Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3722_Библиотеки_им_академика_М_И_Перельмана
.pdf
6 Arterial Revascularization
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
97
widths above the ankle joint to prevent puncture of the muscle compartments.
• The tibial arteries in patients with CLI tend to
be calcied along with low intravascular pressure from more proximal disease, which may
pose as a technical challenge.
• In the setting of multilevel occlusive disease,
the distal artery wall may be more pliable than
normal due to low lling pressures and puncturing the artery wall with the needle may
require the operator to change the angle of
entry. In addition, because of the lack of stiffness of the arterial wall the vessel may escape
the needle trajectory.
• The operator may also face difculty with the
amount of pressure required to successfully
puncture given the low lling pressure and
lack of artery wall stiffness. The vessel may
collapse under such pressure, and eventually,
the needle will puncture the posterior wall.
This represents a true Seldinger technique.
The operator will have to withdraw the needle
very slowly while gently advancing the wire
to aid in releasing posterior wall from the needle and allowing the access wire to easily
advance within the true lumen. Figure 6.16
shows a longitudinal view of needle access
into the distal PT.
Imaging protocols for diagnostic ultrasound
assessment of tibial arteries vary by institution.
In a CLI center, technologists perform an extensive evaluation, or mapping, of the three tibial
arteries. In addition, particular attention is paid to
areas of disease, vessel integrity, and proximal
and distal CTO location. Evaluating collateral
ow and communication between tibial arteries
is of particular importance for the operator in
planning the revascularization approach.
• As tibiopedal access becomes an essential part
of treating CLI patients, the use of arterial
mapping can dene patients that have adequate targets for tibial access.
• A phenomenon described as the white stop
sign refers to complete loss of vessel lumen
preventing successful access. In these patients,
the distal tibial artery is completely opacied
with calcied plaque along the length of a segment of the vessel.
• EVUS can distinguish this feature from short
areas of occlusion, a situation in which the
operator can choose another location within
the same vessel to access, usually above or
below the occlusion to obtain successful
access.
Table 6.1 shows a list of common US land-
marks the operator can depend on to identify
position within the vascular tree
EVUS is also able to identify prominent
branches of the tibial arteries. The proximal anterior tibial (AT) artery gives way to the anterior
tibial and posterior tibial recurrent branches.
Identifying this landmark is important because in
many instances the AT occlusion occurs in the
proximal segment. The posterior recurrent branch
tends to compensate for the AT if occluded. This
branch is commonly mistaken for the AT.
• This collateral tends to be tortuous and
becomes very small toward the ankle. It is
important to recognize this vessel, especially
with retrograde tibial access, in order to prevent the wire from naturally sub-selecting this
branch.
Another important landmark for tibial access
is the anterior and posterior communication
branches of the peroneal artery. While each
Fig. 6.16 An access needle is visualized on EVUS while
obtaining retrograde pedal access
patient is different, EVUS with color Doppler
can identify the communicating vessels, usually
98
I. Ali et al.
Table 6.1 Tips for EVUS Guided Procedures
Detailed Anatomical Map for Procedure Planning
•Multiple modalities including duplex ultrasound,
CTA, and MRA may be used.
•Selective angiography has a better correlation with
arterial duplex imaging and in patients with PVD [30].
•Assessing adequate conduits for access approach.
EVUS Characteristics of Arteries
•Layers of the arterial wall dene the intima, media,
and adventitia to provide safest and most effective
therapy.
•Plaque location and type to ensure safe access and
appropriate therapy.
•Calcium content within the vessel may impact
imaging.
Severe calcication will create acoustic shadowing
rendering US imaging obsolete. Calcium can be as
dense as bone tissue and does not allow the sound
waves to penetrate beyond the anterior wall of a
vessel. In these cases, EVUS may not be effective.
EVUS Anatomical Landmarks
•Identication of the head of the femur for groin
access.
•Identication of collateral branches and bifurcations.
•Identication of the muscle compartments within the
calf for tibial access.
Characteristics of Endovascular Devices
•Echogenic tip needle.
•Bright double lumen of a catheter or sheath.
•Bright single line of a wire.
•Moving/rotating of atherectomy device.
•Stent strut identication.
Chronic Total Occlusion Mapping
•The proximal CTO cap morphology, architecture,
shape.
•The distal CTO cap morphology, shape.
•Collaterals at the proximal CTO cap.
around or just above the ankle. Ideally, if the
operator can visualize the takeoff of these vessels, access can then be achieved above their termination allowing blood ow beyond the access
point to the foot.
Ultrasonic Features of Endovascular
Therapeutic Devices
made up of multiple different types of material to
ensure lubricity and mobility of the wire to prevent sticking to anatomical structures or devices.
The metal of the wire is easily identied with
ultrasound and is visualized as a bright white
line. Because of the movement of the wire and
the density of the material, reverberation artifact
is often seen. Identifying the true position of the
wire will eliminate any complications from this
artifact.
• CTO crossing with EVUS is an advanced
technique that allows the operator to directly
visualize the wire cross into the CTO, avoiding the subintimal space, and ensures that the
wire maintains a true luminal position for the
length of the CTO to provide the best treatment possible.
Catheters andSheaths
Identifying sheath location during intervention is
pertinent, especially for treatment in close proximity to the tip of the sheath. The sheath is visualized as two bright white parallel lines due to the
density of the sheath wall under EVUS.Catheters
look very similar under EVUS, however tend to
be much smaller in size. Visualization of catheters depends on material utilized to build the
device. Typically, larger catheters (0.035″ and
0.018″) are easier to visualize due to their size.
Some catheters are double braided increasing the
echogenicity of the catheter.
• Catheters with a bend tip offer a particular
advantage as the operator rotates the device,
and this is well observed with EVUS.This in
turn will allow the operator to engage areas
within the vessel such as the CTO cap or guide
the wire away from side branches to avoid
complications during treatment.
Needles andWires
Needles are made of stainless steel and may have
indentation along the distal length of the needle
for better ultrasound visualization, referred to as
an “echogenic tip” needle. It is essential to visualize the needle as the skin is punctured, and the
needle is advanced toward the artery. Wires are
Balloons
Angioplasty balloon catheters are made up of
multiple layers. Depending on the balloon type
(rapid exchanged or over the wire), the shaft of
the balloon appears as a lumen with a wire
through it. As the balloon is advanced, the thickening of the catheter indicates that the bladder
6 Arterial Revascularization
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
99
portion of the balloon has come into view. Once
balloon position is conrmed under EVUS and
uoroscopy, EVUS-guided ination of the balloon allows for direct visualization of the arterial
wall interrogation.
• Balloons that are underinated or undersized
will demonstrate a dark echogenic gap
between the balloon wall and the arterial wall.
• Properly sized inated balloons will demonstrate no gap with complete balloon opposition
to the arterial wall, and in some cases, a step
down is visualized at the proximal and distal
end of the balloon to account for vessel recoil.
• Sometimes, the lesion will not immediately
comply with balloon ination. Slow ination
with EVUS guidance allows live monitoring
of vessel wall compliance to ensure adequate
and safe balloon ination while avoiding
uoroscopy.
Atherectomy andCTO Crossing Devices
The appearance of atherectomy devices varies
depending on the mechanical component. For
Diamondback orbital atherectomy (CSI), the
metal crown is covered with a synthetic diamond
coating to modify the surface of the plaque,
allowing for more effective adjunctive therapy.
EVUS allows for visualization of the crown interrogation of plaque. Laser atherectomy creates an
ablation bubble ahead at the tip of the catheter
and creates micro-cavitation within the artery to
disintegrate plaque. The micro-cavitation bubble
created when the catheter is activated can be
visualized with EVUS.
Stents
Stents deployed in the infrainguinal region are
most often self-expanding, while stents deployed
in the tibial arteries tend to be balloon expandable. Regardless of the type of stent, all stents are
well visualized under EVUS due to the thin metal
struts that are highly echogenic. Identifying the
location of the stent struts allows the operator to
successfully interrogate an occluded stent while
avoiding crossing behind the stent. Operators can
visualize wires, catheters, and balloons traversing the stent, preventing equipment from getting
stuck behind a stent strut, or creating a false
lumen between the stent and the arterial wall.
EVUS-guided sizing and deployment of a stent
can also be performed with precision. For example, EVUS-guided stent deployment performed
from a retrograde tibial approach in the ostium of
the SFA allows the operator to avoid stenting
across and jailing the profunda femoral artery
(Fig.6.17).
Ultrasonic Features ofChronic Total
Occlusion (CTO)
CTOs are some of the most complex arterial
pathologies to treat and are composed of a proximal cap and distal CTO cap, often with mixed
plaque types along the length of the occluded
segment. Depending on the length and age of the
occlusion, the CTO segment may have a hibernating lumen in between the proximal and distal
caps. In extreme cases, the whole vessel between
the proximal and distal cap is occluded.
EVUS can be used to assess the type and loca-
tion of the CTO cap. Mapping the morphology of
a bc
Fig. 6.17 (a) A support catheter is seen traversing an
occluded tibial artery, (b) an orbital atherectomy crown
visualized while treating a tibial artery, and (c) a stent is
deployed utilizing EVUS guidance to avoid jailing the
profunda femoral artery
100
I. Ali et al.
the CTO caps will allow better assessment of
access approach and treatment options. While the
composition and calcium content may differ from
one CTO cap to another, one common quality
observed among most CTO caps is the shape.
• The chronic total occlusion crossing approach
based on the plaque cap morphology (CTOP)
analysis evaluated patients with CTOs involving the SFA/popliteal and tibial regions [29].
• Shape of the CTO cap was categorized into
two shapes: concave and convex. The shape is
determined based on the shape of the cap from
an antegrade direction. For example, Fig.6.18
shows a concave-shaped CTO cap. This CTO
cap is imaged via EVUS and angiography.
• The cap description also allows the operator to
predict which CTO cap will allow for true
lumen wire crossing of the vessel and which
will direct the wire into the subintimal space.
• A convex CTO cap will include at-shaped
caps, oblique caps, or oblique caps leading to
a collateral. All of these are features suggestive of a cap that is difcult to penetrate. Based
on a simple dichotomous distinction between
the caps and the fact there are usually proximal and distal caps, there would be four possible combinations in patients with CTOs.
• Utilizing EVUS to assess for CTOP cap morphology will allow the operator to choose
whether or not to implement retrograde pedal
access to mediate CTO crossing.
Conclusion
EVUS utilization for endovascular intervention
in CLI is a viable option for patients with complex disease including multilevel and multivessel CTOs. Patients with CLI can benet from
the utilization of EVUS as it may signicantly
lower the use of contrast and radiation exposure,
especially during access and CTO crossing.
EVUS is an effective tool in obtaining pedal
access and can guide the treatment of complex
tibial disease. The utilization of EVUS in CLI
interventions should be an essential tool for operators tackling advanced PVD and CLI.
Fig. 6.18 A concave CTO cap is assessed with EVUS
and angiography
6.2.2 Femoro-Popliteal Access
andClosure
S.JayMathews
6.2.2.1 Introduction
While radial and pedal access may be preferable
and relatively safe alternative accesses, sometimes they are not feasible nor effective for certain pathologies. Popliteal, antegrade supercial
femoral artery (SFA), and retrograde supercial
femoral artery (SFA) access offer additional
interventional options for challenging anatomies.
However, careful considerations must be made to
optimize the ergonomics of the procedure while
ensuring patient safety during and after the case.
6.2.2.2 Popliteal Access
Popliteal access allows for retrograde crossing of
difcult supercial femoral artery (SFA) occlu-
6 Arterial Revascularization
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
101
sions, especially when the cap morphology is not
amenable to antegrade crossing. In the modern
era, direct pedal access is usually preferable to
popliteal access, offering similar retrograde
crossing capabilities with easy vessel closure via
extra-vascular compression [31].
• In terms of alternative access, popliteal access
is considered one of the least desirable points
of entry due to difculty in compression.
• As a result, postoperative pseudoaneurysms,
hematomas, and bleeding are more common
[32].
• In the setting of poor tibial vessel caliber or
tibial occlusion, and where modied Schmidt
access (direct access into an occluded vessel
segment) is not successful, direct popliteal
access may be preferable as long as the vessel
is not diseased.
Access is most commonly performed with the
patient in the prone position after which the
patient is ipped supine [32].
• If this is a planned procedure, the preparation
process can be simplied as the patient can
have a limited draping performed for sheath
access after which a complete draping done in
the supine position.
• Ideal use a longer sheath (25–45cm) to facilitate easy access once supine. Performance of
the entire procedure can also be done in the
prone position, but obese patients or those
with airway management issues may not tolerate long-duration interventions without anesthesia support.
• Alternative methods of access include placing
the patient in the lateral decubitus position,
but this is ergonomically less ideal for access.
The “frog-leg” position has been described for
popliteal access with external rotation and
gentle knee exion, either from posterior
puncture or anteromedial access [32, 33].
• Given the proximity of the tibial, peroneal,
and more proximal sciatic nerves, access
should not be performed without extravascular ultrasound (EVUS). Moreover, the
popliteal vein also may lay on top of the artery,
which can lead to inadvertent arteriovenous
stula formation with through-and-through
access.
Ideally, access should be kept as small as possible potentially utilizing 2.9 to 4/5 Fr thin-walled
sheaths or sheathless approaches (i.e., Bareback).
Avoidance of the popliteal artery as the solo
access will allow for balloon compression of the
entry site at the end of the procedure from an
alternate femoral access above. Data are limited
with larger sheaths as these may be prone to more
vascular complications. Vascular closure devices
(VCDs) have been used with some success [34].
• Given the mobility of the vessel, extra-
vascular closure devices may be less reliable
leading to hematoma or pseudoaneurysm for-
mation [35].
• Active VCDs (intravascular hemostatic plugs,
active xation/clips, and suture-mediated clo-
sure) may be potentially effective but at the
risk of acute vessel closure, dissection, or
other vascular complications [36].
6.2.2.3 Antegrade SFA Access
Antegrade femoral approaches are utilized over
contralateral femoral access when contralateral
access is unfavorable. This can be due to bifurcation issues (e.g., acute iliac angulation, extreme
iliac tortuosity, bifurcated endografts, or iliac
stents), inadequate shaft length for below-theknee (BTK) interventions, or inadequate support
for difcult crossing [37]. Antegrade SFA access
may be preferable to antegrade common femoral
access [38, 39].
• In patients with even mild amounts of trun-
cal obesity, the angle at the inguinal crease
will be unfavorable resulting in more per-
pendicular access into the common femoral
artery [40].
• Angulation of entry may also drive the access
wire into the profunda rather than down the
SFA.The proximal supercial femoral artery
is fairly supercial under the skin and may
allow a more favorable shallow entry angle
avoiding kinking of the sheath.
102
ab
I. Ali et al.
• Ultrasound-guided access of the proximal
supercial femoral artery is reliable [41].
• Closure of the SFA can be challenging as
manual hemostasis below the femoral head
is impaired by lack of adequate
compression.
• VCD closure of the access site can be performed similar to a retrograde common femoral approach, except in an opposite fashion.
More distal antegrade access increases risk of
closure-related complications, but active vascular closure devices may help secure the
access more reliably.
• In this pictured example, after antegrade
ultrasound- guided SFA access (Fig. 6.19a)
and completion of the procedure, the Celt
ACD vascular closure device is utilized given
its low-prole and easy uoroscopic visualization (Fig.6.19b).
Ergonomics are more challenging with an
antegrade approach. If positioning the patient on
the table in standard fashion, after micropuncture
access of the SFA, the access can be switched to
a 45 cm braided sheath, which can be curved
either ipsi- or contra-laterally and secured with
adhesive dressing.
• The contralateral thigh may be preferable as
the angulation will be less extreme, which will
be less likely to adversely impact stent deploy-
ment systems or delivery of other equipment
(Fig.6.20a).
• Alternatively, the patient can be positioned
with the feet at the head of the table
(Fig.6.20b). This will allow for more natural
access angle, but should be utilized with an
anesthesia halo to avoid covering the patient’s
face with the drape. The uoroscopic image
Fig. 6.19 (a) Antegrade SFA access. (b) SFA Celt ACD occlusion
6 Arterial Revascularization
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
103
Fig. 6.20 (a) Antegrade
SFA access with a 45cm
long sheath with
operator standing on
contra the contralateral
side. (b) Antegrade SFA
access, with a short
(13–30cm) sheath,
patient inverted and
operator on ipsilateral
side
can be also ipped digitally to the correct
orientation.
6.2.2.4 Retrograde SFA Access
Proximal retrograde SFA access has been well
described as an alternative to common femoral
access in patients with high profunda bifurcations or unfavorable common femoral anatomy.
Large vessel access for structural heart procedures
and endovascular aortic repair has successfully
utilized this technique [42].
• Distal retrograde SFA access is more challenging but sometimes necessary when antegrade crossing of an SFA occlusion is not
possible or successful, especially with extreme
calcium or stent fractures leading to unfavorable subintimal crossing.
• Retrograde access below the adductor canal
has been well described and can be safely performed [43]. EVUS should be utilized when
possible but may be challenging as visualization through the musculature may be poor,
especially in obese patients. Fluoroscopic
guided access may be necessary utilizing road
mapping from a proximal injection site.
Occasionally, a modied Schmidt technique
can be used within an occluded stent [44].
ba
• This can be performed with a micropuncture
needle through the strut interstices, with
advancement of an 0.018″ stiff wire (ideally
nitinol based to avoid kinking) torqued into a
drill-like appearance through several rotations.
• This wire is continuously spun clockwise and
counterclockwise with steady force. A micropuncture sheath or sheathless technique can
be used with a 0.018″ crossing catheter after
which the wire can be directed or snared into
the proximal access.
• Sheathless approaches for balloon crossing
and even stenting is also possible from the retrograde SFA access [45].
• Of note, closure of the SFA puncture is usually easily performed with balloon tamponade
from a proximal access, but occasionally with
extreme calcium, a persistent channel may
form requiring adjunctive use of a covered
self-expanding stent.
6.2.2.5 Case Example
An 81-year-old man with diabetes, dyslipidemia,
and chronic tobacco abuse presented with a
Rutherford 5 left hallux wound. Antegrade crossing of a severely calcied SFA was not possible
(Fig.6.21). The tibial vessels could not easily be
identied on EVUS due to occlusion and poor
caliber. Direct SFA access below the adductor
104
ab
I. Ali et al.
Fig. 6.21 Diagnostic angiogram showing heavily calcied arteries, with distal SFA CTO and mid-popliteal artery
reconstitution (a) and inability of antegrade wire crossing (b)
canal was performed with ultrasound guidance
(Fig.6.22). A micropuncture sheath was left in
place with wire crossing retrograde. After antegrade atherectomy, drug-coated balloon angioplasty, and prolonged percutaneous transluminal
angioplasty (PTA) were performed. A persistent
leak was seen once the micropuncture sheath was
removed (Fig.6.23a). Ultimately, a focal Viabahn
(W.L.Gore & Associates, Inc.) covered stent was
necessary to seal the leak (Fig.6.23b).
ease (PAD) treatment toolbox. A radial approach
is typically selected in cases where it is difcult
or unsafe to access the common femoral artery, in
patients with previous abdominal endografts or
bifurcation stenting, or if anticoagulation is
unable to be stopped [46]. With the currently
available tools, plain balloon angioplasty, bare
metal stenting, and atherectomy are the only
treatment options for treating infrainguinal PAD
via radial access, and covered stent graft are yet
to be available. New longer devices that are small
enough to t through a 6 Fr sheath have expanded
6.2.3 Arm Access forPeripheral
Arterial Disease
the scope of PAD interventions that can be performed via TRA.In the past, axillary and bra-
chial accesses were used for interventions
RickiA.Korff, RaghuramPosham,
and RobertA.Lookstein
requiring larger sheath sizes where femoral
access was contraindicated. Now that technologi-
cal advancements have facilitated radial artery
Transradial access (TRA) is an essential component of the endovascular peripheral arterial dis-
access up to 6 Fr in most patients and even 7 Fr in
some patients, axillary and brachial accesses are
6 Arterial Revascularization
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 6.22 Distal retrograde SFA access after failed antegrade access and no suitable tibial access
rarely used. While with good ultrasound-guided
access and other techniques, the common femoral use is still standard for many operators without signicant complications; however,
alternative access and tools are of interest to
many and growing.
105
• The system is then exchanged for a stiff support wire such as a 260 cm angled
GLIDEWIRE (0.035″, Terumo) and an angled
catheter such as an angled GLIDECATH (4
Fr, 120/150cm, Terumo).
Common and external iliac artery lesions:
• Crossed with a support catheter (i.e., 3.2
Fr × 150-cm Quick-Cross Select catheter,
Philips) over a support wire. If stenting is indicated, the stiff support wire is then exchanged
for a super stiff 0.035″ 260cm Amplatz wire
in preparation for stent deployment.
• The largest diameter stent that can be deployed
via TRA is a 12mm diameter×60mm length
self-expanding stent, which is available on a 6
Fr×120cm platform (Boston Scientic Epic
Stent). This allows for stenting of the majority
of external iliac arteries and common iliac
arteries in select patients.
• There are currently no drug-coated balloons
indicated for treatment of the iliac arteries.
• Numerous percutaneous transluminal angioplasty (PTA, POBA) balloons are available on
6 Fr platforms reaching up to 12mm in diameter, with working lengths capable of treating
iliac artery lesions, compatible with both
0.035″ and 0.018″ wire systems (Fig.6.24).
• For treatment of external iliac artery lesions,
the 10 mm diameter self-expanding
WALLSTENT is available on a 6 Fr×135cm
platform (Boston Scientic).
6.2.3.1 Device Selection forRadial
Access
For treatment of common femoral and super-
cial femoral artery (SFA) lesions:
Prior to performing a peripheral arterial intervention via transradial access, preprocedural planning and knowledge of available devices are
essential.
• The short introducer sheath and diagnostic
catheter are exchanged for a long stiff introducer sheath and support guiding catheter.
Examples of long stiff sheaths include R2P
• In a typical transradial PAD case, radial access
is obtained, a 6 Fr radial sheath is placed, and
a radial cocktail is administered.
• A guidewire and catheter such as the 110cm
OPTITORQUE Sarah Radial Catheter (5 Fr,
Terumo) are used to navigate the infrarenal
abdominal aorta.
Destination Slender Sheath (6 Fr, 119/149cm,
Terumo), Pinnacle Destination Guiding
Sheath (6 Fr, 45cm, Terumo) with a 100cm
GLIDECATH (5 Fr, Terumo), R2P
SLENGUIDE Catheter (7 Fr OD, 6 Fr ID,
120/150 cm, Terumo), Sheathless Eaucath
(6.5–7.5 Fr OD, 4–5 Fr ID, 100cm, Asahi),
106
ab
I. Ali et al.
Fig. 6.23 Persistent SFA access site bleeding after prolonged angioplasty (a). Followed by resolution of SFA access
site bleeding after covered stenting (b)
PAD Devices Compatible
with Radial Access
Common and external iliac artery
Angioplasty
interventions
Bare Metal
Stent
- Epic Stent
(6Fr, 120cm, 12mm
max OD, Boston
Scientific)
- Wallstent
(6Fr, 135cm, 10mm
max OD, Boston
Scientific)
(up to 125-135 cm from left wrist, 8-12mm)
Plain Balloon
- Conquest
(6Fr, 120cm, 12mm
max OD, BD
Interventional)
- Dorado
(5-6Fr, 120/135cm,
10mm max OD, BD
interventional)
- Charger
(6Fr, 135cm, 10mm
max OD, Boston
Scientific
Corporation)
- Mustang
(6Fr, 135cm, 10mm
max OD, Boston
Scientific
Corporation)
Common femoral and SFA
Angioplasty
interventions
Bare Metal
Stent
- Everflex Entrust
(5Fr, 150cm, 7mm
max OD, Medtronic)
- R2P Misago Rx
(6Fr, 200cm, 8mm
max OD, Terumo)
(up to 155-170 cm from left wrist, 5-10mm)
Plain Balloon
- Pacific Plus
(4Fr, 180 cm, 7mm
max OD, Medtronic)
- Ultraverse Rx
(4-5Fr, 200cm,
5mm max OD,
Bard)
- Jade PTA
(4-7Fr, 200cm,
7mm max OD,
Cardiovascular
Systems Inc.)
Plain Balloon
Angioplasty
- Advance 14LP
(4Fr, 170cm,
2-4mm OD, Cook)
- Pacific Plus
(4Fr, 180 cm,
2-7mm OD,
Medtronic)
- Ultraverse Rx
(4-5Fr, 200cm,
1.25-7mm max OD,
Bard)
- Jade PTA
(4-7Fr, 200cm,
2-7mm OD,
Cardiovascular
Systems Inc.)
- Sublime
(5Fr, 250cm,
2-4mm OD,
Surmodics)
Popliteal and below-the-knee
interventions
(up to >170 cm from left wrist, 2-7mm)
Atherectomy
- Diamondback
Orbital Atherectomy
System
(4-5Fr, 200cm, CSI)
Fig. 6.24 Peripheral arterial disease devices compatible with radial access. PAD peripheral arterial disease, S FA super-
cial femoral artery, OD outer diameter
Bare Metal
Stent
- R2P Misago Rx
(6Fr, 200cm,
6-8mm, Terumo)
Соседние файлы в папке Библиотека им академика М.И. Перельмана