ILIAC DISEASE: ENDOVASCULAR APPROACH
Approach to TASC A/B Iliac Disease
Equipment, Tips, and Tricks
Ramesh M. Gowda, MD FACC FCCP FSCAI
Director, Peripheral Interventions
Mount Sinai Beth Israel
Assistant Professor of Medicine
Icahn School of Medicine at Mount Sinai
New York, New York
June 17th, 2015
2015 ENDOVASCULAR FELLOWS COURSE
No financial disclosures
TASC Classification of Iliac Lesions
TASC Classification of Iliac Lesions
Type A
lesions
Type B
lesions
Single stenosis of
CIA or EIA <3 cm long
(unilateral or bilateral)
Single stenosis
3-10 cm long, not
extending into CFA
Two stenoses of CIA or
EIA <5 cm long, not
involving CFA
Unilateral CIA occlusion
Revascularization in Aorto-iliac Disease
Continuum of Iliac treatment
Access Options
• Choice depends on specific anatomy and body habitus
• Femoral
– Retrograde
• Most common
– Antegrade
• crossover technique from the contralateral CFA
• Arm (prefer left)
– Brachial
– Radial
• Novel approaches
– TransPedal
• Using Slender Terumo Sheath
• *Ultrasound*
Traditional Access: Femoral
Universal Flush (UF) Catheter / SOS OMNI
Flush Catheter / RIM catheter
65 cm length; 4F or 5F
Radiopaque distal portion: helps reduce the
risk of vascular damage upon entering
tortuous or fragile vessels.
Lesion/Vessel Imaging
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Abdominal Aortic runoff – AP view
CIA / Prox. EIA – contralateral view
Distal EIA – ipsilateral view
DSA imaging, ask patient to hold breath
Use Roadmap for stenting
Take runoff pictures of entire limb to
check for embolization
Step by Step Approach - I
• Diagnostic picture can be taken from radial access,
to determine whether groin access is needed
– 4 fr radial sheath, 4 Fr 90cm UF, 125CM PIG
• If choosing groin access, decide if treating from
contralateral or ipsilateral side
– Cordis Brite tip sheath, 5.5, 11, 23, 35 cm
– Terumo Pinnacle R/O for ispilateral
• Achieve cross over, usually with a UF or SOS Omni
or Rim catheter, use stiff 0.035 wire
– Amplatz, Supracore, Glide
• Use shorter (45, 55cm) cross over sheath for
contralateral access - Cook Balkin, Ansel 2 curve
Equipment Sizing Limitations
• 6 Fr- Radial, Brachial, Groin
– 10 mm Self Expanding stent
– 8 mm Viabahn stent (0. 018 system only)
– 8 mm Balloon Expandable stent
• 7 Fr- Groin Only
– 12, 14mm self-expanding BMS
– 9 mm Viabahn stent
– All iCAST stents
Sheaths
Cook sheath -- 0.018 / 0.035 dilators
http://www.invasivecardiology.com
Special Tools
All should be familiar with
Morph and Re-entry devices
Morph Catheter
• Morph Universal Deflectable Guides
• Morph Access Pro Steerable Introducers Sheaths
– High iliac bifurcation
– Severe iliac tortuous anatomy
– Inserted in a straight configuration and deflected
into the desired shape
Re-entry Devices
• Outback
– radiopaque marker system is simple and easy to
use
• Pioneer
– requires IVUS (most not reimbursed)
Become familiar with these tools
for when you really need them
Wires
• 0.014” & 0.018” –not preferred
• 0.035”
– primarily used to gain access and crossing
– Maximum support and equipment stability
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STORQ wire
SUPRACORE wire
GLIDEWIRE ADVANTAGE
AMPLATZ SUPER STIFF
AQUATRACK
POBA & Specialty Balloons
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Plain Balloon Angioplasty
Scoring balloon
Cutting balloon
Chocolate balloon
Produce focal forced dilatation
– predictable luminal gain
– a lower rate of uncontrolled dissections
– less barotrauma
– Avoid slippage
Stenting Options
• Nitinol Stents
• Stainless Steel
– Bare metal (8, 9,
–Bare metal
10mm)
• Palmaz Genesis,
• Smart, Everflex,
VisiPro
Absolute, Lifestent
–Covered
– Covered
• iCAST
• Viabahn 0.018,
0.035 system
Step by Step - II
• Sizing Vessel –
– IVUS: Volcano Eagle Eye 0.014 Catheter, change diameter to 18
-20 mm to increase field of view
– Use a smaller size 0.035 balloon to assess length and diameter
– Measuring tape
• deep vessels measure longer than tape indicates
• Self expanding stents
– use 1-2mm oversized stent to reference vessel
• Balloon expandable stents
– sized 1-1 to reference vessel size
• Using 0.035 wire for most support and stability with equipment
Radial resistive force plays a role in
maximizing luminal gain
65 yr F smoker, DM, left thigh claudication, ABI 0.7, Duplex PSV 350
Pitfalls and Complications Perforation
• Often associated with calcified plaques
• Prevention:
– Use only heparin- can be reversed
– Use stepwise approach with predil, stent, post dil
– Keep 7 F sheath handy
– Keep covered stent handy (8x38 Icast is most
versatile- can be post dilated to 12mm if needed)
• Use 0.035 balloon for tamponade while
preparing needed equipment
Pitfalls and Complications
Pseudoaneurysm
• Hypertensive and/or in severely calcified vessels
• Acutely – bruising or persistent oozing from the
access site
• Later – “knot” or pulsatile mass in the groin
• Initial assessment is by ultrasound
• Large ones (>2 cm) need ultrasound guided
thrombin injection
• Larger mature lesions may require surgical repair
or covered stent (if no major branches)
Summary
• Endovascular approach has >95% success rate
achieved with proper patient / lesion selection
and operator skills
• PTA is preferred strategy for TASC A/B lesions
• Stenting for short lesions (especially CTOs)
• Familiarity of various existing combinations and
innovative technologies make a procedure safe
with improved short and long term outcomes
• Non-traditional access choices can increase
patient comfort and satisfaction
THANK YOU
Back Up
Overview of the Procedure
• Access - 21 gauge needle and 0.18 wire
– 4F micropuncture set; then a 4F or 5F brite tip sheath
– 4F Pinnacle Precision sheath
• Ultrasound can greatly assist in directly accessing the ‘least diseased’
portion of the vessel
• Upon obtaining access
– heparinize prior to placing the working sheath across the bifurcation
– use a stiff wire while placing the sheath to prevent collapse of the sheath if the bifurcation
is very angulated
– perform an angiogram once the sheath is place to confirm location and anatomy
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If significant risk of embolization and one vessel runoff, consider distal EPD
Use road map or smart mask or reference overlay imaging technique
Use ruler or measuring tape to help clearly identify the area to be treated
Always perform a completion angiogram
– if extensive disease, this should include the entire limb