Endovascular aortounifemoral grafts and femorofemoral bypass for bilateral limb- threatening ischemia Takao Ohki, MD, Michael L. Marin, MD, Frank J. Veith,

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Presentation transcript:

Endovascular aortounifemoral grafts and femorofemoral bypass for bilateral limb- threatening ischemia Takao Ohki, MD, Michael L. Marin, MD, Frank J. Veith, MD, Ross T. Lyon, MD, Luis A. Sanchez, MD, William D. Suggs, MD, John G. Yuan, MD, Reese A. Wain, MD, Richard E. Parsons, MD, Amit Patel, MD, Steven P. Rivers, MD, Jacob Cynamon, MD, Curtis W. Bakal, MD Journal of Vascular Surgery Volume 24, Issue 6, Pages 984-997 (December 1996) DOI: 10.1016/S0741-5214(96)70044-7 Copyright © 1996 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 1 EVG and delivery systems. A, Endovascular thin-walled PTFE graft. A Palmaz balloon-expandable stent (S) is sutured to graft with four diametrically opposed “U” sutures (two on each side), which permit one half of the stent to protrude from graft. B, Double balloon catheter introducer/delivery system used for delivery and deployment of endovascular stented grafts. In this system, the introducer catheter is equipped with two separate balloon catheters. Balloon A functions as a mechanism to form a tapered tip to catheter system and also allows pressurization of the flexible sheath (C) after saline is injected from port D. Second balloon B functions to deploy overlying Palmaz stent (S). With expansion of balloon B, EVG (G) becomes firmly fixed to underlying arterial wall. V, hemostatic valve mechanism. C, Alternative delivery system consisting of single balloon catheter with two balloons on a single shaft. First balloon serves as a tip balloon (A), and stent-graft complex is mounted on to independent deploying balloon (B). Journal of Vascular Surgery 1996 24, 984-997DOI: (10.1016/S0741-5214(96)70044-7) Copyright © 1996 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 2 Algorithm and classification of endovascular grafting for bilateral aortoiliac occlusive disease. Classification of distribution of disease, determination of appropriate side for graft insertion, and identification of location for proximal stent deployment may be approached using this algorithmic outline. Journal of Vascular Surgery 1996 24, 984-997DOI: (10.1016/S0741-5214(96)70044-7) Copyright © 1996 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 3 Surgical procedure for endovascular grafting. The side for graft insertion is selected by using algorithm shown in Fig. 2. Because this case is type I, stenosed side is chosen for recanalization. 7F introducer sheath is inserted via an open arteriotomy in femoral artery. Care must be taken to puncture artery at the center of the planned anastomosis site for subsequent FFB. Recanalization wire and directional catheter are inserted through the sheath. An effort is made to direct recanalization wire and catheter within the stenosed lumen or within the intraintimal layer of occluded artery. Journal of Vascular Surgery 1996 24, 984-997DOI: (10.1016/S0741-5214(96)70044-7) Copyright © 1996 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 4 After successful recanalization, 8-mm balloon angioplasty catheter is inserted over wire through a 7F introducer sheath. Iliac artery and, in some instances, distal aorta are dilatated to the level of arterial entrance site of introducer sheath. Journal of Vascular Surgery 1996 24, 984-997DOI: (10.1016/S0741-5214(96)70044-7) Copyright © 1996 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 5 7F introducer sheath is removed while recanalization wire is held in a stable position. Using scissors, arteriotomy is extended to a size that will accommodate a 14F delivery sheath. Under fluoroscopic control, delivery sheath is inserted over wire and a radiopaque Palmaz stent is positioned at preselected site. In this example of type I disease, proximal stent is deployed within distal aorta. It is crucial to place the stent above the proximal end of the atherosclerotic plaque. Journal of Vascular Surgery 1996 24, 984-997DOI: (10.1016/S0741-5214(96)70044-7) Copyright © 1996 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 6 After accurate positioning of device, tip balloon is deflated and outer sheath is partially retracted so that entire stent is exposed. With inflation of the second balloon, the EVG becomes firmly fixed to the underlying arterial wall. Balloon catheter is then used to gently dilate the PTFE graft in a serial descending segmental fashion as the balloon is withdrawn. Journal of Vascular Surgery 1996 24, 984-997DOI: (10.1016/S0741-5214(96)70044-7) Copyright © 1996 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 7 Distal end of the EVG is endoluminally hand-anastomosed in a customized fashion to patent runoff vessel. Proximal anastomosis of FFB is then performed over the arteriotomy site. Journal of Vascular Surgery 1996 24, 984-997DOI: (10.1016/S0741-5214(96)70044-7) Copyright © 1996 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 8 Completion of endovascular aortoiliac bypass and standard FFB. Journal of Vascular Surgery 1996 24, 984-997DOI: (10.1016/S0741-5214(96)70044-7) Copyright © 1996 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 9 A, Preoperative arteriogram of patient no. 5 demonstrates that the right iliac artery system is diffusely stenosed and occluded from its origin on the left side. Because the right internal iliac artery is negligible (type I), the right side was chosen for recanalization and graft insertion. Pelvic circulation is maintained by the inferior mesenteric artery (open arrow). B, Completion arteriogram of patient no. 5. By placing the stent (S) above the lesion (within distal aorta), a good angiographic result was obtained. C, Arch arteriogram of patient no. 5 reveals a 90% stenosis at the origin of the innominate artery and occluded left common carotid and subclavian arteries. Unrecognized inflow disease may have contributed to failure of two previous axillofemoral bypass procedures. Journal of Vascular Surgery 1996 24, 984-997DOI: (10.1016/S0741-5214(96)70044-7) Copyright © 1996 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

Fig. 10 Hemodynamic improvement after endovascular grafting. After EVG bypass procedure, thigh PVR amplitudes increased from 9 ± 3 mm to 30 ± 7 mm on the side ipsilateral to EVG insertion and from 6 ± 2 mm to 24 ± 4 mm on the contralateral side. Journal of Vascular Surgery 1996 24, 984-997DOI: (10.1016/S0741-5214(96)70044-7) Copyright © 1996 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions