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Carlos
Mena
Sasanka
Jayasuriya
Peripheral
Vascular
Disease
A
Clinical
luwer
Approach
PeripheralVascularDisease
ACLINICALAPPROACH
CarlosMena,MD,FACC,FSCAI
AssociateProfessorofMedicine–Cardiology
DirectorCardiacCatheterizationLaboratories
DirectorVascularMedicine&EndovascularFellowship
YaleNewHavenHospital
NewHaven,Connecticut
SasankaJayasuriya,MBBS,FACC,FASE,RPVI,FSCAI
AssistantProfessorofMedicine
SectionofCardiovascularMedicine
YaleSchoolofMedicine
NewHaven,Connecticut
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Names:Mena,Carlos(CarlosI.Mena-Hurtado)editor.|Jayasuriya,Sasanka,editor.
Title:Peripheralvasculardisease:aclinicalapproach/editedbyCarlosMena,SasankaJayasuriya.
Othertitles:Peripheralvasculardisease(Mena)
Description:Philadelphia:WoltersKluwer,[2020]
Identifiers:LCCN2019017152|ISBN9781496349408(paperback)
Subjects:|MESH:PeripheralVascularDiseases–therapy|EndovascularProcedures–methods
Classification:LCCRC694|NLMWG505|DDC616.1/31–dc23
LCrecordavailableathttps://lccn.loc.gov/2019017152
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Contributors
MahmoudAbde lghany,MDFellowinCardiovascularMedicine,,YaleNewHavenHospital,,NewHaven,Connecticut
S.ElissaAltin,MDAssistantProfessor,DivisionofCardiology,YaleUniversitySchoolofMedicine,NewHaven,Connecticut
HerbertD.Aronow,MD,MPHDirectorofInterventionalCardiology,DivisionofCardiovascularMedicine,WarrenAlpertMedicalSchool
ofBrownUniversity,LifespanCardiovascularInstitute,Providence,RhodeIsland
Je remyD.Asnes ,MDAssociateProfessor,DepartmentofPediatrics,YaleSchoolofMedicine,NewHaven,Connecticut
RobertR.Attaran,MD,FACC,FASE,FSCAI,RPVIAssistantProfessorCardiovascularMedicine,Director,VenousDisordersProgram,
YaleNewHavenHospital,NewHaven,Connecticut
AfshaAurshina,MBBSResident,DepartmentofSurgery,YaleUniversitySchoolofMedicine,NewHaven,Connecticut
WilliamL.Bennett,MD,PhDAssistantProfessor,DepartmentofCardiology,OchsnerClinicFoundation,NewOrleans,Louisiana
KurtBjorkman,MDChiefResident,DepartmentofPediatrics,Yale-NewHavenChildren’sHospital,YaleSchoolofMedicine,New
Haven,Connecticut
PeterA.Blume,DPM,FACFASMedicalDirector/HVC/AmbulatorySurgery,YaleNewHavenHealthSystems,AssistantClinical
ProfessorOfSurgery,AnesthesiaandCardiology,YaleSchoolofMedicine,NewHaven,Connecticut
FouadChouairi,BSDepartmentofNeurosurgery,YaleUniversitySchoolofMedicine,NewHaven,Connecticut
StacyChu,MDDepartmentofNeurology,YaleUniversitySchoolofMedicine,NewHaven,Connecticut
BrandenCord,MD,PhDDepartmentofNeurosurgery,YaleUniversitySchoolofMedicine,NewHaven,Connecticut
BennettCua,MD,FACCCardiologist,MissionViejo,California
JohnA.Elefteriade s ,MD,PhD(hon)WilliamW.L.GlennProfessorofSurgery,Director,AorticInstituteatYale-NewHaven,Yale
MedicineDepartmentofSurgery,NewHaven,Connecticut
YoungErben,MDSeniorAssociateConsultant,MayoClinicFlorida,Jacksonville,Florida
WassimH.Fares ,MD,MScSeniorClinicalLeader,ClinicalDevelopment,ActelionClinicalResearch,ActelionPharmaceuticalsInc,A
JanssenPharmaceuticalCompanyofJohnson&Johnson,Allschwil,Switzerland
SenthilrajGanes han,MDClinicalCardiologyFellow,DivisionofCardiology,YaleUniversitySchoolofMedicine,NewHaven,
Connecticut
MichaelI.Gazes,DPM,MPH,FACFAOM,AACFASYaleNewHavenFoot&AnkleSurgeons/NortheastMedicalGroup,
DepartmentofPediatricSurgery,YaleNewHavenHospital,ClinicalInstructor,DepartmentofMedicine,YaleSchoolofMedicine,New
Haven,Connecticut
Andre wM.Goldswe ig,MDAssistantProfessor,DivisionofCardiovascularMedicine,UniversityofNebraskaMedicalCenter,Omaha,
Nebraska
AntonA.Gryaznov,MD,PhDResident,AorticInstituteatYale-NewHavenHospital,YaleUniversitySchoolofMedicine,NewHaven,
Connecticut
EileenM.Harder,MDResidentPhysician,DepartmentofInternalMedicine,YaleUniversity,NewHaven,Connecticut
AhmedHarhash,MBBChCardiovascularFellow,DepartmentofCardiology,UniversityofArizona,Tucson,Arizona
FaisalHasan,MDAssociateClinicalProfessorofMedicine,HeartandVascularInstitute,ClevelandClinicAbuDhabi,AbuDhabi,United
ArabEmirates
KhwajaYousufHasan,MBBSAssociateStaffPhysician,HeartandVascularInstitute,ClevelandClinicAbuDhabi,AbuDhabi,United
ArabEmirates
RyanM.Hebert,MDAssistantProfessor,DepartmentofNeurosurgery,YaleUniversitySchoolofMedicine,NewHaven,Connecticut
SasankaJayasuriya,MBBS,FACC,FASE,RPVI,FSCAIAssistantProfessorofMedicine,SectionofCardiovascularMedicine,Yale
SchoolofMedicine,NewHaven,Connecticut
Qurat-ul-AiniJelani,MDPeripheralVascularInterventionalFellow,DivisionofCardiology,DepartmentofMedicine,YaleUniversity
SchoolofMedicine,NewHaven,Connecticut
MicheleH.Johnson,MD,FACR,FASERProfessor,DepartmentofRadiologyandBiomedicalImagingandNeurosurgery,Director,
InterventionalNeuroradiology,YaleUniversitySchoolofMedicine,NewHaven,Connecticut
Andre wKoo,BSDepartmentofNeurosurgery,YaleUniversitySchoolofMedicine,NewHaven,Connecticut
KwanS.Le e,MBBChAssociateProfessorofMedicine,DepartmentofCardiology,UniversityofArizona,Tucson,Arizona
AnnaLynn,B SDepartmentofNeurosurgery,YaleUniversitySchoolofMedicine,NewHaven,Connecticut
Wei-GuoMa,MDVisitingAttending,YaleUniversitySchoolofMedicine,NewHaven,Connecticut;,AssociateProfessor,Departmentof
CardiovascularSurgery,,BeijingAnzhenHospitalofCapitalMedicalUniversity,Beijing,China
CharlesMatouk,MD,FRCS(C)AssociateProfessorofNeurosurgeryandofRadiology&BiomedicalImaging,SectionChief,
NeurovascularSurgery,Director,EndovascularNeurosurgeryFellowship,YaleUniversity/Yale-NewHavenHospital,NewHaven,
Connecticut
CarlosMena,MD,FACC,FSCAIAssociateProfessorofMedicine–Cardiology,DirectorCardiacCatheterizationLaboratories,Director
VascularMedicine&EndovascularFellowship,YaleNewHavenHospital,NewHaven,Connecticut
MichaelMercier,B ADepartmentofNeurosurgery,YaleUniversitySchoolofMedicine,NewHaven,Connecticut
SamehMohareb,MDFellowinCardiology,DepartmentofCardiology,OchsnerClinicFoundation,NewOrleans,Louisiana
Samee rNagpal,MDInterventionalCardiologyFellow,DepartmentofCardiovascularMedicine,YaleUniversitySchoolofMedicine,New
Haven,CT
ReshmaNarula,MDAssistantProfessorofNeurology,YaleUniversitySchoolofMedicine,NewHaven,Connecticut
RishiPanchal,DOPeripheralVascularInterventionalFellow,Yale-NewHavenHospital,NewHaven,Connecticut
ChandniPatel,MDPediatricCardiologyFellow,DepartmentofPediatrics,YaleUniversity,NewHaven,Connecticut
ImaadRazzaque ,MDInterventionalCardiologyFellow,DepartmentofMedicine,TulaneUniversitySchoolofMedicine,NewOrleans,
Louisiana
AymanSaeyeldin,MDResident,AorticInstituteatYale-NewHavenHospital,YaleUniversitySchoolofMedicine,NewHaven,
Connecticut
MamadouL.Sanogo,MDAssistantProfessorofRadiology,UniversityofMichigan,DivisionofVascularandInterventionalRadiology,Ann
Arbor,Michigan
JohnF.Setaro,MD,FACC,FSCAIAssociateProfessorofMedicine,Director,CardiovascularDiseasePreventionCenter,Attending
Physician,AdultCardiacCatheterizationLaboratory,SectionofCardiovascularMedicine,YaleUniversitySchoolofMedicineandYaleNewHavenHospital,NewHaven,Connecticut
SamitM.Shah,MD,PhDClinicalFellow,DivisionofCardiovascularMedicine,YaleUniversitySchoolofMedicine,NewHaven,
Connecticut
MadhanShanmugasundaram,MD,FACC,FSCAIAssistantProfessorofMedicine,UniversityofArizonaCollegeofMedicine,Tucson,
Arizona
M.AbigailSimmons,MDPost-DoctoralFellow,AdultCongenitalHeartDiseaseDepartmentofInternalMedicine,Sectionof
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CardiovascularMedicine,YaleUniversitySchoolofMedicine,NewHaven,Connecticut
AtulSingla,MDAssistantProfessor,SectionofCardiology/DepartmentofMedicine,TulaneUniversitySchoolofMedicine,Southeast
LouisianaVeteransHealthCareSystem,NewOrleans,Louisiana
SamuelSommaruga,MDGenevaUniversityHospital,Geneva,Switzerland
BauerESumpio,MD,PhDProfessorDepartmentofSurgery,RadiologyandMedicineYaleUniversityNewHaven,Connecticut
Tze-Woe iTan,MBBSAssistantProfessorofSurgery,DepartmentofVascularSurgery,UniversityofArizona,Tucson,Arizona
CamiloA.Ve lasquez,MDResident,AorticInstituteatYale-NewHavenHospital,YaleUniversitySchoolofMedicine,NewHaven,
Connecticut
ChiranjivS.Virk,MDAssistantProfessor,DepartmentofSurgery,SectionChiefVascularSurgery,LouisianaStateUniversity,Shreveport,
Louisiana
GabriellaWilson,MDClinicalMedicineResident,DepartmentofInternalMedicine,YaleUniversitySchoolofMedicine,NewHaven,
Connecticut
MohammadA.Zafar,MDResident,AorticInstituteatYale-NewHavenHospital,YaleUniversitySchoolofMedicine,NewHaven,
Connecticut
BulatZiganshin,MD,PhDAssociateResearchScientistinSurgery,YaleUniversity,NewHaven,Connecticut
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Preface
Thisbookiswrittenforendovascularoperatorstosummarizethecurrentindications,techniques,anddatainendovascularintervention.The
goalistopresentthisinformationinasuccinctandcomprehensive“easytofollow”format.
Werecognizethefieldofendovascularinterventionisrapidlyevolving.Thiscouldbeafield,whichhasthehighestturnoverofequipment—
differentnewtechnologiesaregainingpopularitywithsupportivedata;however,oldertechniquesarefiledawayinthearchivesofhistory,at
timestoresurfaceincommonpractice.
Wehavemadeacomprehensiveefforttopresenttoyouasnapshotofcontemporaneouspracticesatthetimethisbookisinprint.Chapters
haveanoutlineformattoensureeaseoffollowingthecontent.Eachchapteralsobeginswithbulleted“KeyPoints”list,createdbytheauthors
andeditors,thathighlightscriticaltopicsdiscussedinthechapter.
Thisguidedoesnotinanywaysubstituteadequatetrainingandathroughknowledgeofendovascularinterventions.Werecommendthat
societalcurrentguidelinesandpracticesbecloselyfollowed.
Wehopeyouenjoythisbookanditaddstoyourstrengthsincaringforthehighlycomplexpatientpopulationwithvasculardisease!
CarlosMena,MD,FACC,FSCAI
SasankaJayasuriya,MBBS,FACC,FASE,RPVI,FSCAI
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Contents
Title
Copyright
Contributors
preface
1HistoryofEndovascularIntervention,Fluoroscopy,BasicsofAngiography,Contrast,PatientSelection,
andInformedConsent
2AcuteStrokeIntervention
3CervicalCarotidandVertebralDisease
4SubclavianArteryStenosis/Interventions
5aCoarctationoftheAorta
5bEndovascularManagementoftheAscendingAortaandtheAorticArch
6EndovascularRepairoftheDescendingAorta
7PulmonaryArteryStenosis
8RenovascularDisease
9EndovascularInterventionofAortoiliacOcclusiveDisease
10EndovascularInterventionsinSuperficialFemoralArteryDisease
11BelowKneeRevascularization
12Drug-CoatedTherapies
13StentTherapiesintheLowerExtremity:Bare-Metal,Drug-Eluting,andReabsorbableStents
14AtherectomyforPeripheralArterialDisease
15CurrentUseandAvailabilityofReentryDevices
16AcuteLimbIschemia:ThrombectomyandThrombolysis
17HybridLowerExtremityRevascularization
18PharmacotherapyinPeripheralArteryDisease
19VascularAccessComplications
20LimbSalvageFromaPodiatricStandpoint
21PulmonaryVascularDiseasesandInterventions
22DeepVeinThrombosis
23May-ThurnerSyndrome
24SuperficialVenousDiseaseoftheLegsandTreatment
Index
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C H A P T E R 1
HistoryofEndovascularIntervention,
Fluoroscopy,BasicsofAngiography,Contrast,
PatientSelection,andInformedConsent
AndrewM.GoldsweigMD
HerbertD.AronowMD,MPH
I.Introduction
II.HistoryofFluoroscopyandAngiography
A.InVivoImaging:LimitationsandAdvances
B.TranscatheterVascularIntervention
III.Fluoroscopy
IV.Radiation
A.Patients
B.Operators
C.ProceduralX-rayDosage
V.Angiography
A.Angiographers
B.PeripheralVascularAngiographyandIntervention
VI.Contrast
A.ModernRadiocontrastAgents
B.AdverseEffects
VII.PatientSelectionandConsent
A.PatientSelection
B.InformedConsent
KeyPoints
■ Major landmarks in the history of endovascular intervention include the
discovery of X-rays by Röntgen, the synthesis of nonionic contrast media by
Almén,thedevelopmentofangioplastybyGrüntzig,andthefirstuseofvascular
stentsbyPuelandSigwart.
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■ Fluoroscopic systems generate X-rays via Bremsstrahlung. After passing
through a patient, these X-rays initiate a cascade of energy transfers that
ultimatelyconvertsthesignalintoanelectronicdigitalimage.
■X-rayexposurecausesDNAmutationsthatmayresultindeterministiceffects
(ie,tissuedamage)aswellasstochasticeffects(ie,malignancy).
■Each vascular territory and intervention is best imaged from specific
angulations. Endovascular intervention relies heavily upon digital subtraction
imaging(DSA).
■Contrastagentsareionicornonioniciodine-containingmoleculesthatattenuate
X-rays. Risks associated with contrast agents include contrast-induced acute
kidneyinjury(CI-AKI)andhypersensitivityreactions.
■Patient selection for endovascular procedures relies upon history, physical
examination, noninvasive imaging, and guidelines for each vascular territory
(when available), and should incorporate patient preference. Patients and
providersmustdiscusstherisks,benefits,andalternativesofaprocedureduring
thepreproceduralinformedconsentprocess.
I.Introduction
Endovascular intervention offers effective, minimally invasive therapy for many diseases of the
peripheralarteriesandveins.Nowfourdecadesold,thefieldofendovascularinterventioncontinuesto
seeexplosivegrowthandrapiddevelopmentofnew,advancedtechnologies.Thischapterintroducesthe
basicsofendovascularintervention,beginningwithareviewofthemajorlandmarksandpioneersinthe
developmentoffluoroscopy andangiography.Anunderstandingofthefundamentals ofX-rayimagingis
necessarytoall endovascular operators, asis anappreciationforthe risksofworkingwithradiation.
Effective angiography requires knowledge of optimal technique and contrast use. Finally, procedural
specialistsmustcarefully selectwhichpatients maybenefitfromendovascularinterventionandreview
with these patients the risks, benefits, and alternatives of the planned procedures. Expertise in
fluoroscopyandangiographycoupledwithappropriatepatientselectionprovidesthebasisforsuccessful
endovascularintervention.
II.HistoryofFluoroscopyandAngiography
The modern era of medical imaging began on November 8, 1895, when German physicist Wilhelm
Conrad Röntgen first produced X-rays and generated an image of his wife Anna’s hand on a barium
platinocyanide screen (Fig.1.1).1 For his discovery, Röntgen was awarded the first Nobel Prize in
Physicsin1901.WithinayearofRöntgen’sinvention,ThomasEdisondevelopedthefirstfluoroscopein
1896beforeabandoningX-rayresearchowingtothedangersassociatedwithradiationexposure.2Also
in1896,AustriansEduardHaschekandOttoLindenthaldissolvedbismuth,lead,andbariumsaltsinoil
toperformthefirstangiograminanamputatedhand(Fig.1.2).
3
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