PTA OVERVIEW AND HARDWARE
DEEPAK NANDAN
INTRODUCTION
• Endovascular revascularization of infrarenal aortic and iliac disease- high
rate of technical success and with lower morbidity and mortality than
open bypass surgery
• Preferred modality for treatment of patients with Trans-Atlantic InterSociety Consensus Document (TASC) II type A and B lesions
• Surgical revascularization preferred for patients with TASC type C and D
lesions
• In contemporary practice, surgery is reserved for failure of endovascular
approach
Modified TASC Morphological Classification
(TransAtlantic Inter-Society Consensus)
TASC -Femoral-Popliteal Lesions
AortoIliac and Common Femoral
Intervention
5 YEAR PATENCY RATES OF AORTOILIAC INTERVENTIONS
Vessel diameter
Vessel
Size in mm
Infrarenal Aorta
14-20
Common Iliac
8-12
External Iliac
7-10
Common femoral
6-7
Recommendation for vascular access of
aortoiliac intervention
Location of lesion
Vascular access
Aortic bifurcation
Bilateral retrograde CFA
Ostial common iliac
Ipsilateral retrograde CFA, brachial artery
Common and EIA stenosis
Ipsilateral retrograde , contralateral CFA
Common and EIA occlusion
Ipsilateral+/- contralateral CFA, brachial artery
Common femoral
Contralateral retrograde CFA
Common, EIA,SFA , popliteal
Contralateral retrograde CFA
Vascular Access
• Relatively disease-free, without signi Ca
• Over a bony structure, if possible
• Angle of entry- 30⁰-45⁰
• Obtained with an 18-gauge needle that will
accommodate most 0.038 “ or smaller Wires
• A smaller 21-gauge needle with a 0.018-inch wire
- “micropuncture kit” (Cook, Bloomington, IN)
• Used for difficult femoral, brachial, radial, or
antegrade femoral approaches
Retrograde Common Femoral Artery
Access
• Common access site used for
peripheral diagnostic angiography
and intervention
• Prevent injury to the less
diseased extremity
Contralateral femoral retrograde
access
•
iliac occlusions are best
treated from a
contralateral approach
• SFA,PFA- lesions OF
CFA/involve SFA/PFA
ostium • allows treatment B/L
disease with a single
arterial puncture
Femoropopliteal Artery Intervention
• Contralateral femoral retrograde access :
Advantage
Disadvantage
Less subsequent complications including
hemorrhage from puncture site
Working from a distance with exchangelength wires and balloons
Ability to image CFA and its bifurcation
Lack of support while traverse of critically
narrowed or occluded sites
Ability to treat iliac and infrainguinal
disease in the same setting
Antegrade Common Femoral Artery
Access
Ipsilateral popliteal retrograde
access
• Required for infrainguinal proced
• Approx 3cm CFA lies betw ligament &
FA bifurcation
• Inorder to access CFA, skin entryprox to ing ligm
• Access too close to F bifurc –inadeq
working room to selectively cath SFA
• Useful in SFA occlusion with failure
to cross from contralateral or
antegrade
• Ostial SFA/CFA lesions may also be
approached via PA in acute angled
terminal ao bifurc
• CI- aneurysms of PA, pathology of
popliteal fossa- Baker’s cyst
Brachial Artery
Access
• Pref access for visc arterial [CA, SMA] interventions
• PC approach at BA can lead to a ↑compli rate
– UL arts – smaller, prone to spasm
– A small hematoma- Could lead to brachial plexopathy
• Itv req >6F sheaths/smaller pt→open approach
preferred
• Left BA access pref over Rt- can avoid carotid origin
• A micropuncture tech should be used for all PC BA
intervention
• Left brachial approach has approximately 100
mm greater reach than the right brachial approach
Estimated distances from FA access
GUIDEWIRES
•
Guidewires are used to introduce, position, and exchange catheters
•
In a standard guide wire, a stainless steel coil surrounds a tapered inner core
•
A central safety wire filament is incorporated to prevent separation in case of
fracture
•
5 charecterstics- size, length, stiffness, coating, and tip configuration
• Typically they are 100 to 120 cm in length but can also be 260 to 300 cm
(good rule of thumb to follow is that the guidewire should be twice the length of the longest catheter being
used)
•
Tip of the wires can be straight, angled, or J-shaped
•
Varying degrees of shaft stiffness- extra support,to provide a strong rail to
advance catheters in tortuous anatomy vs extremely slick hydrophilic with low
friction
Wire selection
•
Diameter vary from 0.014“ to 0.038“
•
Most commonly used size is 0.018“/0.035“ ( upper extremity) and
0.014“/ 0.018“ ( lower extremity)
•
Length between 130 and 300cm
•
Tip configurations are; straight, angled Tip and J shape
•
Varying degrees of shaft stiffness ( e.g. extra support, super stiff
wires) allow advancement of stiff devices
Hydr-angle tip–
Glidewire
Can be used for
crossing tight
lesions and can
be advanced
independent of a
guidewire
038:18g needle,
018:21g needle
GuidewireLesion
Interaction
• Floppy portion moving in a linear fashion
• Floppy portion piles up prox to lesion—no chance
to cross- backup,redirect,if straight tip→steerable
• Floppy tip bent with min R—Cautiously adv wireonce crossed, wire should straighten- advancing
a “buckledup” wire- force→embolization
• Floppy tip “buckledup” —backup,redirect,adv dissect,embolz,wire damag
PTA Guide wires
Guide wire Functions
PTA Guidewires are designed to:
•
–
–
–
Track through the vessel
Access a lesion
Cross a lesion
Provide device delivery support
Coils & covers
Outer coils
Tip coils only
Polymer cover
Polymer sleeve
Tip coils
Coils & covers
•Coils provide tactile feedback, radiopacity and maintain
constant overall diameters
• Polymer covers/sleeves provide optimal lubricity to overcome
resistance and access to the lesion
Allows smooth tracking through tortuous anatomy
Better device tracking over the guidewire
Not to be confused with coating (hydrophilic or hydrophobic)
Covers and Coatings – Summary
Lu
br
ici
ty
Tactile Feedback (related to coils)
Hydrophilic
Coating
Hydrophobic
Coating
No
Coating
Delivery &Device Interaction
Polymer Cover
with hydrophilic
Coating
PTA GUIDE WIRES
• Glidewire (TERUMO)
Peripheral Guidewires
(0.032"-0.038")
Standard Glidewire
Shapeable Tip Glidewire
Long Taper Glidewire
Stiff Shaft Glidewire
Stiff Shaft Long Taper Glidewire
1 cm Taper Glidewire
J-Tip Glidewire
Bolia Curve Glidewire
Glidewire Advantage™
Small Vessel Guidewires
(0.018"-0.025")
Glidewire Standard and Shapeable T
ip
Glidewire GT Super-Selective
Glidewire Gold
•Terumo Glide Technology™ hydrophilic coating
smooth, rapid movement through tortuous vessels
crossability over difficult lesions
•Core-to-tip design provides 1:1 torque ratio
•elastic nitinol core for optimal performance
•Resists kink &Retains shape
•Tungsten in polyurethane jacket- radiopacity
•Carries the risks of vessel dissection
and perforation
•should not be used to traverse needles because of
the potential of shearing
ABBOT
Hi-Torque Steelcore Peripheral
Guide Wire (190/300 cm)
Hi-Torque Spartacore
Peri Wire
• Excellent .014" Support SS shaft
• Superb Steerability and a Soft
Shapeable Tip
• Core-to-tip design
• 130/190/300 cm lengths
• MICROGLIDE Coating
• PTFE up to distal 7 cm (130 cm)
• Available in 5 and 10 cm
Hi-Torque Supra Core 35
Hi-Torque Versacore Guide
Wire
•
•
•
•
•
•
• Torqueable wire for
deliverability through
tortuous or challenging
lesions
One-to-one torque
exceptionalsteerability
MICROGLIDE coating
Radiopaque tip
035" shaft
Soft Shapeable tip
• Soft shapeable tip
designed to for lesion
acces
BOSTON SCIENTIFIC
Amplatz Super Stiff Guide
Wire
• For stiffness, strength and
stability during catheter
placement and exchange
• Diameters: 0.035", 0.038"
• Lengths: 145cm,180cm,
260cm
• Tips Styles: Straight, J, Short
• Core Material: Stainless
steel
• Coating: PTFE
Magic Torque Guide Wire
• Magic Markers spaced at
1cm increments
• designed for enhanced
visualization and excellent
torque control
• Diameters: 0.035"
• Lengths:180cm, 260cm
• Tips Styles: Straight
(shapeable)
• Core Material: Stainless
steel
• Coating: Glidex Hydrophilic
Coating (tip)
Meier Guide Wire
• Stiff shaft excellent
supp
• flexible tip is ( AAA
endovascular graft
procedures)
•
•
•
•
•
Platinum Plus Guide Wire
• Designed for negotiation
of tortuous anatomy and
contralateral approaches
• Diameters: 0.014",
0.018", 0.025"
Diameters: 0.035"
• Lengths (cm): 60, 145,
Lengths: 185cm, 260cm, 180, 260, 300
300cm
• Tips Styles: Straight –
Long or short taper
Tips Styles: J, C
Core Material: Stainless • Core Material: Stainless
steel
steel
• Coating: Glidex
Coating: PTFE
Hydrophilic
Thru way Guide Wire
• Designed for excellent performance in acutely
angled vessels, such as renals and other
peripheral interventions
•
•
•
•
Diameters: 0.014", 0.018"
Lengths (cm): 130, 190, 300
Tips Styles: Straight, J
Core Material: Stainless steel
Coating: Silicone
CORDIS
• EMERALD™ Guidewires
• Fi xed-Core, PT F E Coated, Exchange Wires
COOK
Amplatz Stiff Wire Guides
•
•
Stiff shaft
Gradual transition to a very
flexible distal tip
– TFE Coated Stainless
Steel-035,038:
145,180,260-straight
– TFE Coated Stainless
Steel with Heparin
Coating-035:
145,180,260-straight
• 8 cm-flexi tip
Amplatz Extra-Stiff Wire
Guides
• ↑ inner diameter -extrastiff + tip flexibile
– TFE Coated Stainless
Steel-025,035,038:
80,145,180,260straight & curved:
– 300-straight
– TFE Coated Stainless
Steel with Heparin
Coating-035:
80,145,180,260straight & curved
Amplatz Ultra-Stiff Wire Guides
• The increased inner diameter of the wire
guide coil allows utilization of an ultra-stiff
mandril while maintaining tip flexibility
– TFE Coated Stainless Steel-035,038: 80,145,180straight
– TFE Coated Stainless Steel with Heparin Coating035: 145,180-straight
• 8cm-flexi tip
Roadrunner Extra-Support Wire
• Complex diagnostic/interventions where extra support needed for cath exchange
/manipulation of devices
• Heavy-duty nitinol alloy mandril provides
support while imparting 1:1 torque response to
distal platinum spring coil tip
• Angled tip facilitates directional control
• Lubricious TFE coating -low coefficient of friction
• 014,018
• 180,270,300
Cope Mandril Wire Guides I
• Stainless Steel
• Platinum coil ↑visualization
and an angled floppy tip for
precise directional control
Cope Mandril Wire Guides II
• Nitinol
kink resistant
1:1 torque control
• Platinum coil -↑visualization
• 018
• angled floppy tip for precise
directional control
• 40,60,100,125
• 018
• Standard taper-7cm coil
• 60,100,125
• Standard taper-7cm coil, short
taper-7cm coil
Rosen Curved Wire Guides
• The heavy-duty mandril, 2 cm flexible tip and
tightened “J” configuration
• Ideal for Renal int- less traumatic
• TFE Coated Stainless Steel-035:
80,145,180,220,260
• TFE Coated Stainless Steel with Heparin
Coating-035: 145,180,260
The Graduate Measuring Wire Guides
•
•
•
•
•
•
Used to determine accurate sizing of vessel
Gold radiopaque markers delineate 25 cm length
Six distal markers are spaced 1 cm apart.
Four proximal markers are spaced at 5 cm increments.
035
145,180
Reuter Tip Deflecting Wire Guide
• Used with Reuter Tip Deflecting Handle for curving or
deflecting catheter tips during selective and superselective
angiography
• Facilitates catheter tip movement by controlling the deflection
of the wire guide tip within catheter lumen
• Distal tip of wire guide must never extend beyond tip
BIOTRONIK
Cruiser Guide Wire
• 0.014“
• L: 190 cm
• Tip Shape: Straight and J
Cruiser-18
• Hi-support Guide Wire
• 0.018”
• Stiff: 195 cm and 300 cm
Medium: 195 cm and 300 cm
Catheter
An “ideal catheter” should be able to sustain high-pressure
injections, to track well, be nonthrombogenic, have good
memory, and should torque well
Catheter ( diagnostic/ guiding)
Length depends on location for using
Sizes are 5 to 8 French
a) abdominal aorta = 60 to 80 cm length
b) BTK,carotid or subclavian areas 100 to 125cm length
Polyethylene- ↓coef friction, pliable
Polyurethane- softer, even ↑pliable→ tracks wires better
Nylon- stiffer, can tolerate ↑flow rate- amenable to angio
Teflon- stiffest- used mainly for dilators & sheaths
wire braid in the wall to impart torquibility and strength
Guiding Catheter vs Sheath
• Operator dept
• Sheaths are designed with a simple diaphragm or a hemostatic valve,
guiding catheters always require hemostatic valves be attached
• During intervention, the guide catheter or sheath should be placed near
the lesion to provide for better visualizationand improved support
Flush /Non-Sel
Selective
CATHETERS
BALKIN Sheath (cook)
• Contralateral access to the iliac artery
•
Flexibility without kinking or compression
• Radiopaque band- identifies precise location of sheath’s distal
tip for positioning accuracy
• The Check-Flo valve prevents blood reflux and air aspiration
during catheter manipulations
• 5.5 Fr-8 Fr- 40cm - .038” compatible
Super Arrow-Flex® Sheath /Dilator Set
with 90° curved tip (ARROW International)
• 6-7Fr
• 45cm length Assures successful access to the renal arteries. “Y”
Connector + Tuohy Hemostasis Valve a+ 3-Way Stopcock
• 90° Curved Tip Both sheath and dilator have a curved tip for easy access to
the renal artery
• Sheath replaces guide catheter -eliminates the need for using a guiding
catheter - reducing size of puncture
• Radiopaque tip marker-locate and control sheath advancement into RA
TERUMO GUIDING SHEATH( Pinnacle Destination)
• Guiding Sheaths (5-8 Fr)
•
•
•
•
5-8 F
45,65,90
Hydrophilic coating
All dilators are 0.038" wire compatible
▫
▫
▫
▫
▫
▫
▫
▫
• Glidecath (4 Fr)-65,100,120-038
• Glidecath XP (5 Fr)-65,100-038
• Glidecath (5 Fr)-65,100-038
TERUMO
TERUMO GLIDE CATH
• Hydrophilic Coated Catheters
• Hydrophilic coated distal tip (15 cm) for smooth passage through tortuous
vasculature
• Double-braided stainless steel mesh middle layer ↑ shaft rigidity and
torque transmission
• Nylon-rich polyurethane inner layer for smooth flow of therapeutic agents
and 0.035"/0.038" embolization coils
• Large lumen (0.038" wire compatible) and small profile (4 Fr) is ideal for:
Use as a guiding catheter for microcatheters
Diagnostic procedures that require high flow rates
Excellent trackability and navigation –most tortuous anatomies
SOS Omni selective catheter
• Soft, atraumatic, Super-radiopaque tip
• Reforming in desc thoracic aorta – below great
vessels rather than transverse arch –safety
• Pulled from the desc ao into abd ao with a floppy
guidewire “leading,” sometimes with a rotating
motion
• Soft, flexible atraumatic tip can be placed deeper
into the artery (>1 cm), ↓chance of “catheter
kickout.”
• Shaped tip allows the guidewire to flick into the
origin of the RA
Omni Flush Angiographic Catheter
• Flush aortography B/L“run off” studies of LL
• Cross ao bifurcation with ease for C/L diagnostics in
interventional procedures
• Super-Radiopaque tip
• Reforms and maintains shape—even under injection
pressure—with less catheter whipping-less vessel
wall injury
• Less contrast reflux than other flush catheters-lower
total contrast dose
• 4F IMPRESS Simmons 1
Catheter 65cm..038
• Side Ports:N/A
• Catheter Shape:SIMMONS
1
• French Size:4
• 5F IMPRESS Simmons 2
Catheter 65cm..038
• Side Ports:N/A
• Catheter Shape:SIMMONS
2
• French Size: 5
Microcatheters (TERUMO)
• Progreat™ (2.4 Fr, 2.7 Fr)- 110/130- OD 2.9Fr/2.7
• Progreat™Ω (2.8 Fr)- 110/130- OD 3Fr/2.8
Slip-Cath Beacon Tip Catheters (C00K)
• Hydrophilic Coating
• Enhanced radiopaque Beacon tip
• Sixteen stainless steel wire braid imparts 1:1
torque control to catheter tip & ↑pushability
• Nylon material resists softening during
prolonged catheter manipulation
Slip-Cath Beacon Tip Catheters
CXI Support Catheters(C00K)
• For use in small vessel/superselective anatomy for diagn
& interv procedures, incl peripheral use
• Low profile from tip to hub ensures smooth transition
through small vessels
• Shaft's polymer material offers desired flexibility
• Braided SS entire length -pushability
• Hydrophilic coating
• Embedded radiopaque markers -size the vessel segment
length
Veripath Peripheral Guiding
Catheter(ABBOT)
•
•
•
•
•
Three-Layer Construction
50 cm length
5 catheter shapes
6,7,8 F
014/018
• CORDIS
Accesses and Selective Guiding Catheters for Some Basic Interventions
Carotid Artery
1.First choice access—either FA
2.Alternative access—left BA
3.Selective catheter—
Right carotid: H1,Simmons,Vitek
Left carotid : angled glidecath,H1,Simmons
Subclavian Artery
1.First choice—either FA
2.Alternative access—ipsilateral BA
3.Selective catheter– angled Glidecath,H1,Simmons,H3
Celiac or SMA
1.First choice—either FA
2.Alternative access—left BA
3.Selective catheter—RIM,Chuang
Renal Artery
1.First choice—contralateral FA
2.Alternative access—left BA
3.Selective catheter—C2,RDC,Sos-omni
Infrarenal Aorta
1.First choice —either FA
2.Alternative access—left BA
3.Selective catheter—omni-flush,RIM,C2
Superior Femoral Artery
1.First choice—contralateral FA
2.Alternative—ipsi retro FA for run-off; ipsi antegrade for interv
3.Selective catheter—Berenstein,Kumpe,Vertebral
Tibial Arteries
1.First choice—contralateral FA
2.Alternative—ipsi retro FA for run-off; ipsi antegrade for interv
3.Selective catheter—Kumpe,Vertebral
Vessel size
• The vessel in each territory have their own different size,
important to know to choose a proper balloon or stent
Balloons
Balloons
• In selecting a balloon, the following criteria should be considered :
a) Guidewire ( 0.014“, 0.018“, 0.035“)
b) Over the wire (OTW) or monorail system
c) Shaft length
•
Balloon shaft lengths are commonly 75 cm or 120 cm, can be coaxial
or monorail and designed to be inserted over 0.014-in., 0.018-in., or
0.035-in. wires
• 0.014“ balloon system is usually for carotid, vertebral, renal,
infrapopliteal arteries
• 0.018“ balloon system also in SFA, infrapopliteal- operator dept
• 0.035“ balloon system for subclavian, innominate, aortoiliac,
superficial femoral artery
• Circumfer force/tension (T) exerted on wall of an inflatd balln ~P within
balln & R (T=P×R)(LAPLACE)
• Larger ballns -require ↓P than smaller ballns to generate substantial
dilating forces
• Larger vessels (Ao) require ↓P to dilate & rupture
1.
2.
3.
4.
•
Diameter matching vessel beyond lesion
Balloon length should be > lesion
Balloon centered on lesion & inflated slowly
Inflation maintained for 20s- deflated- reinflated 3 inflations of 20s
Patient’s complaint of low back pain during balloon inflation may be a
warning sign of adventitial stretch, which may occur before aortic rupture
ATB ADVANCE PTA Dilatation Catheter
Advance 14LP
Advance 18LP
Advance 35LP (C00K)
• Designed for iliac, renal, popliteal, infrapopliteal, femoral and
iliofemoral
• Also intended for postdilatation of balloon-expandable
peripheral vascular stents
• 40,80,120
• Low profile
• Hydrophilic
Advance 14LP (C00K)
• Low Profile
• Provides the trackability and pushability to reach
even the most remote infrapopliteal lesions
• Hydrophilic coating on balloon and distal shaft,
along with a smooth tip transition
• Maintains super-low profile after inflation
• 4 Fr sheath compatibility for all sizes
• 20 to 200 mm in 2, 2.5, 3, 4 mm D
• 170
FoxCross .035 PTA (ABBOT)
• D-(3-14 mm), L-(20-120 mm), and cath L (50,
80 &135 cm)-OTW
• Good trackability, rapid inflation/deflation
• Crossability -useful in calcified lesions
• 5-7 F
• Guide wire compatibility: 035
• Nylon Polymer
• JETCOAT coating
ABBOT
Fox sv PTA Catheter
• OTW designed for
challenging small vessel
procedures
• Range of BTK and SFA
sizes (2-6 mm) 90,150
• Sheath Compatibility:4F
for all sizes
• Guide wire
compatibility:.014"/.018
Fox Plus PTA Catheter
• Low Profile
• Compatible with a 5 Fr
sheath up to 7mm
balloons
• Shaft Technology-dual
lumen-Rapid infl and
deflation
• JET coated - Reduces
friction and facilitates
access and crossing of
target lesions
Sterling Balloon Dilatation Catheters
(BOSTON SCIENTIFIC)
• Breakthrough 4F Profile
• Both Over-the-Wire and rapid exchange
• 40,80,135
• Specifically designed for use in carotid, renal and lower
extremity arteries
• Sterling SL Balloon
Dilatation Cath
• Sterling ES Balloon
Dilatation Cath
• long lengths-BTK specifically designed infrapopliteal procedures
• 0.014" balloon cath
• 014, 018
• Both OTW and rapid
exchange platforms
•
• Ultra-low profile balloon
OTW and Monorail
• .017" tip entry profile
• 90,150
• 140
BIOTRONIK
Passeo-18
Passeo-35
• Balloon Catheter 0.018” /.035” OTW
• Hydrophobic patchwork coated balloon
ensures a smooth crossing through tortuous
vessels and across high grade stenosis whilst
minimising the risk of slippage during inflation
experienced using hydrophilic coated balloons
Stents
a) Balloon-expandable
b) Self-expandable
c) Stent graft
Balloon-expandable stents
• Require positive pressure for expansion
• Typically rigid with high radial force
• Size of the balloon-expandable stent equals to the size of the
reference vessel diameter
• Ideal for immobile sites of the body
subclavian, renal, mesenteric, iliac arteries and at
ostial locations
PALMAZ Bal-Exp Stent (unmounted)
CORDIS
•
•
•
•
•
Closed cell
SS
Stent D (Expanded) 4-8mm
Stent L (Unexpanded) 10,15,20,29,39mm
Sheath Introducer 6F, 7F
Dynamic Renal (BIOTRONIK)
• Balloon-Expandable Cobalt Chromium Stent
0.014” / Rx
Dynamic
• Balloon-Expandable Stainless Steel Stent
0.035” / OTW
SELF EXPANDABLE Stents
• Deployed in vessels that are flexible or twist during movement of
neck, shoulder or leg
Carotid, Axillary, SFA, Popliteal artery
• Nitinol - metal - provides best flexibility and memory
• Stent is simply compressed over a stent delivery catheter and
covered with a sheath
• Stent deployment is achieved by pulling back the sheath
• Stent diameter should be 1-2mm larger than the reference vessel
diameter- adequate stent apposition with the vessel wall
Self-expandable Stents
• Some degree of foreshortening- to be taken into
account when choosing
• More difficult to place with absolute precision
• Generally comes in longer length than BES
• Their ability to continually expand after delivery
allows them to accommodate adjacent vessels of
different size
BX- vs SX stents for iliac
BX stent
SX stent
intervention
Advantages
Disadvantages
Suitable lesions
High radial force
Elasticity, flexibility
Minimal foreshortening
Conformability
Good visibility
MRI compatibility
Absolute precision
Continually expand – vessel size
Risk of edge dissection
Need post-dil
Stent crushing
Suboptimal radial strength
Incomplete stent apposition
Foreshortening
Artifacts on MRI
Non precise
Heavily calcified lesions
Non-ostial lesion
Immobile
EIA; CFA -mobile
Ostial
Long lesions
Decision between SE or BE stents in Iliac Lesions
• Balloon expandable
–
–
–
–
Aortoiliac bifurcation
Common iliac
Calcified lesions
Chronic occlusions (?)
• Self expanding
– Vessels flexible/twist
during movement
– Tortuous vessels
– Distal external iliac
artery
– Contralateral approach
– Long diffuse lesions
– Aortoiliac bifurcation
(long lesions)
Stent Grafts
• Combination of a metal stent covered with fabric
• Used to exclude aneurysm, treat perforations when prolonged balloon
inflation failled
• Wallgraft and Viabahn are the two options currently available for
treatment of perforations of aneurysm in larg vessels
Equipment
Ipsilateral retrograde
approach
Contralateral approach
Brachial artery approach
6-8F Sheath, length 11cm or 23cm
6-8F cross- over Sheath
6-7F 90cm sheath
6-7F Guiding catheter
0.035“ wire, length 180-190cm
0.035“ wire, length 180-190cm
0.035“ wire, length 260-300cm
0.035“ wire compatible Balloon
catheter ,
diam. 6-9mm,
Shaft length 75-90cm
Balloon catheter , diam. 6-9mm,
Shaft length 75-90cm
Balloon catheter , diam. 6-9mm,
Shaft length 130cm
BX stent, diam. 8-9mm, shaft
length 75-110cm
BX stent, diam. 8-9mm, shaft
length 75-110cm
BX stent, diam. 8-9mm, shaft
length 130cm
SX stent , diam.8-14mm, shaft
length 75-110cm
SX stent , diam.8-14mm, shaft
length 75-110cm
SX stent , diam.8-14mm, shaft
length 130cm
Retrograde iliac stent placement
Cross-over stent placement
Subintimal angioplasty
• Hydrophilic wire not passing
• Carefully adv into subintimal plane- if not
spontaneously, gentle inflation of balloon at
edge of the plaque
• Wire traversed the lesion subintimaliy
• Hydrophilic catheter or other re-entry device
passed OTW to guide it back into lumen
• Standard angioplasty of subintimal plane
performed, with stent placement
Subintimal angioplasty
Femoropopliteal Artery Intervention
Four potential routes of access to the SFA and popliteal:
• Contralateral femoral retrograde access
• Ipsilateral femoral antegrade access
• Ipsilateral popliteal retrograde access
• Brachial retrograde access
Balloon
• Balloon size and length is matched to the size ( ~5-6mm) and lesion
length( ~40- 300mm) of SFA
• Improved angiographic results may be accomplished with
prolonged inflation times ( 3-5 minutes)
• Dissections are commonly seen after balloon dilation ( due to heavy
calcification)
Femoropopliteal Artery Intervention
Stent implantion ( always SX-Stents):
• Sizing the SX- stent ~ 1mm greater than the RVD of SFA
• Postdilation with 5.0-6.0 mm diameter balloon
• Popliteal artery -> avoid stent = high risk of stent compression or fracture
SX-Stent problems:
• Stent fracture -especially in stent overlap
• “ In-Stent-Restenoses“-in long stented segments, multiple stents
DEB
Five-year patency (%) of femoral popliteal
revascularization
Outcome
Kasapis C, et al Eur Heart J. 2009;30:44- 55
Infrapopliteal Intervention
4 anterior tibial artery
5 tibio-peroneal trunk
6 posterior tibial artery
6a peroneal artery
6b perforating branch of the peroneal artery
6c communicating branch of the peroneal artery
7 dorsalis pedis
8 medial plantar artery
9 lateral artery
10 plantar arch
Vascular Access
•Cross- over technique ( retrograde access)
•Ipsilateral antegrade access ( recommended)
•Retrograde pedal access
•Brachial access
•Radial access
wire selection
only atraumatic 0.014“ / 0.018“ guide wires should be used
0.014“ prefered due to vessel diamet( floppy, medium,stiff)
Balloon Angioplasty
Low profile balloon with high pushability and trackability
Vessel conformability
Flexibility in small collateral branches
0.014”/ 0.018" wire compatibility
Diameter 1.5mm-4.0mm
Long (20-210 mm)& tapered tip to reduce procedure times and dissection
Infrapopliteal- Stent implantation
Requirements - BTK BE-Stents
• “PTA balloon like” flexibility
• Ultra-low profile and extreme flexible delivery system with 0.014”
guidewire compatibility
• 2 - 4 mm stent delivery system diameter
• Long stents ( up to ~ 80mm)
• 4F introducer sheath compatibility
• braided sheath design - pushability and flexibility to enable easy
negotiation in tortuous anatomies without kinking
Infrapopliteal Intervention-Equipment
Contralateral approach
Antegrade Approach
5F-6F cross-over-sheath, 55cm or 70cm
4F-6F short sheath
0.035“
0.035“
300cm wire
190cm wire
5F-6F Guiding catheter, if no long sheath is used
5F-6F Guiding catheter, if no long sheath is used
0.014“-0.018“ wire ( 0.014“ prefered)
0.014“-0.018“ wire ( 0.014“ prefered)
Balloon catheter, 1.5-4.0mm diameter, length 20mm210mm, shaft length 150cm
Balloon catheter, 1.5-4.0mm diameter, length 20mm210mm, shaft length 120cm
0.014“ balloon expandable stent, 150cm shaft length
0.014“ balloon expandable stent, 120cm shaft length
0.014“-0.018“ self-expandable stent, long shaft
0.014“-0.018“ self-expandable stent, short shaft
Guide wire support catheter ( facilitate wire
Crossing)
Guide wire support catheter ( facilitate wire
Crossing)
• Limb salvage rate is high, but restenoses rate also high
• Restenoses rates ~ 70% @ 3 months- depends on
severity of disease
Efficacy of Coronary DES in Infrapopliteal Arteries
Advances in Treatment of Aortoiliac
Occlusions
• Inability to cross an occlusion with a guidewire or to
reenter the true lumen beyond the occlusion
remains the most common cause for technical failure
1. Front Runner device
2. Crosser catheter
3. Reentry devices
• The Frontrunner® (Cordis) or Quickcross® catheters are
designed to maintain the wire in the center of the lumen and
penetrate the plaque and/or thrombus in a controlled fashion
Subintimal dissection plane
• buckling a glide wire the subintimal plane is entered
• Following with an angled glide catheter-re-enter the lumen
distal to the obstruction
• This step is the limiting factor
• Adjuncts - Outback® or Pioneer® catheter which allow an
angled needle to puncture back into the true lumen
FRONTRUNNER® XP CTO Catheter (cordis)
•
Enables controlled crossing of CTOs using blunt microdissection to create
a channel through the occlusion to facilitate wire placement.
• Low profile. Features a crossing profile of .039" with actuating jaws that
open to 2.3 mm.
• Hydrophilic coating along the entire catheter length to facilitate crossing
• Catheter steerability.- shapeable distal tip + effective torque control
enhance maneuverability and catheter steerability
• No guidewire lumen.Variable support from advancing and retracting the
4.5F Micro Guide Catheter.
CROSSER Catheter (Flow Cardia Inc, Sunnyvale, Calif)
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High-frequency mechanical vibrations (20, 000 cycles/ second to a depth
of 20 µm) propagated through a nitinol core wire to a stainless steel tip
A generator, transducer, foot switch, and disposable catheter
Generator applies AC current to the piezoelectric crystals in the transducer
Vibrational mechanical impact and cavitational effects - penetration
1.1 mm in diameter, monorail, and hydrophilic
Can be mounted on a standard 0.014” guidewire
Compatible with a 6F guiding catheter
Vessel size- a minimum diameter of 2.5 mm is recommended
cordis
Cordis
• Low profile, 6F sheath compatible
• Highly visible "L" and "T" markers. Orient the re-entry cannula
toward the true lumen easily, eliminating the need for
additional visualization equipment
• Effective torque control
• On average 8 minutes to gain re-entry (↓ procedure time)
• Lubricious, hydrophilic coating along the entire catheter
length to facilitate subintimal passage
• Easy to use
OUTBACK CATHETER
(J&J, Cordis, New Brunswick, NJ, USA)
Pioneer reentry catheter (Medtronic)
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Distal 25-gauge nitinol reentry needle
64-element phased-array IVUS transducer
120 cm long
accomm -2 -0.014”guidewires (1 to track the
device and 1 for the reentry needle)
• Compatible with a 7F sheath
• The device is brought into the subintimal tract over a wire,
and under intravascular ultrasound imaging, color flow is
identified in the true lumen
• The catheter is rotated to position the true lumen at the “12
o’clock” position, after which the needle is advanced and the
true lumen is wired
Advances in Balloon Angioplasty-Based
Approaches
1. Drug-coated balloons
2. Cryoplasty
3. Cutting balloons
Drug-coated balloons
• Paclitaxel is the most commonly used agent
for drug-coatedballoons (DCBs)
• high local drug conc and
• # neointimal proliferation -brief exposure
• had lower late loss and angiographic
restenosis at 6-month follow-up (17% vs 44%
in the Thunder study; 19% vs 47%in FemPac)
• Occlusion,containement &Perfusion therapy
• low pressure balloon infusion maximizes drug penetration locally within the
vessel
• B-L/10-50mm,DM-1-4mm
• 134cm-Rapid ex
• 40,80,90,140 cm -OTW
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Cryoplasty (PolarCath, Boston Scientific)
Combines angioplasty with simultaneous delivery of cold
thermal energy to the arterial wall
liquid nitrous oxide - balloon inflation/ cooling - 10°C
MOA-plaque modification, reduction of elastic recoil, and
induction of apoptosis in the smooth muscle cells -↓
dissection and need for stenting
Insufficient data to support its routine use
Advances in Stent Technology
• Drug-eluting stents
• Nitinol self-expanding stents
• Bioabsorbable stents
• Nitinol stent grafts and covered stents
(cook)
• The Zilver PTX Drug-Eluting Stent is a self-expanding stent made of nitinol
and coated with the drug paclitaxel
• It is a flexible, slotted tube that is designed to provide support while
maintaining flexibility in the vessel upon deployment
• The stent is preloaded in a 6.0 French delivery catheter
• 0.035 inch wire
• recommended for use in above-the-knee femoropopliteal arteries having
reference vessel diameter from 4 mm to 9 mm
• Zilver PTX ( Cook) showed good results in TASC A/ B lesions(RESILIENT
STUDY)
COOK
Zilver 518
• Vascular Self-Expanding
nitinol Stent- iliac
arteries
Zilver 518 RX
• Vascular Self-Expanding
Nitinol Stent – Rapid
Exchange-iliac
• Recomm
5.0 Fr sheath/7.0 Fr gui
ding cath
• Recommended
5.0 Fr sheath/7.0 Fr gui
ding catheter
• Accepts .018 inch wire
• Accepts .018 inch
diameter wire guide.
Zilver 635
• Vascular Self-Expanding Nitinol Stent
• Recommended 6.0 Fr sheath/8.0 Fr guiding
catheter size
• Accepts .035 inch diameter wire guide
Absolute Pro LL Peripheral SelfExpanding Stent (ABBOT)
• 035
• designed to treat longer SFA lesions
• 120,150
Absolute Pro LL
Xpert Self-Expanding Stent(ABBOT)
• 4F compatible -speci designed for small
vessels
• Peri vessels from D 2-7 mm
• 018
• Nitinol
• low strut profile
• Conformability
Self-Ex: S.M.A.R.T. CONTROL Iliac
(cordis)
• MicroMesh Geometry, Segmented Design
• Nitinol
• 12 Tantalum MicroMarkers define stent ends for easy visualization
and placement
• Stent D 6-10, 12, 14mm (should be 1-2mm >vessel D)
• 80,120 cm
• Maximum Guidewire .035"
4-year follow-up patency rates
• 79% TLR free after 4 years
• 59% Binary Restenosis free after 4 years
(lowest published)
• Sheath Compatibility 6F (6-10mm), 7F (12-14mm)
• Guide Compatibility 8F (6-10mm), 9F (12-14mm)
Self-Ex: PRECISE Carotid Stent System
(cordis)
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MicroMesh Geometry, Segmented Design
Nitinol
Stent D 5-10mm
135cm, Over-the-Wire
Maximum Guidewire .018"
Sheath Compatibility 5.5F (5-8mm diameters), 6F
(9-10mm diameters)
• Guide Compatibility 7F (5-8mm diameters), 8F (910mm diameters)
Self-Ex: PRECISE PRO RX Carotid Stent
(cordis)
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MicroMesh Geometry, Segmented Design
Nitinol
Stent Diameters 5-10mm
135cm, Rapid Exchange
Maximum Guidewire .014"
Sheath Compatibility 5F (5-8mm diameters), 6F
(9-10mm diameters)
• Guide Compatibility 7F (5-8mm diameters), 8F (910mm diameters
Astron-biotronik
• Self-Expanding Nitinol Stent 0.035” / OTW
Astron Pulsar-Biotronik
• Self-Expanding Nitinol Stent OTW
• For treatment of diseases of femoral and
infrapopliteal arteries.
• Self-expanding stent to the peripheral vasculature via a
sheathed delivery system
• Flexibte mesh tube made from Nitinol
• Intended to improve luminal diameter in the treatment of
symptomatic de-novo or restenotic lesions up to 240 mm in length
in the native superficial femoral artery and proximal popliteal
artery with reference vessel diameters ranging from 4.0-6.5 mm
Covered Stents
GORE
Jostent Peripheral Stent Graft (Abbot)
• High grade surgical stainless steel 316L PTFE Graft material
• Recommended minimum sheath size- introducer size that is
two sizes larger than the sheath size
• Wall thickness after expansion
Standard version: 0.40 mm
Large version: .45 mm
Minimal crimped outer diameter
Standard version: 2.3 mm = 7F
Large version: 2..7 mm = 8F
• Minimal deployment pressure
4 bar
• Biocompatibility, the ability of a material to
induce a “normal” response within a host
• Biodegradation, a biological agent like an enzyme or a
microbe is the dominant component in the degradation
process. Biodegradable implants are usually useful forshortterm or temporary applications
• Bioresorption and bioabsorption imply that the degradation
products areremoved by cellular activity, such as
phagocytosis, in abiological environment
• Bioerodible polymer is a water-insoluble polymer that has
been converted under physiological conditions into watersolublematerials
Polylactide and trimethylene carbonate
KYOTO-MED GP-JAPAN
• Biodegradable polymer PLLA (poly-L-lactic acid)
• Characteristics of being dissolved into water and carbon dioxide and
absorbed into vessel tissue within a few years after implantation
• Metal allergies or pats who are still growing
•
Will not interfere with other procedures such as restenting/Sx
•
More useful for containing drugs compared to metal stent- intended as a
platform for drug eluting stents.
Advances in Plaque Removal or Debulking
• Excimer laser
• Excisional and rotational atherectomy
Excimer laser
• The 308-nm excimer laser -fiberoptic catheters to deliver intense bursts of
ultraviolet energy in short pulse durations
• The adv of uv light –
short penetration depth of 50µ m
break molecular bonds directly by a photochemicalprocess
ability to ablate thrombus and to inhibit platelet aggregation.
• Removes a tissue layer of 10 µm with each pulse of energy.
• Ablated only on contact without a rise in temp to surrounding tissue
• Ability to treat long occlusions and complex disease
SPECTRANETICS
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Turbo Elite® laser catheters
utilize ultraviolet light to
vaporize arterial blockages
into particles,
most of which are smaller
than a red blood cell.
Treat Above-the-Knee
Total Occlusions
Long Diffuse Disease
Treat Below-the-Knee
Total Occlusions
Long Diffuse Disease
Treat Lesions Comprising
Multiple Morphologies
Atheroma
Fibrosis
Calcium
Plaque
• Combining a laser guide
catheter with an
excimer laser
atherectomy catheter
• angled ramp allows for
circumferential
guidance and
positioning of the laser
catheter within the
vessel
SilverHawk Plaque Excision System (Fox Hollow Technologies)
High-speed cutting blade excises a ribbon of plaque that is collected
into the catheter nose cone.
7 different sizes
monorail catheters meant for rapid exchange and operate over a 0.014-inch
diameter wire system
cutter blade (long arrow)
luminal plaques (small arrow)
Plaques are excised (double
arrows)
ROTATIONAL ATHERECTOMY DEVICES
Pathway Medical PV system (Pathway Medical
Technologies,Redmond, Wash)
expandable, rotating scraping blades
(“flutes”)
ports between the flutes that allow flushing
and aspiration of plaque material/thrombus
The Orbital Atherectomy System (Cardiovascular Systems,St
Paul, Minn)
high-speed rotational atherectomy system
eccentric, diamond-coated abrasive crown
When rotated at high speeds, the abrasive crown
moves in an orbital path within the artery,
potentially creating a lumen larger than the
diameter of the crown
BRIDGING THE GAP: ROLE OF HYBRID
PROCEDURES
• Multilevel peripheral arterial occlusive disease
• Older patients with several comorbidities
• Common examples of hybrid procedures include
common femoral artery endarterectomy combined
with angioplasty of the iliac or SFA
• Comparable outcomes to open surgical procedures,
but with decreased length of stay, morbidity, and
mortality
Hybrid procedure for CFA/SFA dis
THANKYOU
Antegrade puncture of the patent popliteal artery and successful
crossing of the native SFA
Vascular Access
“SAFARI” Technique
Arterial Flossing with Antegrade–Retrograde Intervention)
(Subintimal
• Useful for completing subintimal recanalization when there is failure to reenter distal true lumen from antegrade approach or limited target artery
available for re-entry
• Technique improves technical success with subintimal recanalization
• Limb salvage rates comparable to those with antegrade subintimal
recanalization
Below the Knee Tools
Stiff, steerable guidewire
Crossability
Infrapopliteal 0.014” Guidewire
Low-profile OTW
balloon with suitable
sizes in balloon length
and diameter.
LONG BALLOONS
Dedicated long stent
systems
Infrapopliteal PTA Balloon
Catheter OTW 0.014”
Infrapopliteal Co-Cr Stent
System OTW 0.014”
Crossing occlusions
Avoiding abrasion, damage
and risk of dissection
Bail-out
situations
Infrapopliteal self-expanding
Stent System OTW
Drug eluting Balloon
Restenosis prevention
Paclitaxel-eluting PTA
balloon catheter