Training Iliac / SFA

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Agenda Presentation Part 1 Hands-on Tools Break Presentation Part 2 Time Title Notes 09:00 - 09:45 Presentation Part 1 General, Access, Tools 09:45 - 10:15 Hands-on Tools Clinical tools presentation 10:15 - 10:30 Break   10:30 - 11:15 Presentation Part 2 DSA, Intervention, Closure 11:15 - 12:45 Simulator Warm-up VIST-C, Usage, Angiography, Case 201 & 203 12:45 – 13:30 Lunch 13:30 - 15:30 Simulation - Treatment Case 212 & 213 15:30 - 15:45 15:45 - 16:45 Individual Cases - Strategy 5-6 cases with strategy discussion 16:45 - 17:00 Resume

Learning Objectives The learning context will give you An introduction to endovascular tools used in the cathlab The basic steps for a peripheral endovascular intervention Knowledge of common complications and how to handle them Expected pre-knowledge Anatomy Theory on radiation protection Disease panorama & interventional options, BMT/Endo/Open LARS: please review

Iliac / SFA Stenosis

Disease panorama versus indications for treatment Options Best Medical Treatment (BMT) Endovascular Open surgery LARS: please review, maybe add an anatomy overview image

Stenosis Common Iliac Artery Superficial Femoral Artery

Prior to the Procedure

First steps Informed Consent Pre-planning with the Team Position of the patient (here for a right-handed operator)

Vascular Access

Vascular Access first important step to a successful intervention a suboptimal access can make a straight-forward procedure difficult (also for a closure device) a bad access can threaten the patients life

Arterial Puncture Site superficial and fixed position of the artery Artery compressible over bone to obtain hemostasis factors that influence the puncture site Previously interventions and open procedures (hostile groin) Site and generalization of vascular disease Access strategy size of material

Puncture Seldinger technique Reference.: Acta radiol. 1953 May;39(5):368-76 Video ”Puncture.wmv”

Access – Femoral Approach Retrograde Ipsilateral Contralateral / Crossover / ”over the hill” Antegrade ”down the barrel”

Retrograde Access Common access for iliac interventions Puncture the common femoral artery (CFA) Below the inguinal ligament (green lines) Access to all aortic branches above the iliacs

Retrograde - Ipsilateral Medtronic Images!!! Copyright

Retrograde - Contralateral Cross-over access to iliac and femoral artery by retrograde puncture of CFA Technique: Retrograde puncture Cross-over catheterization Guide wire beyond the lesion to contralat CFA Cross-over sheath (4—6F) Copyright!!

Retrograde - Contralateral Advantages Avoid (the more challenging) antegrade puncture Treatment of contralateral iliac and femoral artery by one puncture No compression needed on tx site Disadvantages Cross-over catheterization has its own obstacles

Antegrade Micropuncture technique + US Antegrade puncture of CFA Difficult access in obese Indicated in BTK lesions Cave: Low puncture may cause a direct access into the deep femoral artery guidewire to go to deep femoral artery

Other Arterial Access Locations Popliteal Pedal Brachial Radial

Tools

Tools Introducer Sheath Guide Wire Catheter Balloon (Dilatation catheter) Stent (BE or SE)

(Introducer) Sheath Measurement in French F, 1 F = 1/3 mm Typical (inner) diameters: Range: 4F-8F Different lengths / shapes Range: 5-45cm Shape; numerous in order to faciliate the intubation of tools into vessel orifices Purpose Gain stable and safe arterial access supporting the exchange of tools into te vessels Image of a sheath

Guide Wire Measurement in Inch ”, 1” = 25,4 mm Typical (outer) diameters: 0.014”, 0.018”, 0.035” Different materials respectively stiffnesses Hydrophilic / Teflon Soft / Stiff / Super Stiff Different lengths / shapes Range 60-300cm/numerous Purpose Navigation through arteries Support of catheters / balloons / stents

Guide Wire – Typical Thicknesses

Guide Wire – Typical Shapes flexible tip / soft end (range 0,5-8 cm ) J-shape long & short Angled 30⁰, 45⁰,… Straight Always use soft end! (In real life) Never push against resistance! Never out of sight of your field of view (fluoroscopy) when advancing! LARS: please suggest the most common tip shapes, maybe with special use for Iliacs/SFA

Catheter Measurement in French F, 1 F =1/3 mm Typical (outer) diameters: range 3-7F Diagnostic Flush Catheters (holes for contrast injections) End-hole Catheter Side-hole Catheter Guide/guiding Catheter Different lengths / shapes Range 45-110cm Purpose Contrast injections Guiding through arteries Flush catheter imagediscription

Catheter – Example of Typical Shapes Straight Pigtail Cobra Multipurpose Never advance without the wire! Flush first on the table and then check that no bubbles in the system or syringes! LARS: please suggest the most common tip shapes, maybe with special use for Iliacs/SFA

The Balloon (Dilatation Catheter) Properties Compliant /Semi-compliant/ Non-compliant  Different lengths / sizes Working length (60-130cm) Sizes ranges (1,5-14cm), aortic occlusion balloons (up to 40cm) Characteristics Material: affects pushability, trackability, kink resistance Coating: influences crossability, drug-eluting coatings Design: influences inflation-deflation time Purpose Dilatation Drug Delivery Bail out

OTW vs RX Over the wire (OTW) Rapid exchange (RX) Guide wire through whole length of shaft Need for longer guide wires More expeditious exchange More pushability and trackability Rapid exchange (RX) Guide wire only through distal parts of shaft (max 20cm) Allow use of shorter guide wires Faster exchange Less pushability and trackability

The Stent Balloon-expandable vs Self-expandable Stainless steel/cobolt vs memory alloy Different lengths / sizes Length: 13 – 200 mm, diameter: 2.0 – 12 mm Different introducer- and guide wire- compatibility Characteristics Different materials Different coatings OTW vs RX Purpose Reestablish Blood Flow

Stents for the Iliacs Pros & Cons: Self-expandable (S.E.) vs balloon-expandable (B.E.) Diameter: vessel size + 1 mm (S.E.), vessel size (B.E.) Length: adapted to lesion Prefer 1 long stent over 2 overlapping stents 0.035" vs 0.018" vs 0.014" " vs SE BE

Hands-on Tools

DSA – Digital Substraction Angiography

DSA – Digital Substraction Angiography Images are produced using contrast medium by subtracting a 'pre-contrast image' or the mask from later images, once the contrast medium has been introduced into a structure. Hence the term 'digital subtraction angiography'. Contrast agent is injected Background (bones, organs, tools) is subtracted (“pre-contrast image” from contrast image) Just contrast agent (vessels) visible -

DSA – Projections for Iliacs 30-40° LAO (left anterior oblique) 30-40° RAO (right anterior oblique) Visualize the origin of the hypogastrics! In this example: 2 frames/sec, total contrast volume 15ml, 12ml/sec, psi 1000, injection delay 0.8 sec

Steps A guide wire is inserted into the introducer The guide wire is advanced upon the aortic bifurcation A pigtail catheter is advanced over the guide wire Guide wire is removed to allow pigtail catheter gaining its shape and to allow for contrast injections Prepare for contrastinjection LARS: please review if it is general enough

TEST-Injection Slow (see where you are) Increase flow Watch backflow Do not empty syringe

No Injection If catheter points into plaque/wall If catheter points into a stenosis If pressure is damped If no back-flow

Evaluation of the Lesion Visualisation Localisation Stenosis vs occlusion Length Diameter Thrombus Calcifications Significant stenosis Visual or pressure gradient

Tips Think before you push Never push hard Know your technique & material Monitor the patient Keep cool Expect problems and be prepared to solve them Communicate with your team and with the patient

Crossing the Lesion

Crossing the Lesion Standard access (Iliac-SFA) Cross-over access Guide wire with angled or shapeable tip (0,035”) Standard length (+/- 180 cms) Support with straight or vertebral-like curved catheter when necessary Cross-over access Material for cross-over access (selective catheter, stiff wire, cross-over sheath) Standard or long guide wire (+/- 260 cms)

Considerations Heparin General rule: 100U/kg, 70 kg ex.: 4.000U upon access 3.000U upon X-lesion Adjust to ACT > 250s (300s) But in general practise one shot IV of 3000-5000 IU is good enough without adjusting to ACT! General rule: Short lesions - intraluminal Long lesions - subintimal

SFA Lesion

Let the wire ”swim” through the stenosis Crossing the Lesion Wire Follow with catheter Re-entry control Let the wire ”swim” through the stenosis

Intervention - PTA & Stent

PTA – Percutaneous Transuminal Angioplasty Never ever loose your guide wire position (Golden Rule!) Choose your balloon size carefully according to you DSA or CTA examination The balloon-catheter is advanced over the wire and placed fully covering the lesion and ideally extending 0,5 cm on both ends (use the radio-opaque markers on the balloon) The balloon is dilated for about 30 seconds and/or to discomfort for the patient Repeated dilatations when needed

SFA – PTA – Dissection

Stenting Never ever loose your guide wire position (Golden Rule!) The stent-catheter is advanced over the wire and placed fully covering the lesion and ideally extending a few mm:s on both ends Deploy stent according to IFU S.E.: Retract outer sheath B.E.: Dilate with indeflator Post-dilations when needed

SFA – PTA – Dissection - Stent

Completion Angiogram

Completion Angiogram Inject contrast through your catheter or introducer sheath Check run-off and target region (two different angulations)

Completion Angiogram Visualize the vascular tree Residual stenosis? Pressure measurement Complications? Interpret images and patients status Dissection Embolus Thrombosis Etc---

Arterial Closure

Hemostasis Manual compression Closure device Unappealing and unpopular Discomfort (patient and operator) Time-consuming Closure device Comfort (patient and operator) Time-saving

Options for Post-Cath Hemostasis Manual compression 2minutes/Fr -- Diagnostics 3minutes/Fr --Intervention Post Cath Manual compression assist products Hemostatic patches Compression devices Vascular Closure Devices VCD

Considerations for Selecting a Closure Method Hostile groins Earlier Interventions Type of Interventional Procedure Access vessel Bypass? Vessel Size Sheath Size Presence of peripheral vascular disease Pre-existing or procedure-related complications Patient allergies and co-morbidities Anxiety/Collaboration

Clinical Benefits of VCD Use Patients can stay on antiplatelets Procedure completed in the cath lab Reliable, fast hemostasis No need to reverse anti-coagulation therapy Earlier patient ambulation / discharge Improved patient care, comfort and satisfaction

Hospital Benefits of VCD Use Increased staff efficiency Reduced recovery room time Potential cost saving Ability to complete additional procedure

VCD-Complications Stenosis Laceration Intra-arterial placement of closure device Embolization of (part of) closure device Adventitial closure Infection Thrombosis Femoral neuralgic syndrome Retainment of (part of) closure device Periarterial and intra-arterial fibrosis Cutaneous migration

Simulation

Simulator Warm-up How to use the simulator How to select tools How to control fluoro & C-arm Do an angiography and examine the lesion! (Case 201 & 203) Now: 2 persons/simulator, 90 minutes Tab video of Ben on simulator!!

1. Round: Simulation - Treatment How to cross the lesion? How to treat the lesion? Do an angiography and treat the lesion! (Case 212 & 213) 13:30-15:30 : 2 persons/simulator

2. Round: Individual Cases - Strategy You get the Angiographic images! You suggest the strategy! 15:45-16:45: 2 persons/simulator Images are provided on the computers (from the customer or from us when wished)