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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3722_Библиотеки_им_академика_М_И_Перельмана
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Arterial Revascularization
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
IbrahimAli, BulentArslan, RobertBeasley,
CarlosBechara, PaulineBerens, VenitaChandra,
OmarChohan, ClaudiaCote, FarnazDadrass,
SabeenDhand, AnahitaDua, FakhirElmasri,
BryanFischer, AhmadOmarHallak, DanielK.Han,
CarmenHeaney, KevinHerman, UmanJaer,
SamuelJessula, AhmedKayssi, NicoleKeefe,
NealKhurana, MaureenKohi, RickiA.Kor,
PrakashKrishnan, AbhishekKumar, ChadLaurich,
RobertA.Lookstein, SreekumarMadassery,
AlisonMaringo, JesseMartin, S.JayMathews,
ReubenPerezMcCon, AnkitMehta, JimG.Melton,
JorgeMiranda, AbigailMize,
MiguelMonteroBaker, JihadA.Mustapha,
MohamedNagi, ZolaN’Dandu, MuratOsman,
BlakeP.Parsons, RaghuramPosham,
AishwaryaRaja, RehanRiaz, MicheleRichard,
JohnH.Rundback, FadiA.Saab, GloriaSalazar,
BrianJ.Schiro, EricSecemsky, JillSommerset,
DavidM.Tabriz, JordanTaylor, AnishThomas,
SriniTummala, VenkatTummala, OmarM.Uddin,
JosVan Den Berg, MicahWatts,
BretN.Wiechmann, andAugustYsa
6
I. Ali · U. Jaffer · P. Krishnan
Department of Interventional Cardiology, Mount
Sinai Hospital, New York, NY, USA
B. Arslan · S. Madassery (*) · M. Osman · R. Riaz
D. M. Tabriz · O. M. Uddin
Department of Vascular and Interventional Radiology,
Rush University Medical Center, Chicago, IL, USA
e-mail: Bulent_Arslan@rush.edu;
Murat_osman@rush.edu; rehan_m_riaz@rush.edu;
David_M_Tabriz@rush.edu;
Omar_M_Uddin@rush.edu
R. Beasley
Palm Vascular Centers, Fort Lauderdale, FL, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. Madassery, A. Patel (eds.), Limb Preservation for the Vascular Specialist,
https://doi.org/10.1007/978-3-031-36480-8_6
C. Bechara
Department of Surgery, Division of Vascular Surgery,
Loyola University Medical Center, Hines, IL, USA
e-mail: Carlos.Bechara@lumc.edu
P. Berens · V. Chandra
Department of Surgery, Division of Vascular and
Endovascular Surgery, Stanford Medicine,
Palo Alto, CA, USA
e-mail: pberens@stanford.edu;
vchandra@stanford.edu
O. Chohan
Great Lakes Medical Imaging,
Williamsville, NY, USA
77
78
I. Ali et al.
C. Cote
Division of Cardiac Surgery, Department of Surgery,
Dalhousie University, Halifax, NS, Canada
e-mail: Claudia.l.cote@dal.ca
F. Dadrass · R. A. Korff · R. A. Lookstein · R. Posham
Department of Diagnostic, Molecular, and
Interventional Radiology, Icahn School of Medicine
at Mount Sinai, New York, NY, USA
e-mail: farnaz.dadrass@mountsinai.org;
robert.lookstein@mountsinai.org;
raghuram.posham@mountsinai.org
S. Dhand
Los Angeles Imaging and Interventional Consultants,
Los Angeles, CA, USA
A. Dua
Division of Vascular and Endovascular Surgery,
Massachusetts General Hospital, Harvard Medical
School, Boston, MA, USA
e-mail: Adua1@mgh.harvard.edu
F. Elmasri · V. Tummala
Lakeland Vascular Institute, Lakeland, FL, USA
e-mail: lmasri@lakelandvascular.com
B. Fischer
HCA Healthcare Tristar Division, The Surgical Clinic
PLLC, Nashville, TN, USA
A. O. Hallak
Department of Internal Medicine, Ochsner Health
System, New Orleans, LA, USA
D. K. Han
Department of Surgery, Icahn School of Medicine at
Mount Sinai, New York, NY, USA
e-mail: Daniel.han@mountsinai.org
C. Heaney · A. Mize · J. A. Mustapha · F. A. Saab
Advanced Cardiac and Vascular Centers,
New York, NY, USA
e-mail: cheaney@acvcenters.com;
amize@acvcenters.com; jmustapha@acvcenters.com;
fsaab@acvcenters.com
K. Herman · J. H. Rundback
Advanced Interventional & Vascular Services LLP,
New York, NY, USA
e-mail: jrundback@aivsllp.com
S. Jessula
Massachusetts General Hospital, Harvard Medical
School, Boston, MA, USA
e-mail: sjessula@mgh.harvard.edu
A. Kayssi
Department of Vascular Surgery, Sunnybrook Health
Sciences Centre, Toronto, ON, USA
e-mail: Ahmed.Kayssi@sunnybrook.ca
N. Keefe · M. Kohi · G. Salazar · J. Taylor
Department of Radiology, Division of Interventional
Radiology, University of North Carolina at Chapel
Hill, Chapel Hill, NC, USA
e-mail: Maureen_kohi@med.unc.edu;
gloria_salazar@med.unc.edu;
jordan.taylor@unchealth.unc.edu
N. Khurana · C. Laurich
Vascular& Interventional Specialists of Siouxland,
Dakota, SD, USA
e-mail: nkhurana@visofsiouxland.com;
claurich@visofsiouxland.com
A. Kumar
Department of Radiology, Division of Vascular and
Interventional Radiology, Rutgers New Jersey
Medical School, Newark, NJ, USA
e-mail: kumarab@njms.rutgers.edu
A. Maringo · M. Nagi · M. Richard
Department of Surgery, Division of Vascular Surgery,
Rush University Medical Center, Chicago, IL, USA
e-mail: Alison_E_Maringo@rush.edu;
Mohamed_M_Nagi@rush.edu;
Michele_Richard@rush.edu
J. Martin
Department of Radiology, Division of Interventional
Radiology, Maine Medical Center, Portland, ME, USA
S. J. Mathews
Department of Interventional Cardiology, Bradenton
Cardiology Center, Manatee Memorial Hospital,
Bradenton, FL, USA
R. P. McCon
Ochsner Health System, New Orleans, LA, USA
A. Mehta · S. Tummala
Department of Interventional Radiology, University
of Miami Health System, UM Miller School of
Medicine, Miami, FL, USA
J. G. Melton · B. P. Parsons
CardioVascular Health Clinic, Miami, FL, USA
e-mail: jmelton@cvhealthclinic.com
J. Miranda
Department of Surgery, Division of Vascular Surgery
and Endovascular Therapy, Baylor College of
Medicine, Houston, TX, USA
e-mail: Jorge.Miranda@bcm.edu
M. M. Baker
HOPE Vascular and Podiatry Institute, Houston, TX, USA
e-mail: mmontero@vascularhope.com
Z. N’Dandu
Department of Cardiology, Ochsner Health System,
New Orleans, LA, USA
6 Arterial Revascularization
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
A. Raja
Department of Medicine, NewYork-Presbyterian/
Columbia University Irving Medical Center,
New York, NY, USA
e-mail: Air9020@nyp.org
B. J. Schiro
Miami Cardiac and Vascular Institute,
Miami, FL, USA
E. Secemsky
Beth Israel Deaconess Medical Center, Harvard
Medical School, Boston, MA, USA
e-mail: esecemsk@bidmc.harvard.edu
J. Sommerset
Advanced Vascular Centers, Boston, MA, USA
A. Thomas
6.1 Aortoiliac Revascularization
VenkatTummala
Aortoiliac inow is critical for wound healing in
chronic limb-threatening ischemia (CLTI)
patients. Preprocedural imaging, when available,
can be valuable for treatment planning of endovascular, hybrid, or open surgical interventions
(Fig. 6.1) in patients with aortoiliac disease
(AOID). Knowing the status of adjacent mesenteric vessels, hypogastric artery, common femoral artery, and lower extremity runoff is paramount
and can have signicant implications on procedural outcomes. In the setting of iliac occlusive
disease, associated aortic aneurysmal disease
(4–10%) poses challenges when considering
endovascular vs open surgical approach [1–3].
Knowledge of unexpected pathology on CTA/
MRA beforehand can be helpful to modify the
treatment approach accordingly.
Endovascular approach is tailored to the location and extent of stenotic/occlusive disease and
might require ipsilateral (single access), bilateral
(both femoral accesses), or may require additional accesses in difcult lesions (brachial/radial
access).
Mercy Clinic Heart and Vascular LLC,
St. Louis, MO, USA
J. Van Den Berg
Department of Interventional Radiology, Centro
Vascolare Ticino, Ospedale Regionale di Lugano,
Sede Civico, Lugano, Switzerland
e-mail: josua.vandenberg@eoc.ch
M. Watts
Atlantic Medical Imaging, Pleasantville, NJ, USA
B. N. Wiechmann
Vascular & Interventional Physicians,
Pleasantville, NJ, USA
A. Ysa
Department of Vascular and Endovascular Surgery,
Hospital Universitario Cruces, Bizkaia, Spain
e-mail: august.ysa@osakidetza.net
Fig. 6.1 Preprocedural CTA showing infrarenal aortoiliac occlusion (blue arrow) sparing the CFA bilaterally
(purple arrows). After discussion of surgical and endovascular options, patient chose an endovascular option.
However, if CFA were to be involved, hybrid option
would be pursued
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I. Ali et al.
a
b
cd
Fig. 6.2 (a) R CFA angiogram shows R CIA occlusion.
(b) L CFA angiogram shows L CIA occlusion. (c)
Occlusion of the distal abdominal aorta. (d) Aortoiliac
The tool kit involves conventional angiographic catheters and guidewires needed for
peripheral angiography. Aortoiliac interventions
reconstruction using the Kissing stent grafts at the aortoiliac bifurcation and bare metal stent extension across
the hypogastric artery in an outpatient setting
can be performed in a variety of practice settings
including hospital and ambulatory surgery centers (Fig.6.2).
6 Arterial Revascularization
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81
• Ultrasound guidance during vascular access
can help with rst-pass success, especially
with diminished femoral pulses in these
patients [4].
• Initial vascular arterial access involves a 5 to 6
Fr sheath followed by upsizing to the appro-
priate sheath size required for stent/stent graft
delivery.
• Pre-close techniques can be employed prior to
the introduction of large bore delivery systems
but may need to be deferred until the lesion is
crossed and angioplasty is performed in
patients with occlusive external iliac disease.
• IVUS can be valuable in many aspects, includ-
ing but not limited to, evaluation of the extent
of disease, nature of occlusion, stent sizing,
and post-stent evaluation [5].
• Re-entry devices can aid in scenarios with
subintimal crossing and help regain luminal
entry [6]. In the setting of extensive calcic
stenotic disease in the aortoiliac segments,
shock wave lithotripsy can aid with delivery
of large bore devices [7].
• Angiographic imaging can be tailored based
on preprocedural imaging ndings, when
available. Oblique projections (contralateral
oblique for CIA bifurcation and ipsilateral
oblique for CFA bifurcation) can help in iden-
tication and characterization of ostial
disease.
• Combination of antegrade and retrograde
injections performed separately or simultane-
ously can help to map out the extent of the
lesion. Delayed imaging performed after the
initial bolus is useful in evaluation of
reconstituted arteries that would otherwise
appear occluded on initial angiography.
• Lesion crossing is typically achieved with
035″ guidewire and support catheters from a
retrograde femoral access, antegrade up and
over-approach, or upper extremity access.
Occasionally, 018/014″ chronic total occlu-
sion (CTO) wires can be used for a bail out
(Fig.6.3).
Many commercially available stent options
exist including covered, bare metal, balloonexpandable, and self-expanding stent platforms.
Stenting with percutaneous transluminal angio-
plasty (PTA) has gained widespread adoption
over PTA alone due to higher technical success
rates and reduced risk of long-term failure [8].
• The 5-year results of the COBEST trial demonstrated that the covered stent has an enduring patency advantage over the bare metal
stent in both the short term and long term.
• In addition, covered stents showed acceptable
patency rates for the treatment of more severe
TASC C and D lesions, and patients who
received a covered stent required fewer revascularization procedures [9, 10].
– Covered balloon-expandable stents are a
viable treatment option for patients with
complex aortoiliac lesions due to their
higher rates of technical success and favorable patient across all devices at 12months
[11].
• Unibody bifurcated endografts such as
Powerlink/AFX (Endologix, Irvine, CA) had
been shown to be feasible and effective with
excellent midterm patency in TASC D patients
that are poor candidates for aortobifemoral
bypass. The unibody conguration preserves
the anatomic aortic bifurcation and allows for
future up and over treatment options in CLTI
patients with infrainguinal occlusive disease
[12] (Fig.6.4).
6.1.1 Hypogastric Considerations
Key considerations in aortoiliac stenting include
preserving hypogastric ow and inferior mesenteric artery (IMA) when applicable.
• If the celiac and superior mesenteric artery
(SMA) are compromised, covering the IMA
could lead to disastrous mesenteric ischemia.
• Hypogastric artery occlusion can lead to pelvic ischemia and can severely impair quality
of life due to buttock claudication and possible new-onset erectile dysfunction in males
[13, 14].
• When CIA disease spans into the external
Iliac artery, bare metal stenting can be performed to preserve the hypogastric artery [15]
(Fig.6.5).
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I. Ali et al.
a
b
Fig. 6.3 (a) Aortogram via R CFA access showing high-
grade R CIA tight stenosis and L CIA occlusion. Length
of L CIA occlusion and proximity to L hypogastric origin
not clear on this view. (b) Retrograde L CFA injection
identies the distal extent of LCIA occlusion and its relationship to L hypogastric origin. (c) Successful L CIA
Focal aortic ow-limiting stenosis/occlusion
can be treated with stent graft and PTA while
avoiding major visceral branches. Stent size and
CTO crossing using both antegrade and retrograde
approach with 018″ wire. (d) Successful reconstruction of
bilateral CIA using kissing balloon-expandable kissing
stents. Overlapping bare metal stent extended into L EIA
for ow-limiting dissection
type can be chosen based on the anatomical location of the lesion, lesion type, aortic diameter,
access vessel size, etc. (Figs.6.6 and 6.7).
ab
6 Arterial Revascularization
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83
Fig. 6.4 (a) Elderly patient with aortic aneurysmal and
right Iliac occlusive disease treated with AFX unibody
bifurcated endograft using a percutaneous approach.
Heavy calcic burden noted at aortoiliac conuence and
intravascular lithotripsy used to facilitate endograft delivery. (b) Completion angiogram shows successful aortoiliac reconstruction while excluding associated aortic
aneurysm
ab
Fig. 6.5 (a) Abdominal aortogram from femoral approach
shows infrarenal distal aortoiliac occlusion. Retrograde
injection (not shown) revealed patent hypogastric arteries
bilaterally, with disease limited to distal CIA bilaterally.
(b) Completion angiogram shows successful aortoiliac
reconstruction using double-barreled self-expanding covered stents in aorta and balloon- expandable covered stents
in the CIA bilaterally. Hypogastric arteries bilaterally
were preserved
84
Fig. 6.6 Elderly patient with severe focal infrarenal aortic calcic stenosis, poor open surgical candidate
I. Ali et al.
6.1.2 CERAB andC-CERAB
In cases of more extensive disease involving the
infrarenal aortoiliac conuence, covered endovascular reconstruction of aortic bifurcation
(CERAB) and Chimney CERAB (C-CERAB)
has gained popularity.
• CERAB was introduced in 2013 to improve
endovascular and clinical outcomes aimed at
minimizing the turbulence and stasis seen with
kissing stents, by employing a more anatomical
and physiological reconstruction [16, 17].
– Freedom from target lesion revasculariza-
tion (TLR) at 12months was found to be
100% [18]. Three-year outcomes employing CERAB showed a 97% limb salvage
rate [19].
• In this technique, a balloon-expandable stent
graft is rst deployed in the aorta followed by
aring of the proximal edge to match the patent
adjacent aorta. Then, two appropriately sized
kissing balloon-expandable stents are placed
into the aortic stent graft creating a raised new
aortic bifurcation (Fig.6.7). VBX (W.L.Gore &
Associates, Arizona, USA), LifeStream (BD &
Co, Arizona, USA), and other commercially
available balloon- expandable stent grafts can be
employed in CERAB [11, 20]. Chimney
CERAB has been shown to be technically feasible and can be an alternative to open surgery
for complex aortoiliac disease [21].
• C-CERAB is employed for juxta renal/visceral disease with placement of additional
stent graft to preserve the juxtaposed renal/
visceral artery.
Fig. 6.7 Treated with Endurant II Aortic cuff (Medtronic,
Minneapolis, USA). The accessory R renal had to be compromised due to lesion extending to the ostium. Main
renals and IMA were preserved
An additional consideration in lesions where
the aortic and iliac disease is non-contiguous is
that spaced targeted stenting of the lesions can be
accomplished without raising the aortic bifurcation (Fig.6.8).
In AIOD associated with CFA disease, a hybrid
approach can be undertaken with femoral endarterectomy and aortoiliac endovascular reconstruction performed in the same setting (Fig.6.9).
ab
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6 Arterial Revascularization
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85
Fig. 6.8 (a) Angiogram showing focal high-grade cal-
cic infrarenal aortic stenosis caudal to IMA takeoff.
Bilateral popcorn calcic CIA stenosis noted sparing the
distal most aorta. This was treated by separate spaced aortic and bilateral CIA balloon-expandable covered stents,
without raising the bifurcation. IMA was preserved. (b)
Kissing CIA stents placed without raising aortic bifurcation. (c) Followed by aortic balloon-expandable covered
stent placement avoiding IMA coverage. (d) Completion
angiogram showing successful aortoiliac reconstruction
without raising the bifurcation. IMA preserved
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I. Ali et al.
a
b
Fig. 6.9 (a) CLTI patient with bilateral external iliac
occlusive disease and CFA involvement. Treated using
hybrid approach with femoral endarterectomy and xing
iliac inow endovascularly. (b) Fluoroscopy image showing successful external Iliac artery crossing using ante-
grade and retrograde approach with wire ossed and
externalized. (c) Left CFA endarterectomy done followed
by pelvic angiogram showing the extent of L EIA occlusion. (d) Successful stenting of L EIA avoiding extension
across the inguinal ligament
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