Novel Use Of Microcatheters Techniques To Perform Angiography and Provide Thrombolytics for Acute CLI in EVAR and Aorto-bifem Pts Michael Wholey, MD MBA VA Audie Murphy San Antonio Interventional Radiology And Vascular Surgery

Michael Wholey, MD MBA DISCLOSURES: Consultant: Heraerus Medical   DISCLOSURES: Consultant: Heraerus Medical Owner: Attache Group LLC

How do you treat these EVAR and Aorto-Bifem cases? How can you get easily across from a retrograde femoral approach? How do you deliver diagnostic and infusion catheters into contralateral limb which is diseased/occluded?

EVAR and Aorto-Bifem Grafts with Acute Arterial Occlusion PROBLEM- From a standard contralateral retrograde femoral approach, how to perform: Diagnostic Angiogram and contralateral lower extremity angiogram Deliver thrombolysis for acute arterial occlusion Often, can not advance traditional 0.035” wire and 4-5 French Infusion Catheters Can not rely on Antegrade Access Do not know status of ipsilateral limb (without CTA) Take off of SFA is often too close to graft anastomosis

Preferred Catheter(s) for Thrombolysis Infusion Catheter Ultrasonic Core 4 Fr, 5 Fr Lengths 0.035” Wire Platforms EKOS Ultrasound Assisted Catheter 6FR Angiodynamics Uni*Fuse™ Infusion Catheter Cragg-McNamara™ Valved Infusion Catheter

The Problem: How to get across? 72 year old male. Pt s/p AAA repair in remote town, requiring prosthetic graft to bilateral common iliac arteries. -CAN NOT GET 0.035” REGULAR GLIDEWIRE ACCROSS

The Problem: How to get across? Answer: -Park a 5 Fr catheter at bifurcation -Advance Microcatheter (2.8 French) and wire -Roadmap helps -Once in place direct hook up with angiographic injector --(Do not aspirate back)

Equipment 5 Fr Diagnostic Catheters Omni™ Flush Angiographic Catheter -Angiodynamics BSX Contralateral SOS Omni® Selective Catheter -- 5 Fr --0.038” ID --65 cm length *Alternatively, 6 Fr Guide Catheter Rim Rim

Current Microcatheters 2.4 Fr, 2.8 Fr braided catheters with 0.014”, 0.016” and 0.018” guidewires Initially used in IR for embolization and TACE Coaxially goes through 4-5Fr Diagnostic catheters Manufacturers Penumbra Green Latern BSX Renegade Hi Flo Terumo Progreat

2.8 Fr Microcatheters BSX High-Flow Renegade Terumo Progreat Remember: 4 cc/sec Remember: when connecting to injector, do not aspirate back

Acute Limb Ischemia in EVAR pt 90 year old male. S/P EVAR two years earlier with 1.4 cm popliteal aneurysm. Presents with sudden pain left leg. Absent pulses. Cold left foot

EVAR TPA Case Non Contrast CT Shows close proximity and sharp angles of the limbs of the Stent Graft

Technique Advancing 5 Fr Omniflush catheter to perform the abd angiogram and then pulling down to assess the limbs with use of 0.035”regular Glidewire At the bifurcation, park the Omniflush towards the contralateral limb and coaxially advance a high-flow microcatheter (2.8 Fr) and its 0.014-0.018” guidewire Advance the microcatheter first to the common femoral and then into the SFA/Popliteal for start of treatment

EVAR TPA Case -Access Left Limb with 0.016” Transend wire -Exchange for 2.8 Fr Microcatheter with wire -Advance to Left CFA -Access Right CFA -Omni Flush at prox. Portion -Advance Microcatheter to the proximal left SFA

EVAR TPA Case -Popliteal artery abrupt occlusion -Observe Distal Runofff -Gently probe for channel with wire -Posterior Tibial diseased, tapers and stops with lateral plantar branch

EVAR TPA Case: Overnight

EVAR TPA Case: Overnight -TPA 1 mg/hr with IV heparinization (700 units/hr) through the microcatheter -Foot became warmer and pulses returned. -Placed on anticoagulation and treated later

Thrombolysis: EVAR and AAA In the complete acute arterial occlusions, we will use the high flow microcatheter to deliver the TPA at 1 mg/hour (20-25 cc/hr) in addition to IV heparin (500-700 units/hr via sheath). Prior to this, we will use a guidewire to gently create a channel through the thrombus if possible. Patients will be monitored for overnight thrombolytics and returned the next day for assessment. Depending upon what is seen the next day, antegrade access can be made, elective surgery can be planned, or patient can return for elective endovascular intervention

Results: AAA and EVAR Occlusions Results: We have performed 11 cases with the use of microcatheter 9 cases with diagnostic evaluations to the contralateral limb for EVAR and Aortobifemoral bypass grafts. 2 Thrombolytic cases We had no minor or major adverse complications from the use of this system.

Concept: Smaller is Better Thrombolytic Therapy Dose: 1 mg/hr of tPA Mixture 25 mg in 250 cc NS to run at 20 cc/hr 20 cc/hr  0.006 cc/sec So, with such a small rate of infusion, why do you need a catheter almost twice the diameter that results in four-fold reduction in flow: Remember, Hagen–Poiseuille equation about Radius Target Artery 6 Fr Catheter 2.8 Fr Catheter

Another Treatment with the Microcatheter with EVAR Treatment Use the micro catheter for microcoil embolization and/or glue of lumbar branch off the internal iliac artery

Conclusions Use of the High Flow Microcatheter has very unique advantages with routine retrograde CFA access in patients with AAA Repair and EVAR: Able to cross easily through 5 Fr Diagnostic catheter to get into contralateral limb Quick diagnostic run of the iliacs and femorals Remember 4 cc/sec for runs with angiographic injector Able to deliver thrombolytics (tPA) for acute arterial occlusions of the contralateral limb Able to get into contralateral internal iliac to embolize lumbar arteries for Type II Endoleaks

Thank you Michael Wholey MD MBA wholey@uthscsa.edu San Antonio, Tx