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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3663_Библиотеки_им_академика_М_И_Перельмана
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16 Shooting Your Way Out: Endovascular Arterial Bypass Via Gunsight
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
57
Fig. 16.2 Superior and inferior approach snare loops
Fig. 16.3 Coaxial needle access through superior and inferior snare
loops
58
M. C. Kryger et al.
Fig. 16.4 Pseudoaneurysm (white arrow) status post initial placement
of Viabahn stent
Fig. 16.5 Status post stenting and angioplasty of the subintimal conduit. Proximal pseudoaneurysm is still visible
16 Shooting Your Way Out: Endovascular Arterial Bypass Via Gunsight
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
59
Fig. 16.6 Status post stenting and angioplasty of the subintimal
conduit
Fig. 16.7 Exclusion of previous left SFA pseudoaneurysm (white
arrow)
Unconventional Endovascular Salvage
ofanIatrogenic Dissecting Fusiform
Long Segment SFA Aneurysm
GauravDilipGangwani
17
A 50-year-old male patient with 20 years of uncontrolled
diabetes and tobacco use presented with severe rest pain in
his right thigh and foot; his visual analogue scale pain score
was 9/10. He had undergone multiple prior endovascular
interventions for severe bilateral life-limiting claudication at
another institute; among these were bilateral common iliac
arterial stents 8years ago, and right supercial femoral artery
(SFA) stent placement 5 months earlier with E-Luminex
6mm×120mm bare stents for a long segmental SFA occlusion. He provided a vague history of a proximal SFA pseudoaneurysm 1 month after stent placement, which was
reportedly treated with ultrasound-guided compression.
After excluding infectious causes, the working diagnosis
for his sonographic ndings (Fig.17.1) was fusiform dissecting SFA aneurysm—likely due to subintimal deployment of
the self-expandable metallic stent without adequate proximal
and distal coverage of proximal entry zone or distal exit
zone. The patient refused the options of surgical femoral-
popliteal bypass (with ligation of proximal and distal aneurysm neck). Accordingly endovascular intervention was
planned.
Access site choice was a challenge due to bilateral iliac
stents, the relatively large introducer prole for stent grafts
and “short” proximal deployment zone required to prevent
jailing of profunda femoris artery but nevertheless yield
proximal neck sealing. Thus an 8-French ipsilateral retrograde popliteal arterial access (Fig.17.2) was used to deploy
two overlapping SFA stent grafts [6×100mm and 6×80mm
Fluency, BD, Germany] (Fig. 17.3) resulting in complete
aneurysmal occlusion; this was conrmed on nal femoral
angiography (See Fig.17.4). Interim sonographic follow-up
at 6weeks and 3months afrmed continued aneurysm occlusion and thrombosis. The patient was relieved of rest pain for
6months after which he developed an unrelated burn injury
and secondary necrotizing fasciitis requiring a below knee
amputation.
ab
Fig. 17.1 (a) Ultrasound of the proximal right thigh (longitudinal)
reveals high grade stenosis secondary to visible oblique ap in the proximal SFA and fusiform aneurysmal segment distal to it with a metal
stent within the posterior aspect of the aneurysm segment. The transverse projection on the right reveals the stent lying along the right
G. D. Gangwani (*)
Department of Interventional Radiology, Bhaktivedanta Hospital
and Research Institute, Thane, Maharashtra, India
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR,
https://doi.org/10.1007/978-3-031-24251-9_17
postero- lateral aspect of the aneurysmal femoral segment. (b)
Ultrasound of the distal right thigh (longitudinal) reveals distal extent of
the aneurysm further distal to the terminal stent ending with another
focal stenosis secondary to a visible ap
60
17 Unconventional Endovascular Salvage ofanIatrogenic Dissecting Fusiform Long Segment SFA Aneurysm
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
ab
61
Fig. 17.2 (a) Retrograde popliteal digital subtraction angiogram
(DSA) revealed the terminal extent of the fusiform aneurysm segment
distal to the terminal stent struts. (b) Retrograde supercial femoral
ab
Fig. 17.3 (a) Road map image of right groin in lateral projection
reveals proximal stent graft deployment with proximal extent distal to
CFA bifurcation preventing jailing of profunda but proximal to the
angiogram revealed proximal extent of the fusiform aneurysmal
segment cranial to the proximal stent struts
entry zone/ap of the aneurysm. (b) AP uoroscopic projection of right
hip with balloon dilatation within the proximal stent graft for sealing
the entry zone
62
G. D. Gangwani
ab
Fig. 17.4 (a) Right common femoral angiogram (DSA) suggestive of
good antegrade ow across supercial femoral artery and complete
occlusion or non-opacication of the aneurysm. (b) Right common
femoral angiogram (DSA) with projection at level of distal SFA
suggestive of good antegrade ow across distal supercial femoral
artery and stent graft and complete occlusion or non-opacication of
the aneurysm
“Musashi” Snuffbox Access
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forSimultaneous Arterial andVenous
Access
UeiPua
A 64-year-old with history of colo-rectal cancer was referred
for microwave ablation of a solitary metastasis to the right
adrenal gland. As the mass was partially encasing the inferior vena cava (IVC) (Fig.18.1) and to allow for complete
ablation without inadvertent IVC perforation, an imaging
catheter was placed in the IVC (Fig.18.2) to allow for contrast opacication during probe placement under CT uoroscopy. Together with a need for intra-arterial blood
pressure monitoring as a standard for adrenal ablation, decision was made for dual arterial and venous access over the
anatomical snuffbox, an access we termed “Musashi
Access.”
Under US guidance, a vena comitans of the distal radial
artery was rst accessed within the anatomic snuffbox of the
18
Fig. 18.1 CT image of the right adrenal metastasis partially encasing
the IVC (circle)
U. Pua (*)
Department of Diagnostic Radiology, Tan Tock Seng Hospital,
Singapore, Singapore
Fig. 18.2 Fluoroscopic image of the catheter position caudal to the
region of ablation to allow good opacication of the IVC
left hand, using a trans-radial sheath set (5F Glidesheath
Slender, Terumo, Tokyo, Japan), this was followed insertion
of a 5F, 125 cm long catheter (Ultimate 1, Merit Medical,
UT) with the tip positioned over L3 vertebral body (Figs.18.3
and 18.4). A second sheath set was then used to access and
place an arterial sheath in the distal radial artery using standard technique (Figs.18.3 and 18.4). This was used for intraarterial blood pressure monitoring. Two microwave ablation
probes (PR 15; NeuWave Medical, Madison Wisconsin,
USA) was positioned in a criss-cross fashion straddling the
IVC under CT uoroscopic guidance with intermittent IVC
opacication (Fig. 18.5) by injection contrast through the
diagnostic catheter. Complete ablation was achieved
(Fig.18.6) and the patient was discharged well.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_18
64
18 “Musashi” Snubox Access forSimultaneous Arterial andVenous Access
65
Fig. 18.3 Intra-operative picture of the left anatomical snuffbox with
two radial sheaths in situ, in the distal radial artery (black arrow) and a
vena comitans (white arrow) with a diagnostic catheter in situ
Fig. 18.5 Intra-operative CT image showing opacication of the IVC
by injection of 10cc of diluted contrast through the diagnostic venous
catheter (curved arrow). Criss-cross placement of the microwave probes
allowed for complete ablation of the tumor
Fig. 18.4 Clinical photo of the dual access over the anatomical
snuffbox. The access was closed using standard radial compression band
This access is nicknamed after Miyamoto Musashi, who
was a well-known samurai famous for his technique of using
two swords to ght simultaneously.
Fig. 18.6 Completion CT showing non-enhancement of the tumor
consistent with complete ablation
Modified SAFARI Technique: Using
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
aRe-entry Device andaTarget Balloon
toConnect Antegrade andRetrograde
Subintimal Lumina
AthanasiosDiamantopoulos andRommanNourzaei
19
An 82-year-old man with chronic limb-threatening ischemia
(CLTI), and ulcers, was referred for endovascular revascularization of his occluded popliteal artery following occlusion
of a supercial femoral artery to proximal anterior tibial
artery (ATA) bypass. His comorbidities included hypertension and dyslipidemia.
Using a 7Fr antegrade access, digital subtraction angiography (DSA) showed occlusion of the P2/P3 segments of the
popliteal artery and proximal ATA with reconstitution at the
distal anastomosis of the occluded bypass (Fig. 19.1a, b).
Multiple intraluminal and subintimal attempts to cross the
native artery through both antegrade and retrograde ATA
approaches were unsuccessful despite the use of an antegrade re-entry device, resulting in two unconnected lumina
(Fig. 19.2a). These were then bridged using a modied
SAFARI technique. A 4mm diameter × 40mm long angio-
plasty balloon (Cook Medical, In, USA) was advanced retrograde from the ATA access whilst a re-entry “outback”
catheter (CORDIS, Ca, USA) was advanced antegrade to the
P1 segment. The balloon was inated and the re-entry device
was used to puncture it, thus connecting the subintimal
planes (Fig. 19.2b). A 0.014″ STABILIZER ™ Plus
Guidewire (Cordis, Ca, USA) was looped into the ruptured
balloon and advanced out of the distal access (Fig.19.2c).
Thereafter, the guidewire was manipulated into the distal
ATA.The occlusion was treated with antegrade angioplasty
and two 5.5 mm diameter × 150 mm long overlapping
SUPERA stents (ABBOTT, Il, USA) (Fig. 19.3a). Final
DSA showed excellent ow with increased perfusion to the
foot (Fig.19.3b). Dual antiplatelet therapy (Aspirin 75mg/d
and Clopidogrel 75mg/d) was begun. At 6-week follow-up
the ulcers had become dry and demonstrated good healing.
A. Diamantopoulos (*)
Department of Interventional Radiology, Guy’s and St. Thomas’
NHS Foundation Trust, London, UK
School of Biomedical Engineering and Imaging Sciences, Faculty
of Life Sciences and Medicine, Kings College London,
London, UK
e-mail: athanasios.diamantopoulos@nhs.net;
athanasios.diamantopoulos@gstt.nhs.uk
R. Nourzaei
Department of Interventional Radiology, Guy’s and St. Thomas’
NHS Foundation Trust, London, UK
e-mail: Romman.Nourzair@gstt.nhs.uk
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_19
66
19 Modied SAFARI Technique: Using a Re-entry Device and a Target Balloon to Connect Antegrade and Retrograde Subintimal…
ab
67
Fig. 19.1 Digital subtraction angiogram conrming (a), occlusion of the P2/P3 segments of the popliteal and proximal ATA (b). The mid ATA
was patent with occlusion in its distal segment
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