Arterial Revascularization

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Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.

Pre-Procedure

Indications:
• Peripheral vascular disease - including focal or long segment stenoses and/or chronic total occlusions.

Contraindications:
• Uncorrectable bleeding diathesis
• Stenotic/occlusive disease with high thromboembolic risk
• Renal failure
• Extreme vessel tortuosity

Things to check:
• History and Physical
• Patient anticoagulation status
• Creatinine, coagulation profile
• Any prior imaging - Vascular ultrasound, CTA, MRA
• Lower extremity pulses

Procedure

Procedural steps:
• Access common femoral artery of contralateral leg using micropuncture needle under US
• Advance wire centrally
• Place a 5, 6 or 7 Fr sheath (depending on the potential atherectomy device).

Angiography
• Advance flush catheter over the wire into the aorta.
• Perform AP aortogram - 15 mL/sec for 30 mL.
• Pull flush catheter back into the distal aorta
• Perform iliac artery arteriogram - 10 mL/sec for 20 sec.
• Keep catheter in distal aorta and perform lower extremity runoff arteriography - 8 mL/sec for 80 mL

Evaluate lesion(s)
• Exchange for a selective catheter and catheterize target artery.
• Position catheter proximal to lesion.
• Administer heparin bolus prior to crossing lesion (2500-5000 U)
• Gently advance guidewire across stenosis.
• If resistance is met - avoid dissection and retract wire. Redirect catheter and readvance wire until successful passage.
• Direct guidewire through central canal of lesion. Advance selective catheter over wire across the lesion
• Angiogram following lesion crossing to confirm position
• Exchange crossing guidewire for a 0.014" guidewire.

Treatment:
• Many options from balloon angioplasty to atherectomy
• Introduce atherectomy device over guidewire; perform atherectomy across lesion
• Inject contrast through sheath or catheter to evaluate progress. Determine if further intervention is needed. May need balloon angioplasty, or stent placement if dissection occurs.
• Remove access sheath and close arteriotomy site - closure device or manual pressure.

Post-Procedure

Obtain hemostasis
• Supine bedrest for 3 hours with closure device. 6 hours with manual pressure

Complications:
• Arterial injury - dissection, rupture, hematoma, distal embolization, thrombosis.
• Groin complications

Related Procedures

No related procedures.

 

References

[1] Mittleider D, Russell E. Peripheral Atherectomy: Applications and Techniques. Tech Vasc Interv Radiol. 2016;19(2):123‐135. doi:10.1053/j.tvir.2016.04.005
[2] Wilkins LR, Sabri SS. Strategies to Approaching Lower Limb Occlusions. Tech Vasc Interv Radiol. 2016;19(2):136‐144. doi:10.1053/j.tvir.2016.04.006
[3] BackTable, LLC (Producer). (2017, August 16). Ep 9 - #StopTheChop [Audio podcast]. Retrieved from https://www.backtable.com/podcasts

Join The Discussion

 

Demos

Demos are not yet available for this procedure.

Please check back soon.

Atherectomy of Common Femoral and Superficial Femoral Arteries

Dr. Chris Metzger performs atherectomy of the common femoral and superficial femoral arteries.

Complex Revascularization of SFA Occlusion Using Rotational Atherectomy

Dr. Jihad A. Mustpha demonstrates treatment of a CTO in a patient with diabetes, CKD-3, and CAD. He highlights technique and the benefits of vessel prep with atherectomy prior to DCB.

CO2 Angiography

Dr. Craig Walker demonstrates CO2 angiography and discusses the advantages of this imaging technique. He then shows the tools and technique to image an iliac artery.

Critical Limb Ischemia and Left Foot Ulcer

This demo description is not yet available.

Complex Below-the-Knee Revascularization by Dr. Scott Brannan

Dr. Scott Brannan demonstrates wire escalation strategies, intravascular ultrasound, and rotational atherectomy to achieve revascularization in complex BTK disease

Let's Talk IVUS and PAD

This presentation gives viewers an overview of IVUS as well as its applications and benefits related to PAD interventions.

 

Tools

Tools are not yet available for this procedure.

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Literature

Literature is not yet available for this procedure.

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Seminars in Interventional Radiology (Dec 2014)

Overview of Classification Systems in Peripheral Artery Disease

A review of the various classification systems for the diagnosis and treatment of PAD and advantages of each system.

 

Podcasts

Podcasts are not yet available for this procedure.

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Building a Limb Salvage Program Podcast Guest Dr. Jihad Mustapha

Dr. Jihad Mustapha

Dr. Sabeen Dhand

CLI fighters Dr. Jihad Mustapha and Dr. Sabeen Dhand building a Limb Salvage program, including broadening skill sets such as pedal access, and meticulous patient follow up.

&

#StopTheChop Podcast Guest Dr. Kumar Madassery

Dr. Kumar Madassery

Dr. Sabeen Dhand

Dr. Kumar Madassery and Dr. Sabeen Dhand discuss their PAD practices and the story behind the #stopthechop hashtag.

&

Treating PAD in the OBL Podcast Guest Dr. Mike Watts

Dr. Mike Watts

Dr. Omar Saleh

Dr. Mike Watts and Dr. Omar Saleh discussing the ins and outs of treating PAD in the Outpatient Based Lab (OBL) setting.

&

Retrograde Pedal Access BackTable Podcast Guest Dr. Jim Melton

Dr. Jim Melton

Dr. Blake Parsons

Dr. Jim Melton and Dr. Blake Parsons discuss the benefits of retrograde pedal access in the treatment of PAD, as well as the multi-disciplinary team approach of their outpatient CardioVascular Health Clinic.

&

 

Blog Articles

Blog articles are not yet available for this procedure.

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Building a Multidisciplinary Limb Salvage Program

Defining limb salvage for critical limb ischemia treatment and building a successful limb salvage program with a multidisciplinary approach .

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Taking a Multidisciplinary Approach to Peripheral Arterial Disease

From podiatry to interventional radiology, peripheral arterial disease (PAD) is managed by numerous medical specialties. A multidisciplinary approach to trea...

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Access Points and End Points in Peripheral Arterial Disease

Vascular access decisions should be tailored to the location of disease burden in patients with peripheral arterial disease. PAD experts Dr. Sabeen Dhand and...

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Challenges and Evolutions in Limb Salvage

Challenges with building a limb salvage program and advances in tibial-pedal access and extravascular ultrasound for optimal CTO crossing.

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Intraoperative Management of Peripheral Arterial Disease

Anesthesia choice and intraprocedural anticoagulation are critical for optimal patient outcomes, and IRs have some options when it comes to management during...

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Imaging to Atherectomy: Technologies to Identify and Treat Peripheral Arterial Disease

There are numerous modalities available to characterize and treat peripheral arterial disease (PAD). Dr. Kumar Madassery and Dr. Sabeen Dhand highlight their...