Endovascular Interventions E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
ENDOVASCULAR INTERVENTIONS A practical and systematic approach to current endovascular surgical techniques An increasingly popular alternative to open vascular surgery, endovascular intervention offers many advantages, including reduced patient discomfort, smaller incisions, shorter recovery time, and decreased risk of adverse complications. Practitioners and trainees alike require expert guidance on current technologies and up-to-date techniques. Endovascular Interventions provides clinicians with an easy-to-follow guide for minimally invasive treatment of vascular disease. This invaluable resource delivers concise and accurate instructions on a wide range of endovascular interventions, including aorta, renal and mesenteric interventions, lower extremity interventions, venous interventions, and supra-aortic interventions in high-risk patients. Sequential phases of skill development broaden the reader's abilities as they progress through each chapter, supplying step-by-step instructions on when each procedure should be used and how it can be safely and effectively performed. This book offers a complete reference to essential techniques and procedures, suitable for both novice and experienced vascular surgeons, cardiologists, and radiologists. Endovascular Interventions also: * Reinforces comprehension of each procedure with templated chapters, equipment lists and boxed key learning points * Provides full-color clinical images and detailed illustrations to demonstrate surgical procedures * Presents authoritative coverage of modern endovascular technologies and techniques * Written by a team of respected experts and practicing surgeons from internationally recognized hospitals and universities Suitable for varying skill levels, Endovascular Interventions is a precise, accessible instruction manual for safe and effective endovascular intervention, helping practicing clinicians sharpen their existing abilities and keep pace with the latest surgical technologies while instructing trainees on this innovative approach to vascular surgery.
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Veröffentlichungsjahr: 2023
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Table of Contents
Cover
Title Page
Copyright Page
List of Contributors
1 Innominate & Carotid Artery Intervention in High‐Risk Patients
Introduction
Innominate Interventions in High‐Risk Patients
Carotid Artery Intervention in High‐Risk Patients
Conclusions
References
2 Subclavian Artery Intervention: Catheter-Based Therapy
Introduction
Endovascular Versus Open Surgical Revascularization
Endovascular Revascularization Techniques
Conclusion
References
3 Vertebral Artery Intervention: Catheter-Based Therapy
Introduction
Preprocedural Considerations
Management of Potential Complications
Postprocedural Care
References
4 Endovascular Repair of Thoracic Aortic Aneurysms: Catheter-Based Therapy
Introduction
Relevant Anatomy
Indications/Contraindications to Procedure
Available Endografts
Preoperative Evaluation
Positioning and Intraoperative Monitoring Needs
Procedural Steps
Postoperative Course/Surveillance
References
5 Endovascular Abdominal Aortic Aneurysm Repair (EVAR)
Introduction
Patient Selection
Preoperative Imaging and Measurements
Graft Selection
Graft Sizing
Step 1. Vascular Access
Step 2. Imaging
Step 3. Wires
Step 4. Delivery and Deployment
Completion Angiogram
Step 5. Troubleshooting
Conclusion
References
6 Severe Renal Artery Stenosis: How to Intervene
Introduction
Background and Clinical Significance
RAS Assessment
Indications for Revascularization
Intervention
References
7 Mesenteric Ischemia: Chronic and Acute Management
Introduction
Chronic Mesenteric Ischemia
Complications
Follow‐Up and Outcomes
Acute Mesenteric Ischemia
Mesenteric Venous Thrombosis
Follow‐Up and Outcomes
References
8 Aorto‐Iliac Interventions
Introduction
Preoperative Workup
Noninvasive Studies
Invasive Imaging
Classification of Lesion and Planning of Intervention
Step 1. Patient Factors
Step 2. Vascular Access
Step 3. Crossing the Lesion
Step 4. Intervention
Step 5. Closure
Step 6. Complications
Cases
References
9 Femoropopliteal Arterial Interventions in the Claudicant
Introduction
Patient Evaluation and Indications for Treatment of Femoropopliteal Arterial Pathology
Indications for Revascularization Femoropopliteal Claudication
Vascular Imaging in Endovascular Treatment
Vascular Access and Lesion Crossing Techniques
Working Wire Size and Changing Between Systems
Conclusions
Acknowledgments
References
10 Tibial Interventions in Patients with Critical Limb‐Threatening Ischemia
Introduction
Indications and Goals of Endovascular Revascularization
Considerations for Access Site
Single Versus Multitibial Artery Revascularization
TAMI Retrograde Revascularization
Reentry and Externalization Devices
Deep Venous Arterialization (DVA)
References
11 Acute Limb Ischemia: Endovascular Approach: Endovascular Approach
Introduction
Procedure Planning, Equipment, and Considerations
References
12 Pedal Reconstruction
Introduction
Pedal Arch Reconstruction
Indications for Pedal Revascularization
Technical Considerations
Special Considerations of the Pedal Intervention
Summary
References
13 Endovascular Management of Access Site Complications
Introduction
Complications Related to Common Femoral Artery Access
Access Site Bleeding
Balloon Tamponade, Endovascular Coiling, and Covered Stent Placement
Femoral Pseudoaneurysms
Arteriovenous Fistulas
Vascular Closure Device Related Complications
Radial Artery Related Complications
References
14 Acute Deep Vein Thrombosis
Introduction
Treatment Strategy
Initial and Long‐Term Treatment of VTE
Extended Treatment
Conclusion
References
15 Lower‐Extremity Venous Stenting
Introduction
Follow‐Up
References
16 Intervention for Pulmonary Embolism
Introduction
Pulmonary Angiography
Catheter‐Directed Thrombolysis
Mechanical Disruption
Large Catheter Aspiration
AngioVac for Clot‐in‐Transit
AngioVac for Right Heart Vegetation
References
17 Catheter‐Based Therapy for Varicose Veins
Introduction
Thermal Techniques
Radiofrequency (RF) Ablation
Endovenous Laser Ablation (EVLA)
Nonthermal Techniques
Mechanico‐Chemical Ablation (MOCA)
Limitations
Summary
References
Index
End User License Agreement
List of Tables
Chapter 1
Table 1.1 High‐risk features reported in the literature.
Chapter 3
Table 3.1 Major adverse events associated with vertebral angioplasty.
Table 3.2 Interventional tools.
Chapter 6
Table 6.1 Etiologies of renal artery stenosis.
Table 6.2 Who to screen for RAS (AHA/ACC 2006).
Table 6.3 Indications for renal artery revascularization (AHA/ACC 2006)....
Chapter 7
Table 7.1 Indications for percutaneous intervention.
Chapter 9
Table 9.1 Examples of wire sizes and device types.
Table 9.2 Major plaque modification/atherectomy devices, specifications, an...
Chapter 10
Table 10.1 Classification, staging and clinical symptoms of intermittent cl...
Chapter 11
Table 11.1 tPA agents (US FDA approved).
Table 11.2 Commercially available infusion catheter.
Table 11.3 tPA absolute contraindications.
Table 11.4 tPA relative contraindications.
Table 11.5 Mechanical adjunct to thrombolysis [1–7].
Table 11.6 Distal embolic protection devices.
Chapter 13
Table 13.1 Common arterial access complications by access site.
Table 13.2 Most common femoral arterial complications and their management ...
Table 13.3 Risk factors for bleeding complications after femoral arterial ac...
Table 13.4 Common vascular closure devices (VCDs), their mechanism of actio...
Chapter 14
Table 14.1 Parenteral and oral anticoagulants.
Chapter 15
Table 15.1 Villalta PTS Scale.
List of Illustrations
Chapter 1
Figure 1.1 (a) Heavily calcified aorta and supra‐aortic vessels. (b) Baselin...
Figure 1.2 Predilatation with undersized balloon.
Figure 1.3 Stent in position at ostium of innominate.
Figure 1.4 Larger balloon inflation.
Figure 1.5 Final angiogram.
Figure 1.6 Femoral artery access.
Figure 1.7 Baseline selective angiography with reference object.
Figure 1.8 Angiogram through a diagnostic catheter in the external carotid a...
Figure 1.9 EPD positioned in the internal carotid artery.
Figure 1.10 Predilatation with distal embolic protection.
Figure 1.11 Retrieval of the EPD.
Figure 1.12 Final angiogram after stenting.
Figure 1.13 Mo.Ma device with ECA balloon inflated.
Figure 1.14 Stent and postdilatation.
Figure 1.15 ECA balloon deflated with proximal balloon inflated.
Figure 1.16 Final angiogram.
Chapter 2
Figure 2.1 Left‐sided subclavian stenosis. (a) and (b) arrows show initiatio...
Figure 2.2 (a) Catheter engaged in ostium left subclavian artery and previou...
Chapter 3
Figure 3.1 Aortic arch angiography showing main supra‐aortic vessels.
Figure 3.2 Vertebral artery anatomy.
Figure 3.3 Ostial right vertebral artery stenosis (Arrow).
Figure 3.4 Circle of Willis anatomy.
Figure 3.5 Balloon dilatation of lesion: multipurpose guide and 0.014 guidew...
Figure 3.6 Result of balloon angioplasty – Not satisfactory result.
Figure 3.7 4.0 × 23 mm Stent positioned 2 mm proximal to vertebral artery os...
Figure 3.8 Stent position confirmation during deployment.
Figure 3.9 Final result.
Chapter 4
Figure 4.1 Aortic landing ones.
Figure 4.2 Cook Zenith Alpha Graft.
Figure 4.3 Cook TX2 graft and dissection stent.
Figure 4.4 (a) and (b) Gore cTAG endoprosthesis.
Figure 4.5 Terumo relay aortic graft.
Figure 4.6 Medtronic valiant thoracic endograft.
Figure 4.7 Confirmation of common femoral cannulation.
Figure 4.8 Intravascular ultrasound displaying true and false lumen (probe i...
Figure 4.9 Arch aortogram to identify seal zone.
Figure 4.10 (a)–(d) Measurement of coverage length and completion angiogram....
Figure 4.11 (a)–(c) Treatment of penetrating aortic ulcer, initial endoleak,...
Figure 4.12 Endoleak classification.
Chapter 5
Figure 5.1 Pictured on the left is a traditional CTA coronal view of an infr...
Figure 5.2 In cases where aortic anatomy is not suitable for on‐label device...
Figure 5.3 Repeat contrast angiography prior to complete deployment of the m...
Figure 5.4 Cannulation of the contralateral gate can prove challenging, as d...
Figure 5.5 The completion angiogram above from a single case demonstrates ex...
Figure 5.6 Completion angiogram demonstrates a Type IA endoleak. Aneurysmal ...
Figure 5.7 In cases where aneurysmal degeneration extends to the iliac arter...
Chapter 6
Figure 6.1 Indirect engagement of renal artery: (a) renal artery stenosis (b...
Chapter 7
Figure 7.1 Flush aortagram performed via a femoral approach. Imaging is perf...
Figure 7.2 Morph sheath placed via a femoral approach. The tip of the sheath...
Figure 7.3 A hydrophilic wire has been advanced through a stenotic lesion us...
Figure 7.4 Balloon‐expandable stent placement. Note minimal extension of the...
Figure 7.5 Poststent angiogram performed using a flush catheter via a femora...
Figure 7.6 Selective angiogram of the SMA showing a thrombus (arrow) in the ...
Figure 7.7 6 Fr 55 cm vascular sheath advanced into the SMA via a right femo...
Figure 7.8 Residual stenosis (arrow) after aspiration of thrombus.
Figure 7.9 Angioplasty of stenotic lesion in SMA using Savvy 5 mm × 4 cm ang...
Chapter 8
Figure 8.1 A 3D reconstruction of CTA imaging demonstrating extensive calcif...
Figure 8.2 TASC II classifications for aortoiliac occlusive disease.
Figure 8.3 Commonly used bare‐metal stents.
Figure 8.4 Commonly used covered stents for iliac intervention.
Figure 8.5 Aortogram with right external iliac artery occlusion. Through and...
Figure 8.6 Balloon angioplasty of lesion and completion angiogram following ...
Figure 8.7 Preoperative CTA with reconstruction demonstrating occluded left ...
Figure 8.8 Aortogram with occluded left iliac artery and imaging with Amplat...
Figure 8.9 Deployment of bilateral VBX stents and completion angiogram with ...
Chapter 9
Figure 9.1 CO
2
angiography (a) The device is placed in a sterile bag on the ...
Figure 9.2 Example of the measurements typically taken with intravascular im...
Figure 9.3 (a) Prep in the foot and ultrasound. (b, c) Visualization of the ...
Figure 9.4 (a) Cutting balloon example (b) Chocolate balloon (c) Dorado high...
Figure 9.5 (a) Excimer laser, (b) Rotablator (c) Jetstream (d) Phoenix (e) R...
Figure 9.6 Example of Nav6 Emboshield Filter Deployment and removal. (a) Car...
Chapter 10
Figure 10.1 Angiosomes. This figure illustrates the concept of the angiosome...
Figure 10.2 Wire inside a tibial vessel. This figure demonstrates the appear...
Figure 10.3 Crossing of a CTO of the lateral plantar artery with subsequent ...
Chapter 11
Figure 11.1 Acute thrombus of popliteal, note hazy white appearance.
Figure 11.2 EKOS Endosonic catheter 40 cm in a patient with acute thrombotic...
Figure 11.3 Use of Penumbra Indigo CAT3 in a patient with acute thrombus of ...
Chapter 12
Figure 12.1 Lateral view of the ankle shows the distal AT artery and PT arte...
Figure 12.2 The anterior circulation consists of dorsalis pedis artery, late...
Figure 12.3 The posterior circulation consists of the medial plantar artery ...
Figure 12.4 Pedal arch subtypes: Type 1: both dorsalis pedis and plantar art...
Figure 12.5 (a) Occlusion of distal PT artery and severe stenosis of distal ...
Figure 12.6 (a) Severe stenoses of the distal AT, distal PT, and dorsalis pe...
Chapter 13
Figure 13.1 Bleeding and contrast extravasation (red arrow) of a small vesse...
Figure 13.2 Pseudoaneurysm arising from the CFA as demonstrated by color dup...
Figure 13.3 Algorithm for the management of femoral pseudoaneurysms.
Figure 13.4 (a) Femoral angiography via contralateral access demonstrating a...
Figure 13.5 Hematoma classification proposed in the Early Discharge After Tr...
Chapter 14
Figure 14.1 Diagnostic management of patients with suspected DVT or PE [1]....
Figure 14.2 Approach to initial treatment of venous thromboembolism (onset t...
Figure 14.3 Approach to long‐term and extended treatment of VTE (after initi...
Chapter 15
Figure 15.1 CT scan axial view showing left common iliac vein (CIV) compress...
Figure 15.2 Venogram. Access site left common femoral vein. Exchange 4 Fr or...
Figure 15.3 Postdeployment series of Wallstent dilatation placed in left ili...
Figure 15.4 IVUS guided venous stenting, left iliac vein. (a) Pre‐interventi...
Chapter 16
Figure 16.1 Second‐generation device consists of a control unit to deliver p...
Figure 16.2 (a) Infusion catheter tip and ultrasonic core. (b) Cross‐section...
Figure 16.3 EKOS infusion catheter.
Figure 16.4 Appropriate final catheter positions.
Figure 16.5 FlowTriever thrombus aspiration system.
Figure 16.6 Tricuspid valve crossed using a balloon‐tipped catheter to avoid...
Figure 16.7 PA angiogram defining location of proximal thrombus.
Figure 16.8 Contrast injection through the multipurpose catheter.
Figure 16.9 Thrombi extracted via aspiration through the F20.
Figure 16.10 Positioning (a) and deployment (b) of FlowTriever catheter and ...
Figure 16.11 AngioVac system utilizes a large intravascular cannula attached...
Figure 16.12 (a) Generation 2 device with balloon‐actuated funnel, straight ...
Figure 16.13 (a–e) AngioVac circuit assembly.
Figure 16.14 AngioVac cannula advanced to the right pulmonary artery from a ...
Figure 16.15 (a–e) Clot‐in‐transit is generally mobile and can be engaged by...
Figure 16.16 (a–c) When using generation 2 device for right heart vegetation...
Chapter 17
Figure 17.1 Steps in accessing the saphenous vein under ultrasound guidance ...
Figure 17.2 Steps in catheter positioning and tumescent anesthesia administr...
Figure 17.3 EVLA laser tip visualization through the skin with red beam.
Figure 17.4 The ClariVein device consists of a 9 V battery‐motorized handle ...
Guide
Cover Page
Title Page
Copyright Page
List of Contributors
Table of Contents
Begin Reading
Index
WILEY END USER LICENSE AGREEMENT
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Endovascular Interventions
A Step‐by‐Step Approach
Edited by
Jose M. Wiley, MD, MPH
Sidney W. and Marilyn S. Lassen Chair of Cardiovascular MedicineProfessor of MedicineChief, Section of CardiologyJohn W. Deming Department of MedicineTulane University School of MedicineNew Orleans, LA, USA
Cristina Sanina, MD
Interventional Cardiology FellowDivision of CardiologyDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, MA, USA
George D. Dangas, MD, PhD
Professor of MedicineDirector of Cardiovascular InnovationsThe Zena and Michael A. Weiner Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew York, NY, USA
Prakash Krishnan, MD
Professor of MedicineDirector of Endovascular ServicesThe Zena and Michael A. Weiner Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew York, NY, USA
This edition first published 2023© 2023 John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Jose M. Wiley, Cristina Sanina, George D. Dangas, and Prakash Krishnan to be identified as the authors of the editorial material in this work has been asserted in accordance with law.
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Library of Congress Cataloging‐in‐Publication DataNames: Wiley, Jose M., author. | Sanina, Cristina, author. | Dangas, George D., author. | Krishnan, Prakash, author.Title: Endovascular interventions: a step‐by‐step approach / Jose M. Wiley, Cristina Sanina, George D. Dangas, Prakash Krishnan.Description: Hoboken, NJ : Wiley‐Blackwell, 2023. | Includes bibliographical references and index.Identifiers: LCCN 2023012153 (print) | LCCN 2023012154 (ebook) | ISBN 9781119467786 (paperback) | ISBN 9781119467847 (adobe pdf) | ISBN 9781119467861 (epub)Subjects: MESH: Endovascular Interventions.Classification: LCC RD598.5 (print) | LCC RD598.5 (ebook) | NLM WG 170 | DDC 617.4/13–dc23/eng/20230531LC record available at https://lccn.loc.gov/2023012153LC ebook record available at https://lccn.loc.gov/2023012154
Cover Design: WileyCover Image: © Cristina Sanina
List of Contributors
Tyrone J. Collins, MDDepartment of Cardiovascular Diseases, John Ochsner Heart & Vascular Institute, The Ochsner Clinical School, University of Queensland School of Medicine New Orleans, LA, USA
Saadat Shariff, MDDepartment of Cardiothoracic & Vascular Surgery (Vascular Surgery) Albert Einstein College of Medicine‐Montefiore Medical Center Bronx, NY, USA
Isabella Alviz, MDDepartment of Medicine, Albert Einstein College of Medicine‐Montefiore Medical Center Bronx, NY, USA
Cornelia Rivera, MDDepartment of Medicine, Albert Einstein College of Medicine‐Montefiore Medical Center Bronx, NY, USA
Michelle Cortorreal, MDDepartment of Medicine, Albert Einstein College of Medicine‐Montefiore Medical Center Bronx, NY, USA
James S. Jenkins, MDDepartment of Cardiovascular Diseases, John Ochsner Heart & Vascular Institute, The Ochsner Clinical School, University of Queensland School of Medicine New Orleans, LA, USA
Tamunoinemi Bob‐Manuel, MDDepartment of Cardiovascular Diseases, John Ochsner Heart & Vascular Institute, The Ochsner Clinical School, University of Queensland School of Medicine New Orleans, LA, USA
Aksim G. Rivera, MDDepartment of Surgery (Vascular Surgery), Albert Einstein College of Medicine‐Jacobi Medical Center Bronx, NY, USA
Patricia Yau, MDDepartment of Surgery (Vascular Surgery), Albert Einstein College of Medicine‐Jacobi Medical Center Bronx, NY, USA
John Denesopolis, MDDepartment of Surgery (Vascular Surgery), Albert Einstein College of Medicine‐Jacobi Medical Center Bronx, NY, USA
John Futchko, MDDepartment of Surgery (Vascular Surgery), Albert Einstein College of Medicine‐Jacobi Medical Center Bronx, NY, USA
Katie MacCallum, MDDepartment of Surgery (Vascular Surgery), Albert Einstein College of Medicine‐Jacobi Medical Center Bronx, NY, USA
Mohammad Hashim Mustehsan, MDDivision of Cardiology, Albert Einstein College of Medicine‐Montefiore Medical Center, Bronx, NY, USA
Jose D. Tafur, MDDepartment of Cardiovascular Diseases, John Ochsner Heart & Vascular Institute, The Ochsner Clinical School, University of Queensland School of Medicine New Orleans, LA, USA
Cristina Sanina, MDDivision of CardiologyDepartment of MedicineBeth Israel Deaconess Medical Center Harvard Medical School Boston, MA, USA
David A. Hirschl, MDDepartment of Radiology, Albert Einstein College of Medicine‐Montefiore Medical Center Bronx, NY, USA
Michael S. Segal, DODepartment of General Surgery Wyckoff Heights Medical Center Brooklyn, NY, USA
Sameh Elrabie, DODepartment of General Surgery Wyckoff Heights Medical Center Brooklyn, NY, USA
Rajesh K. Malik, MDDivision of Vascular Surgery Wyckoff Heights Medical Center Brooklyn, NY, USA
Sahil A. Parikh, MDDivision of Cardiovascular Diseases Columbia University Irving Medical Center, New York, NY, USA
Joseph J. Ingrassia, MDDivision of Cardiovascular Diseases Columbia University Irving Medical Center, New York, NY, USA
Matthew T. Finn, MDDivision of Cardiovascular Diseases Columbia University Irving Medical Center, New York, NY, USA
Raman Sharma, MDDivision of Cardiology, The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Prakash Krishnan, MDDivision of Cardiology, The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Roberto Cerrud‐Rodriguez, MDDivision of Cardiology, Albert Einstein College of Medicine‐Montefiore Medical Center, Bronx, NY, USA
Shunsuke Aoi, MDDivision of Cardiology, Albert Einstein College of Medicine‐Montefiore Medical Center, Bronx, NY, USA
Amit M. Kakkar, MDDivision of Cardiology, Albert Einstein College of Medicine‐Jacobi Medical Center, Bronx, NY, USA
Ehrin J. Armstrong, MDUniversity of Colorado School of Medicine‐Rocky Mountain Regional VA Medical Center, CO, USA
Rory Brinker, MDUniversity of Colorado School of Medicine‐Rocky Mountain Regional VA Medical Center, CO, USA
Manaf Assafin, MDDivision of Cardiology, Albert Einstein College of Medicine‐Montefiore Medical Center, Bronx, NY, USA
Miguel Alvarez‐Villela, MDDivision of Cardiology, Albert Einstein College of Medicine‐Montefiore Medical Center, Bronx, NY, USA
Robert Pyo, MDDivision of Cardiology, Renaissance School of Medicine at Stony Brook University, NY, USA
Pedro Cox‐Alomar, MDDivision of Cardiology, Louisiana State University School of Medicine New Orleans, LA, USA
Vishal Kapur, MDDivision of Cardiology, The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Sagar Goyal, MDDivision of Cardiology, The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Asma Khaliq, MDDepartment of Cardiology, Lenox Hill Heart & Vascular Institute Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health New York, NY, USA
Sandrine Labrune, MDDepartment of Cardiology, Lenox Hill Heart & Vascular Institute Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health New York, NY, USA
Seth I. Sokol, MDDivision of Cardiovascular Diseases, Albert Einstein College of Medicine‐Jacobi Medical Center Bronx, NY, USA
Wissam A. Jaber, MDDivision of Cardiology, Emory University Hospital, Atlanta, GA, USA
Yosef Golowa, MDDepartment of Radiology, Albert Einstein College of Medicine‐Montefiore Medical Center Bronx, NY, USA
Juan Terre, MDDivision of Cardiology, Albert Einstein College of Medicine‐Montefiore Medical Center, Bronx, NY, USA
Nelson Chavarria, MD, MScDivision of Cardiology, Albert Einstein College of Medicine‐Montefiore Medical Center, Bronx, NY, USA
Jose M. Wiley, MD, MPHSection of Cardiology John W. Deming Department of Medicine Tulane University School of Medicine New Orleans, LA, USA
George D. Dangas, MD, PhDDivision of Cardiology, The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
1 Innominate & Carotid Artery Intervention in High‐Risk Patients
Tyrone J. Collins
Department of Cardiovascular Diseases, John Ochsner Heart & Vascular Institute, The Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA, USA
Introduction
Revascularization of supra‐aortic arterial disease (complicated peripheral artery disease) is usually elective and prophylactic to prevent initial or recurrent ischemic events. Surgical revascularization was once considered the treatment of choice [1]. Successful reports of percutaneous transluminal angioplasty (PTA) and stenting introduced endovascular treatment as an equal or possibly better than surgery option [2]. Each patient is unique, and the risk is multifactorial with both demographic and anatomic risk factors.
Several “high‐risk” features are generally considered when treating carotid artery disease in these patients [3] (Table 1.1). Some of these features are also risk factors for innominate intervention.
The level of stenosis and/or occlusion, vessel tortuosity, amount of calcification, presence or absence of thrombus, concomitant vascular abnormalities, and comorbid conditions will also affect the risk with revascularization of the other supra‐aortic vessels.
Although some authors may consider endovascular therapy the treatment of choice for innominate atherosclerotic disease, surgical therapy has been shown to be safe and effective [4]. During a period of almost 20 years from 1974 to 1993, Kieffer et al. revascularized surgically 148 patients with acceptable rates of complications, late mortality, long‐term patency, freedom from neurologic events, and reoperation [4].
Table 1.1 High‐risk features reported in the literature.
CAS in females
CAS in octogenarians
CAS with type II, type III, or bovine arch
Tortuous common carotid artery, angulated ICA, and/or distal ICA
Long lesions ≥15 mm
Ostial‐centered lesions
Calcified arch and/or heavily calcified lesion
High‐grade stenosis
Contralateral carotid occlusion
Presence of vertebral artery occlusion and/or stenosis
Patient with CKD
Innominate Interventions in High‐Risk Patients
Catheter‐based Therapy for An Innominate (Brachiocephalic) Stenosis
Step 1. Identification of the level of stenosis is the initial step. Computed tomography angiography (CTA) can be useful prior to an invasive procedure. This can allow for planning the interventional strategy and considering alternative forms of treatment. Additionally, CTA can be used to size the reference vessels.
When considering the choice of arterial access remember that catheter size is limited with radial access and the need to cross the stenosis is usually necessary from the radial or brachial approach. If intervention is planned, injections are against the direction of blood flow when working from the arm approach. I prefer the femoral approach to innominate stenoses.
Invasive angiography can be done with digital and/or subtraction angiography. A pigtail catheter is positioned in the ascending aorta proximal to the origin of the innominate artery. The angiography is performed in the 30° left anterior oblique (LAO) projection. Selective angiography is done with a Judkins right diagnostic catheter or guiding catheter (Figure 1.1a,b). Other diagnostic catheters can be used for selective angiography. The “working view” is the angulation that allows for delineation of the stenosis, any adjacent branches, and the ostium of the innominate. Road mapping may be useful but also take advantage of any vascular calcification as a point of reference.
Step 2. After the decision to intervene and baseline angiography has been performed, the innominate is engaged with an 8 Fr guide catheter. A different approach is to use a diagnostic catheter to engage the innominate artery, cross the stenosis with the appropriate wire, and introduce a 6 Fr sheath over the wire to the ostium of the innominate. Anticoagulation to achieve an activated clotting time (ACT) > 250 s is administered. Depending on the available balloons and stents, the appropriate wire (0.014–0.035 in.) is steered across the stenosis. The tip of the wire is passed into the subclavian artery. Wire tip can also be placed in the common or external carotid artery. Innominate artery PTA and stenting is usually performed without utilizing a distal embolic protection device (EPD). If you choose to use EPD, the necessary wire or filter can be positioned in the internal carotid artery. Horesh reported a case of innominate stenting with a covered stent and distal protection [5]. He emphasized the need to individualize patients and consider using embolic protection in high‐risk patients. Hybrid procedures have been performed using balloon occlusion to trap embolic debris.
Figure 1.1 (a) Heavily calcified aorta and supra‐aortic vessels. (b) Baseline innominate artery selective angiogram.
Step 3. Predilatation with a balloon is performed. The initial balloon is usually undersized but gives an idea of the ability to distend the lesion (Figure 1.2). The Shockwave Lithoplasty System (Medical Inc.) has been used to successfully treat severely calcified innominate stenosis prior to stenting [6]. This system has also been used in a hybrid operation [7]. Use the balloon inflation to help decide on stent sizing (diameter and length).
Step 4. Stent implantation is done after ensuring the correct position of the delivery system (Figure 1.3). If necessary, magnify the image to demonstrate the stent is appropriately placed. Remember, an undersized stent can be implanted so that the delivery sheath or catheter does not have to be “upsized.” A larger balloon (Figure 1.4) can subsequently be employed to adequately expand the stent without changing the sheath or catheter.
Figure 1.2 Predilatation with undersized balloon.
Figure 1.3 Stent in position at ostium of innominate.
Step 5. Assessment of the poststent result is performed to determine stent apposition and size (Figure 1.5). If necessary, the stent can be postdilated with a larger balloon.
Step 6. After hemostasis the patient is usually monitored overnight and discharged the following day. Dual antiplatelet therapy is maintained for at least one month if there are no contraindications.
Figure 1.4 Larger balloon inflation.
Figure 1.5 Final angiogram.
Carotid Artery Intervention in High‐Risk Patients
Endovascular Treatment of A Carotid Stenosis
Left common carotid artery stenoses are treated endovascularly similarly to innominate artery stenoses. Distal embolic protection is not used routinely. There are endovascular, hybrid, and surgical alternatives.
Transcarotid artery revascularization (TCAR) offers alternative to both carotid endarterectomy (CEA) and carotid artery stenting (CAS) which are done via a transfemoral approach.
CAS can be performed with distal embolic protection and/or flow reversal. Distal embolic protection is the most commonly used choice. It is readily available and technically easier to deploy. However, it is not the best choice for tortuous common and/or internal carotid arteries, heavily calcified vessels, and “string signs.” Distal protection devices require crossing the diseased segment without protection compared to proximal protection where this is not necessary. Additionally, if anatomy warrants, CEA can be the treatment of choice.
Catheter‐based Therapy for Carotid Stenosis
Step 1. Arterial access is obtained for distal embolic protection and flow reversal cases. Distal EPD can be done via femoral, radial, or brachial access. Flow reversal, because of the larger diameter sheath required, is performed via the femoral artery route. Access is obtained with ultrasound guidance or using anatomic landmarks. Femoral angiography is usually performed at the initiation of the case to document the appropriateness of the access and to plan for use of a closure device (Figure 1.6).
Figure 1.6 Femoral artery access.
Figure 1.7 Baseline selective angiography with reference object.
Step 2. Selective carotid angiography (Figure 1.7) of the culprit vessel is performed with a diagnostic catheter. The best angle to visualize the lesion is chosen. Quantitative angiography is done. This can be with a reference object placed at the level of the lesion or with online software. Of note, angiography of all the arch and intracranial vessels is performed prior to intervention. This can be done during the CAS procedure or at an earlier date. Other imaging modalities (CTA or MRI) can be done prior to the CAS. Imaging of the intracranial circulation is necessary in the event that the rare occurrence of neurorescue is needed and it is necessary to document the baseline anatomy.
Step 3. Heparin is administered to achieve an ACT greater than 250 s. A sheath, guide catheter, or neuroprotection device is exchanged over a stiff wire (exchange length 0.035 in. Amplatz wire). The tip is placed in the common carotid artery. During the exchange procedure, the tip of the wire is positioned in the common carotid or external carotid artery. For the flow reversal case, it is necessary to place the stiff wire in the external carotid artery (ECA) through the diagnostic catheter (Figure 1.8) before the exchange procedure.
Step 4. This is where the proximal and distal protection significantly differ. With distal protection, a device is passed through the lesion into the internal carotid artery (Figure 1.9). The EPD is deployed. Balloon predilatation (Figures 1.10) is usually done with a smaller than the reference vessel sized balloon (generally 2.5–3 mm). A stent is deployed (Figure 1.11) and usually postdilatation is skipped. Completion angiography is done (Figure 1.12) along with the intracranial images. Hemostasis can be obtained with a closure device of choice. Generally, these patients are observed in the hospital overnight.
Figure 1.8 Angiogram through a diagnostic catheter in the external carotid artery before exchange.
Figure 1.9 EPD positioned in the internal carotid artery.
Figure 1.10 Predilatation with distal embolic protection.
Figure 1.11 Retrieval of the EPD.
Figure 1.12 Final angiogram after stenting.
When flow reversal is used, it follows the instructions for use with the Medtronic Mo.Ma device. The ECA balloon is inflated in the proximal segment (Figure 1.13). The common carotid balloon is inflated and the stenting is performed (Figures 1.14–1.16) with flow reversal at the end of the procedure prior to reestablishing antegrade flow. Operator should have all equipment ready to insert. I encourage “loading” the balloon and wire in the catheter before starting the proximal occlusion to minimize the occlusion time. Completion angiography, hemostasis, and postoperative care are as above with distal embolic protection.
Conclusions
The operator must carefully consider if revascularization is indicated in the patient with supra‐aortic atherosclerosis. Revascularization is usually performed prophylactically to prevent ischemic events. The risk must be considered compared to the potential benefits. Knowledge of alternative revascularization strategies is paramount before undertaking these procedures.
Figure 1.13 Mo.Ma device with ECA balloon inflated.
Figure 1.14 Stent and postdilatation.
Figure 1.15 ECA balloon deflated with proximal balloon inflated.
Figure 1.16 Final angiogram.
References
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