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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3924_Библиотеки_им_академика_М_И_Перельмана
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x Contents
22 Visceral and renal artery interventions 297
Approach to the visceral arteries 297
Celiac and superior mesenteric artery angioplasty and stenting 297
Renal angioplasty and stenting 302
23 The infrarenal aorta, aortic bifurcation, and iliac arteries: Advice about balloon
angioplasty and stent placement 311
Introduction 311
Aor t a 311
Aortic bifurcation 318
Iliac artery 321
Ipsilateral retrograde approach to the iliac artery 321
Contralateral approach to the iliac artery 323
Self-expanding versus balloon-expandable stents for the aortoiliac segment 326
Use of covered stents 326
Access related issues 327
24 The infrainguinal arteries: Advice about balloon angioplasty and stent placement 329
Introduction 329
Superficial femoral and popliteal arteries 329
Ipsilateral antegrade approach to the superficial femoral and popliteal arteries 330
Up-and-over approach to the superficial femoral and popliteal arteries 334
Access related issues: Difficult up-and-over approach to the superficial femoral and
popliteal arteries 337
Tibial artery occlusive disease: Angioplasty and stenting 341
25 Complex lower extremity revascularization 345
Aortoiliac occlusive disease 345
Femoral–popliteal occlusive disease 353
Tibial artery occlusive disease 365
Angiosomes of the lower leg and foot 367
26 Salvage of previous reconstructions 373
Introduction 373
Previous endovascular reconstruction 373
Managing occluded stents 374
Infrainguinal bypass graft 375
Extra-anatomic bypasses: Axillofemoral and femoral–femoral 378
Reconstructions for aortoiliac disease: Aortofemoral, iliofemoral, and aortoiliac bypasses 378
27 Hybrid procedures 381
Principles of hybrid procedures 381
Technical points for performing hybrid procedures 381
Iliac stent and femoral endarterectomy 387
Femoral endarterectomy plus distal intervention 389
28 Technical aspects of treating aortic aneurysms 391
Introduction 391
Imaging 391
Open access or percutaneous access of femoral arteries 392
Percutaneous large bore access using the pre-close technique 392
Closure of large bore access 394
Managing bad iliac arteries 394
Conduits 398
Endograft placement 401
Cannulation of the contralateral gate 403
Balloon angioplasty after endograft placement 405
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Contents xi
Postplacement stenting of iliac arteries 406
Management of a difficult aortic neck 407
Endovascular graft treatment of a ruptured abdominal aortic aneurysm 411
Hybrid procedures associated with aortic disease: Arch debranching 413
Management of endoleaks after endovascular abdominal aortic aneurysm repair 414
29 Coiling of peripheral aneurysms 419
Co ils 419
Vessel occluders 423
Endovascular management of a popliteal aneurysm 424
30 Puncture site management 427
Obtaining hemostasis 427
Holding pressure 427
Timing the sheath removal 429
Closure devices 429
Managing puncture site complications 432
Selected reading 433
Appendix: Trade/registered/generic names plus current manufacturers 437
Index 441
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xiii
Preface to the Fourth Edition
e goal of Endovascular Skills: Guidewire and Catheter Skills for Endovascular Surgery has always been
to provide a “step-by-step” approach to techniques and procedures that comprise one of the most excit-
ing and rapidly developing specialties in medicine today: minimally invasive management of vascular
disease. e text is meant to capture what might sound like a conversation between two clinicians about
a particular patient or during the course of a procedure. Endovascular technique has gone from a novelty
to a mainstay of vascular care, and this edition of Endovascular Skills has been revised and expanded to
reect these changes. is book serves as a “how-to” guide for endovascular intervention and aims to
assist clinicians in the development and renement of skills that are now essential to vascular practice.
Since Endovascular Skills was rst published in the mid-1990s, endovascular intervention has gone
through a tremendous phase of development. Signicant advances have been made in reopening and relin-
ing vessels in every vascular bed. More extensive patterns of vascular disease are being treated, many of
which would have required open surgery in the past. e endovascular approach has become more broadly
accepted by patients, medical professionals, scientists, engineers, and the public at large. e technical
skills and the device innovations that make endovascular practice possible have advanced and developed
over the past few years, providing new treatment options that are safer and better tolerated. ese skills
and devices will likely continue to develop for the foreseeable future. Simultaneous growth in the public
health challenge of an enlarging patient population at risk for vascular disease will likely prompt wider
adoption and even more new applications.
e skills to perform endovascular techniques are based on several principles, which are outlined in
Endovascular Skills. e book introduces readers to strategy, vascular access, guidewire–catheter han-
dling, and arteriography in a multitude of vascular beds. e knowledge base builds as the text progresses
in much the same manner that the skill of the professional builds as experience is gained by performing
more complex cases and managing complicated patterns of disease. e chapters progress to all aspects of
endovascular therapy, including sheath access, balloon angioplasty, stents, and other treatment modali-
ties. ese sections have been revised to incorporate the most contemporary practices of advanced imag-
ing and endovascular treatment techniques, including use of 0.014-inch guidewires and small caliber
platforms, atherectomy, stent–gras, subintimal angioplasty, carotid bifurcation stenting, hybrid proce-
dures, techniques associated with endovascular aneurysm treatment, and many others.
e possession of endovascular skills by clinicians dedicated to the management of vascular disease is
one of the keys to advancing patient care in this area. e Fourth Edition of Endovascular Skills aims to
assist in that challenging and rewarding endeavor.
Peter A. Schneider
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xv
Abbreviations
ACT activated clotting time
AP anteroposterior (projection)
atm atmosphere of pressure
CAS carotid artery stent
CO
2
carbon dioxide
CT computed tomography
CTA computed tomography angiography
CTO chronic total occlusion
DAPT dual antiplatelet therapy
DCB drug-coated balloon
DES drug-eluting stent
DOAC direct oral anticoagulant
DSA digital subtraction arteriography
FDA Food and Drugs Administration
ID inside diameter
IM intramuscularly
IMA inferior mesenteric artery
INR international normalized ratio
IV intravenously
IVUS intravascular ultrasound
LAO le anterior oblique (projection)
MRA magnetic resonance angiography
NPO nothing per oral
OCT optical coherence tomography
OD outside diameter
OR operating room
PET polyethylene terephthalate
PO per os
POBA plain old balloon angioplasty
psi pounds per square inch
PTA percutaneous transluminal angioplasty
PTFE polytetrauoroethylene
RAO right anterior oblique (projection)
RDC renal double curve
SFA supercial femoral artery
SMA superior mesenteric artery
TCAR transcarotid artery stenting
tPA tissue plasminogen activator
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PART I
Catheter and guidewire skills
1 Case preparation 3
2 Safe and strategic vascular access 7
3 Sheath access 27
4 Guidewire skills 35
5 Small platform guidewires and monorail systems 47
6 Handling catheters 53
7 Guidewire and catheter passage 63
8 Imaging: The key to success 77
9 Selective catheterization 89
10 Principles of arteriography 113
11 Arteriography of the vascular beds 123
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3
1
Case preparation
ENDOVASCULAR SKILLS IN
PRACTICE
Endovascular skills are an integral part of
v ascular patient care and will continue to be for
the foreseeable future. As the scope of catheter-
based treatment broadens, the ability to manage
more complex lesions with these techniques will
continue to increase and, hopefully, drive bet-
ter overall results of care. e development of
guidewire–catheter skills is not an easily denable
goal, but is a dynamic process. As the array of pos-
sibilities in the endovascular eld has blossomed,
the necessary skills included under the heading of
guidewire–catheter skills have likewise increased
substantially. On the basic level, guidewires and
catheters are the universal instruments of success
in endovascular work. A more advanced approach
includes an amazing and expanding myriad of
devices passed over the guidewire to help manage
vascular disease.
Knowledge and facility must be achieved in
several areas that are not necessarily intuitive,
including coordinating uoroscopy–eye–hand
motion, predicting guidewire–lesion interac-
tions, understanding the behavior of various
guidewire and catheter combinations, and learn-
ing the limits of each technique. ese are the
basic endovascular skills. Part I of this book
provides an overview of basic endovascular skills.
Part II presents techniques in endovascular ther-
apy that build on the basic skills, such as guiding
sheath access, balloon angioplasty, stenting, and
how to use these techniques in various vascu-
lar beds. Part III covers advanced endovascular
techniques and devices in an eort to assist the
reader in becoming familiar with rapidly evolv-
ing technology.
REINVENTION OF VASCULAR CARE
Endovascular concepts are reshaping treatment.
e potential for simple, low-morbidity solutions
to complex clinical problems is a common goal
among vascular specialists. Near-term progress
in reconstructive capability is likely to result from
advances in endoluminal technique. Guidewires
and catheters form the technical and conceptual
basis of endovascular intervention and technology,
while device and skill development are taking the
eld to the next level. Endovascular procedures
have dramatically changed the spectrum of vas-
cular practice. Iliac angioplasty and stenting have
almost completely replaced aortofemoral bypass.
Stent–gra repair of abdominal aortic aneurysms
has dramatically altered the management para-
digm for aneurysmal disease. Although some
endovascular procedures are not currently durable
enough to oer long-term solutions, such as many
of the infrainguinal treatment options, they may
still be adequate for patients with multiple comor-
bidities or limited life expectancy. ese tech-
niques also hold hope for becoming more clinically
useful as they are rened and patency improves.
Our focus is on making vascular treatment safer
and more durable, whether it involves medical,
endovascular, or open surgical procedures, or a
combination of these.
SETTING YOURSELF UP FOR
SUCCESS
e success of a case depends in part on address-
ing a few concerns that arise before the procedure
commences. Evaluation of the patient and a prepro-
cedure analysis make a dierence. Decisions about
access and strategy, how compelling the indications
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