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Arterial Revascularization

Arterial revascularization is one of the cornerstones to treatment for peripheral arterial disease. These patients and their procedures can range in scope, complexity and level of difficulty. Understanding key concepts will help an interventionist begin to dive into this complex topic.

Arterial Revascularization Procedure Prep

Learn more on the BackTable VI Podcast

BackTable is a knowledge resource for physicians by physicians. Get practical advice on Arterial Revascularization and how to build your practice by listening to the BackTable VI Podcast, reading exclusing BackTable Articles, and following the work of our Contributors.

Ep 118 Treating Acute Limb Ischemia with Dr. Donald Garbett
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Pre-Procedure Prep

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

Arterial Revascularization Podcasts

Listen to leading physicians discuss arterial revascularization on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #edición-esp-02

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En este episodio de BackTable Español, Dra. Gina Landinez entrevista a Dr. Miguel Montero-Baker sobre la enfermidad arterial periférica y salvamento de extremidades en la comunidad latinoamericana.

In this episode of BackTable Español, Dr. Gina Landinez interviews Dr. Miguel Montero about peripheral arterial disease and limb salvage in the Latin American community.

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Episode #181

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Vascular Surgeon Dr. Mazin Foteh and our host Dr. Sabeen Dhand consider various factors that can influence the choice of treatment methods for calcified common femoral artery (CFA) disease, including discussing the pros and cons of an endovascular vs surgical approach.

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Episode #175

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CLI fighters Dr. Kumar Madassery and Dr. Sabeen Dhand discuss their approach to treating calcified arteries below the knee, including looking at newer technologies and choosing the appropriate device to effect real durable change to the calcified wall.

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Episode #172

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CLI fighters Dr. Bryan Fisher and Dr. Sabeen Dhand discuss their approach to treating calcified arteries above the knee, including looking at newer technologies and choosing the appropriate device to effect real durable change to the calcified wall.

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Episode #118

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Interventional Radiologist Dr. Donald Garbett talks with Dr. Michael Barraza about how he approaches acute limb ischemia, including different endovascular techniques for removing acute arterial clot.

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Episode #113

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Dr. Sabeen Dhand and Dr. Kumar Madassery discuss the importance of below-ankle interventions in limb salvage, including patient selection, technique, and a patient-centered longitudinal care plan.

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Episode #108

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We talk with Interventional Radiologists Dr. Robbie Morrison and Dr. Srini Tummala about the pros and cons of adding a wound care services to your endovascular practice.

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Episode #93

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Interventional Cardiologist Fadi Saab and Interventional Radiologist Sabeen Dhand discuss Percutaneous Deep Venous Arterialization (DVA) for critical limb ischemia (CLI), including workup, technique, and follow-up.

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Episode #90

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Dr. Mary Costantino and Technical Director Jill Sommerset talk technique and utility of using Pedal Acceleration Time for pre- and post-procedure evaluation of CLI patients. They also discuss intra-procedure extravascular ultrasound guidance to aid in safe and effective endovascular interventions.

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Episode #86

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Interventional Radiologist Srini Tummala talks us through how he successfully built a thriving PAD practice alongside Vascular Surgery and Interventional Cardiology at University of Miami Health System.

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Episode #69

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Dr. Jim Melton and Dr. Blake Parsons discuss the benefits of retrograde pedal access in the treatment of PAD, as well as the team approach of their outpatient CardioVascular Health Clinic , which includes Vascular Surgery, Interventional Radiology, and Interventional Cardiology working together as partners for better patient care.

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Episode #60

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CLI fighters Sabeen Dhand and Jihad A. Mustapha discuss the essentials of building a successful Limb Salvage program, including the importance of a multidisciplinary approach, broadening skill sets such as pedal access, and meticulous patient follow up.

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Episode #37

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Special guests Dr. Mike Watts and Dr. Omar Saleh discussing the ins and outs of treating PAD in the Outpatient Based Lab (OBL) setting. Includes great info on practice building, patient safety, and essential equipment. #irad #miips

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Episode #9

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On Episode 9 of the BackTable podcast: Listen to the Dr. Kumar Madassery and Dr. Sabeen Dhand discuss their PAD practices and the story behind the #stopthechop hashtag.

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Procedure Steps

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.

Arterial Revascularization Articles

Read our exclusive BackTable VI Articles for quick insights on arterial revascularization, provided by physicians for physicians.

Calcified popliteal occlusion treated with 5mm Shockwave lithotripsy

Vascular surgeon Dr. Bryan Fisher shares his experiences using Shockwave intravascular lithotripsy to treat lower extremity arterial disease on the BackTable Podcast. Dr. Fisher discusses his treatment algorithm, the unique role of Shockwave lithotripsy, and visualizing technical success following the therapy.

Intravascular ultrasound image of intima, media, and adventitia.

Intravascular ultrasound (IVUS) is a useful method for evaluating vessel stenosis and calcifications. Dr. Bryan Fisher explains how he uses IVUS and intravascular lithotripsy to treat calcified vessels.

Pedal access

Pedal access tools, techniques, and pro tips for beginners treating occluded lower extremity arteries with significant calcification.

Posterior tibial artery retrograde pedal access

Retrograde pedal access is becoming popular among both patients and interventionalists for the treatment of critical limb ischemia and peripheral vascular disease. Vascular surgeon Dr. Jim Melton and interventional radiologist Dr. Blake Parsons discuss IR and vascular surgery collaboration in their practice.

Tibial-pedal access in limb salvage

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

Pedal access for limb salvage

Limb salvage programs focus on preventing amputations from Critical Limb Ischemia (CLI). We spoke with Dr. Mustapha to learn what limb salvage is, how to build a successful limb salvage program, & the importance of a multidisciplinary team.

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

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

Arterial Revascularization Demos

Watch video walkthroughs of arterial revascularization on the BackTable VI expanded content network.

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/shows/vi

Disclaimer: The Materials available on https://www.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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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Podcasts

Enfermedad Arterial Periférica y Salvamento de Extremidades en la Comunidad Latino Americana con Dr. Miguel Montero-Baker on the BackTable VI Podcast)
Surgical vs. Endovascular Management of CFA Disease with Dr. Mazin Foteh and Dr. Sabeen Dhand on the BackTable VI Podcast)
Treating Below the Knee Calcium with Dr. Kumar Madassery and Dr. Sabeen Dhand on the BackTable VI Podcast)
Treating Above the Knee Calcium with Dr. Bryan Fisher and Dr. Sabeen Dhand on the BackTable VI Podcast)
Treating Acute Limb Ischemia with Dr. Donald Garbett on the BackTable VI Podcast)
New Tools to Treat Severe Distal Femoropopliteal Disease with Dr. John Rundback on the BackTable VI Podcast)

Articles

Calcified popliteal occlusion treated with 5mm Shockwave lithotripsy

Shockwave Intravascular Lithotripsy Treatment Algorithm & Technical Success

Intravascular ultrasound image of intima, media, and adventitia.

Using IVUS to Guide Treatment of Calcified Vessels with Intravascular Lithotripsy

Pedal access

Pedal Access Tools, Techniques & Tips

Contributors

Dr. Donald Garbett on the BackTable VI Podcast

Dr. Donald Garbett

Dr. Kumar Madassery on the BackTable VI Podcast

Dr. Kumar Madassery

Dr. Jim Melton on the BackTable VI Podcast

Dr. Jim Melton

Dr. Miguel Montero-Baker on the BackTable VI Podcast

Dr. Miguel Montero-Baker

Dr. Robbie Morrison on the BackTable VI Podcast

Dr. Robbie Morrison

Dr. Jihad Mustapha on the BackTable VI Podcast

Dr. Jihad Mustapha

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