ioxaglate (Hexabrix) Ioxaglate Meglumine and sodium

Access Related Accessories

• Steering/Torque

devices

• Needles 18/21 GA

• Stopcocks

Basic Endovascular Surgery

Diameter Maximum Guidewire Common

Needles (gauge) Diameter (in.) Length

Seldinger 18 0.038 2 ¾ inch

19 0.025

20 0.021

21 0.018

Potts 18 0.038 2 ¾ inch

20 0.021

Amplatz (with 5 Fr Teflon 18 18-gauge 2 ½ inch

sheath over cannula) 20 sheath accepts

0.038

Butterfly 19 0.028 Various

venipuncture 21 0.021

Jelco IV (with Teflon sheath) 18 0.035 Various

20 0.025

NEEDLES

Basic Endovascular Surgery

Diameter Maximum Guidewire Common

Needles (gauge) Diameter (in.) Length

Syringe Needles 18 0.025 Various

20 0.021

21 0.018

Percutaneous Transhepatic 22 (black hub) 0.018 20 cm

Cholangiography 23 (green hub)

Sheath Needle 16G sheath 0.038 24 cm

(19-gauge

stylet)

NEEDLES

Basic Endovascular Surgery

ACCESS

1. Femoral

2. Brachial

3. Axillary

4. Popliteal

5. Radial

Basic Endovascular Surgery

ACCESS

1. Retrograde

2. Antegrade

Basic Endovascular Surgery

ACCESS

1. Single Puncture

2. Double Puncture

Guidewire Anatomy &

Construction • Composite construction

• Materials

– Stainless Steel

– Nitinol

– Jacketed Composite

• Tapered grinds

• Core

• Stainless Steel

– Used for support

– Stiffness varies based on taper / diameter of core

• Nitinol

– Used for it’s flexibility, memory and kink resistance

• Tip

• Platinum / Gold

– Provides radiopacity

– Atraumatic

– Ribbon formed for shaping tip

Core Material

• Core

• Stainless Steel

– Used for support

– Stiffness varies based on taper / diameter of core

• Nitinol

– Used for it’s flexibility, memory and kink resistance

• Tip

• Platinum / Gold

– Provides radiopacity

– Atraumatic

– Ribbon formed for shaping tip

Core Material

• Core

• Stainless Steel

– Used for support

– Stiffness varies based on taper / diameter of core

• Nitinol

– Used for it’s flexibility, memory and kink resistance

• Tip

• Platinum / Gold

– Provides radiopacity

– Atraumatic

– Ribbon formed for shaping tip

Core Material

Grind & Tip Performance

• Stiff

• Intermediate

• Floppy

Variable Tip Grinds & Visibility

Variable Grinds & Tip Stiffness

Tip Shaping

• Shapeable tips

• Pre-shaped tips

Dilators

Sheaths

• Sheaths are hemostatic conduits inserted into the

vessel. They allow passage of guidewires, catheters

and interventional devices. The allows these to be

passed in and out of the body without damaging the

vessel and reducing the blood loss.

Sheath Construction

Hemostatic Valve

3-Way Stopcock

Sheath Conduit

Dilator (obturator)

Sheaths

• Peripheral and coronary sheaths have a universal color code

• Universal color coding

4 Fr = red

5 Fr = gray

6 Fr = green

7 Fr = orange

8 Fr = blue

9 Fr = black

10 Fr = violet

11 Fr = yellow

• Sheaths are measured inner diameter in french size (1fr =

.33mm)

Basic Endovascular Surgery

CATHETERS

1. Straight - End holed

- Flush

2. Rim

3. JB2

4. IMA

5. Pig

6. Omni

7. Head Hunter

8. Simmons/VTEK

9. Cobra 2

10. Berenstein

11. Grollman

Thoracic Endografting

The Future

Is Now !!!