tibial angioplasty

8/12/2019 Tibial Angioplasty

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Dr. Aniruddha Bhuiyan

1st yr Postgraduate In Vascular Surgery

MS Ramaiah Medical College and HospitalsBangalore

Tibial Angioplasty –

Tips and Tricks



INTRODUCTION

• Arterial reconstruction for occlusions of below knee

vessels

• Valuable treatment – diabetic patients : adequate wound

healing and limb salvage rates

• Variable quality of reports – exclusive tibial interventionsnot well studied – cannot compare, challenging

• Development of low-profile balloon catheters, Small-

caliber stents, Steerable and hydrophilic guide wires

• Time-resolved CE MRA and superselective DSA with

proper catheter positioning



WHEN and WHAT

•Do’s - CLI patients with rest pain, ulcers & gangrene

• Don’t - No distal runoff, fixed flexion deformity, inability

to remain immobile, acute septicemia (wet gangrene)

• More options for vessel revascularisation

• BASIL suggested – Conducive anatomy ? for plasty,

primary PTA first line – even if good bypass candidate

• Angiosome targetted revascularisation



PROCEDURE CHECKLIST

• Access Options

• Inflow / Run-off Assessment / Infra-popliteal status

• Lesion assessment:

- Length, stenosis, occlusion, calcium• Hardware, amount of contrast

• Bailout options

• Short/long-term success



TECHNIQUES

• Puncture : Ipsilateral antegrade femoral, pedal

• Angiography : Dilute non-ionic, CO2

• Crossing lesion : 0.014”, 0.018” hydrophilic GW

•Balloon angioplasty : Low profile, non compliant, longlength balloons

• Stents : controversial : balloon expandable – proximal ;

self expanding – distal

• Reocclusion : stent, prolonged inflation, lysis, aspiration



WHAT TO DO IF DIFFICULT ?

•

SNARING OF RETROGRADEGUIDEWIRE

• DOUBLE BALLOON / REZENDEVOUS

- Double balloons tracked subintimally

- plasty to break membrane to enter

true lumen

• SAFARI

- True lumen cannot be reentered,distal wire is snared inside subintimal

space via proximal access



OUTCOMES

• POBA - (24m limb salvage – 70%)

• Improve blood flow – long enough for ulcer to heal

• DEB - offer the antiproliferative effect of local drug

elution (limb salvage – 95.6%)

- Long, Complex lesions, restenosis, poor outflow- Restenosis: 27% vs. 63%

• Stents - residual stenosis, flow limiting dissections,

perforations – reocclusion 50% < 1 yr• DES – under trials

• Cryoplasty , Atherectomy (orbital)



• Image the anatomy well – selective injections

• Intra-luminal strategy in general

• Assess hemodynamic end-point , not just

arteriographic appearance

• Learning curve for crossing occlusions

• Not being overaggressive

• Tibial arteries–

more prone for vasospasm – vasodilators….

• Option for distal bypass

TRICKS



CONCLUSION

•

Tibial angioplasty vs Bypass (long term patency poorbut limb salvage rates similar)

• Unstable looking lesions, limited outflow - SURGERY

• Chance to tide over crisis – 2nd option of distal bypass

• With improved techniques and better hardware……

TIBIAL ANGIOPLASTY is being rewarded with better

LIMB SALVAGE

Thank You

tibial angioplasty

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