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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3823_Библиотеки_им_академика_М_И_Перельмана
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Identify the femoral vein for planned access at the
proximal or mid‐thigh level. Avoid injury to the
superficial femoral artery, typically anterior to the
femoral vein. We recommend bilateral femoral vein
access. Depending on the interventionist, the
contralateral common femoral vein can be used as a
secondary access point for better visualization of the
confluence.
Step 5. Vascular access:
Use a micropuncture kit. It generally includes a 21‐gauge
needle, a 5‐Fr (sometimes 4 Fr) sheath, and a 40‐cm‐
long 0.018‐in. Cope wire. The micropuncture sheath can
be upsized as needed after the guidewire is in place.
Applying the Seldinger technique: Over a sterile field, get
access with a 21‐gauge needle under ultrasound
guidance. Place Cope wire through needle. Remove the
needle over the Cope wire and replace with a
micropuncture sheath. Remove the guidewire and
advance the glide wire through the 5 Fr sheath under
fluoroscopy. Ensure under fluoroscopy that the glide
wire is through the femoral vein with sufficient purchase
(high up enough) before introducing the sheath. Lesions
that are not 100% obstructed allow the glide wire and
glide catheter to go through easily. In presence of
occlusion, a stiff glide wire with a 0.035‐in. support
catheter may be needed. Further progress into the
occlusion is made with the tip of the glide wire with
straight or angled catheter support.
Step 6. Sheath upgrade:
Once access is satisfactory, switch the wire to a stiff
0.035 supra core wire (Figure 15.2) and exchange to a 9
or 10 Fr sheath. The supra core is a supportive wire with
a soft atraumatic tip with great steering and facilitates
catheter placement for diagnostic and contralateral
approach interventions.
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Figure 15.2 Venogram. Access site left common femoral
vein. Exchange 4 Fr or 5 Fr micro puncture catheter over
0.035″ supra core wire placed in IVC to 9 Fr or 10 Fr
sheath.
Step 7. Imaging:
a. After vascular access is established, antegrade
venography under fluoroscopy is performed to
identify the anatomic landmarks and determine the
degree, length, and site of obstruction, and the
presence of collateral vessels.
i. Ipsilateral injection 10 ml/s–15 ml for 900 PSI
is done on AP position under DSA.
ii. Contrast venography is poorly sensitive to iliac
vein obstruction.
b. Following the venogram, use of IVUS (IVUS is 10 Fr
compatible) is strongly encouraged to make an
accurate diagnosis and to aid in treatment strategy
for stent deployment and landing zone for instance.
i. IVUS aids in mapping the venous system from
the femoral vein to the inferior vena cava (IVC):
common femoral vein, external iliac vein,
common iliac vein, and IVC.
ii. A decrease in lumen size by more than 50%
suggests obstruction that requires close
evaluation and/or intervention.
Step 8. Once the area of venous stenosis/obstruction is
identified:
a. After crossing the lesion with a guidewire, dilatation
can be done before (predilatation) or after stent
deployment, at the discretion of the proceduralist.
i. Tip: To monitor the progress of the
recanalization, obtain 45° or 60° oblique
projections to ensure that the glide wire initially
follows the curve of the sacrum and then turns
anterior to the spine.
ii. Predilate using a 6–8 mm balloon, up to 4 atm,
for an inflation time of 30 seconds to one
minute.
iii. Avoid using large balloons for predilation or
predilating to the desired diameter.
Step 9. Once the identified lesion is dilated, determine
the size of the stent.
a. Use IVUS intraprocedurally to estimate best stent
sizing:
i. Measure the diameter and length of the vessel
proximal and distal to the desired landing zone.
ii. TIP: If the contralateral iliac vein is free of
disease, the diameter of the vessel (by IVUS or
preprocedural imaging) can be used for sizing
reference.
iii. Oversizing the stent by up to 4 mm (2–4 mm)
for the anatomic location is recommended to
compensate for the potential recoil of the
recanalized vessel.
Step 10. Stent deployment:
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a. Currently, FDA approved options for venous
stenting include stainless steel and nitinol stents, as
well as covered stent‐graft. The Wallstent; Closed
(8–24 mm/20–90 mm), Vici Veniti by Boston
Scientific; Closed (12–16 mm/60–120 mm), Bard
Venovo; Open (10–20 mm/40–60 mm).
b. Stents shouldn’t be used more distally to the
inguinal ligament due to the risk of stent fracture
from hip flexion.
c. The Wallstent is a closed (8–24 mm/20–90 mm),
self‐expanding stainless steel stent with great
strength and flexibility.
i. It is weakest at the end and foreshortening
makes precise placement difficult.
d. Start beyond the lesion up to below the lesion. It is
important that both ends of the stent land in normal
looking tissue.
i. For nonthrombotic lesions, like NIVL for
instance, start the deployment, 2–3 cm into the
IVC. A deployment over 3 cm risks obstructing
flow to the contralateral iliac vein.
ii. TIP: The Wallstent is retrievable up to a certain
point before complete deployment, a helpful
feature for when the location of the stent is not
optimal.
Figure 15.3 Postdeployment series of
Wallstent dilatation placed in left iliac vein.
iii. When using multiple stents, ensure 3–5 cm
overlap (some say 2–3 cm) between these
stents.
iv. Optimal stent diameters after recoil:
1. 20 mm for the IVC
2. 16–18 mm for the common iliac vein
3. 14–16 mm for the external iliac vein
4. 12–14 mm for the common femoral vein
e. Postdeployment dilatation:
i. This step is recommended even if the stent
appears fully extended.
ii. Prevent foreshortening of the Wallstent by
ballooning the side closest to the lesions (Figure
15.3). Stent will foreshorten as it gains in
diameter. Therefore, if the stent is only placed
in the lesion area (and not from normal tissue
to normal tissue), over time that stent will no
longer be covering the area of stenosis.
iii. Perform balloon angioplasty using high‐
pressure, large‐diameter balloons (12–20 mm ×
4–6 cm) with prolonged inflation time (>30
seconds up to 1 minute) to ensure adequate wall
apposition.
Step 11. Poststenting evaluation:
IVUS is favored over multiplane venography to ensure
there is no residual obstruction, especially distally,
incomplete dilatation, or improper stent apposition
(Figure 15.4). When any residual obstruction or lesion is
seen, further intervention with repeat angioplasty is
required.
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Figure 15.4 IVUS guided venous stenting, left iliac vein.
(a) Pre‐intervention left iliac vein stenosis by IVUS. (b)
Post‐intervention: optimal stent apposition and left iliac
vein stenosis resolution by IVUS.
Step 12. Sheath care:
Remove the sheath after applying the “Figure of 8 or 3‐
Way Stop‐Cock” suture technique and apply light
pressure until homeostasis is achieved.
Follow‐Up
No bed rest needed poststenting. Patient expected to
have severe back discomfort for up to one week
postprocedurally. Start AC (warfarin or rivaroxaban)
night of day of intervention (up to one year). Routine
follow‐up usually occurs 1, 3, 9, and 18 months after
intervention. If patient returns symptomatic (leg
swelling, pelvic edema, persistent leg pain, varicose
veins, etc.) repeat venogram/IVUS.
References
1 Kahn, S.R., Comerota, A.J., Cushman, M. et al. (2014).
American Heart Association Council on Peripheral
Vascular Disease, Council on Clinical Cardiology, and
Council on Cardiovascular and Stroke Nursing. The
postthrombotic syndrome: evidence‐based
prevention, diagnosis, and treatment strategies: a
scientific statement from the American Heart
Association. Circulation. 130 (18): 1636–1661.
2 Kahn, S.R. (2016). The post‐thrombotic syndrome.
Hematology Am. Soc. Hematol. Educ. Program. 2016
(1): 413–418.
3 Utne, K.K., Ghanima, W., Foyn, S. et al. (2016).
Development and validation of a tool for patient
reporting of symptoms and signs of the post‐
thrombotic syndrome. Thromb. Haemost. 115 (2):
361–367.
4 Wahlgren, C.‐M., Wahlberg, E., and Olofsson, P.
(2010). Endovascular Treatment in Postthrombotic
Syndrome. Vascular and Endovascular Surgery. 44
(5): 356–360.
5 Danza, R., Navarro, T., and Baldizan, J. (1991).
Reconstructive surgery in chronic venous obstruction
of the lower limbs. J. Cardiovasc. Surg. 32: 98–103.
6 Neglen, P. and Raju, S. (2002). Intravascular
ultrasound scan evaluation of the obstructed vein. J.
Vasc. Surg. 35: 694–700.
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16
Intervention for Pulmonary
Embolism
Seth I. Sokol1, Wissam A. Jaber2, and Yosef Golowa
3
1
Division of Cardiovascular Diseases, Albert
Einstein College of Medicine-Jacobi Medical Center,
Bronx, NY, USA
2
Division of Cardiology, Emory University
Hospital, Atlanta, GA, USA
3
Department of Radiology, Albert Einstein College
of Medicine-Montefiore Medical Center, Bronx, NY,
USA
Introduction
Sub‐massive or massive, central or saddle pulmonary
embolism (PE) is a severe condition that can cause
cardiogenic shock, death or chronic pulmonary
hypertension. Systemic thrombolysis with rt‐PA or
alteplase (approved by FDA) is only used in
hemodynamically unstable and peri‐code/ code patients.
Catheter –directed therapies have been emerging as
attractive option and warrant optimal angiographic
result, reduction in RV/LV ration and decrease in
pulmonary hypertension.
Pulmonary Angiography
Despite the advent of CTA, pulmonary angiography
retains an important role in diagnosis and treatment of
PE especially to selectively guide interventional
treatment [1].
Vascular Access
Access can be obtained in the common femoral vein,
brachial vein, or internal jugular vein using ultrasound
guidance and a micro‐puncture needle kit.
Injection and X‐Ray Detector Positioning
A balloon‐tipped catheter with multiple sideholes (for
example, Arrow® Berman™ catheter, Teleflex,
Morrisville, NC, USA) is advanced into the main
pulmonary artery. Right atrial, ventricular, and
pulmonary artery pressures can be measured.
Note: Arrow Berman catheter does not have an
endhole and therefore cannot be used for wire
exchanges.
Alternative: 5 or 6 Fr angled Pigtail catheter
delivered over a 0.035 J‐tip or angled tip wire.
For 9 in. detectors, given the limited field, a nonselective
angiogram in the main PA may not include the
peripheral pulmonary vasculature.
Tip: The table should be raised as high as possible
and flat panel positioned as close to patient as
possible to maximize the amount of lung imaged.
A more selective angiogram of the right and left
pulmonary arteries can be performed to assess the entire
lung field. RAO 20° for right PA and LAO 20° for left PA.
Each injection should be with 30–40 ml of dye given
over two seconds (“15 for 30 or 20 for 40”).For 12 in. or
greater detectors, position catheter tip in the trunk of the
main pulmonary artery and inject 40 ml of dye over two
seconds (“20 for 40”). Further selective imaging can then
be done if needed.
Notes: (i) A PA systolic pressure greater than 80
mmHg is a contraindication to pulmonary
angiography with a power injector. (ii) The presence
of a left bundle branch block may require a
temporary pacing wire given the risk of inducing
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complete heart block with right heart catheter
manipulation.
Catheter‐Directed Thrombolysis
EKOS™ Catheter‐Directed Thrombolysis
The EkoSonic (BTG, London, England) endovascular
system is FDA approved for the treatment of pulmonary
embolism (Figure 16.1). The device allows for infusion of
thrombolytics in the pulmonary arteries while delivering
ultrasound energy waves to increase the dispersion of the
drug within the thrombus.
The infusion catheter is 5.4 Fr and multi‐lumen
including a coolant lumen allowing for guidewire
insertion for catheter delivery, injection of contrast
(maximum of 200 PSI) and continuous infusion of saline
to cool the ultrasonic core. A drug delivery lumen with
perforated holes allows for delivery of drug along and
around the chosen treatment length zone (Figure
16.2a,b).
Note: Drug delivery lumens are closed to distal end
of infusion treatment zone.
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