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_3924_Библиотеки_им_академика_М_И_Перельмана
.pdf
344 The infrainguinal arteries: Advice about balloon angioplasty and stent placement
calcication in the vessel wall may be visible. Aer
balloon withdrawal, completion arteriography is
performed through the side arm of the sheath. If
signicant dissection or residual stenosis is pres-
ent, repeat balloon ination may be performed. If
a stent is required in the proximal segment, near
the tibial artery origin, a balloon-expandable stent
is placed (Figure 24.9). is permits the greatest
accuracy of placement. is is a location in the
limb, between the tibia and bula, that is relatively
protected from external forces. If stent placement
is required in the remainder of the artery, a self-
expanding stent is used to accommodate the more
exible and mobile artery segments. ere are no
stents designed to work well at the ankle and foot.
ere are no stents approved for use in the tibial
arteries in the USA. If a balloon-expandable stent
is placed at the mid- or distal tibial level, a blood
pressure cu should not be inated on the leg
because of the risk of crushing the stent.
https://t.me/med1917
345
25
Complex lower extremity
revascularization
AORTOILIAC OCCLUSIVE DISEASE
Recanalizing iliac artery occlusions
ere are several treatment options available for
iliac artery occlusive disease. e previous gold
standard of aortobifemoral bypass is rarely per-
formed. Other open options include a variety of
extra-anatomic bypasses, such as axillofemoral
bypass and femoral–femoral bypass. A combina-
tion of extra-anatomic bypass and some endo-
vascular inow may also be performed. Previous
treatment for unilateral iliac artery occlusion was
frequently a femoral–femoral bypass. e vast
majority of patients with aortoiliac occlusive dis-
ease can be treated with endovascular techniques,
including most patients with TASC D lesions.
Currently available tools permit recanalization of
most iliac artery occlusions. Unilateral iliac artery
occlusion is most common and there is oen ste-
nosis of the contralateral side. Bilateral iliac artery
occlusions may also be treated using a bilateral
endovascular approach. If one of the iliac arteries
can be reopened and the other one cannot, stent-
ing on one side can be performed followed by a
femoral–femoral bypass.
A variety of occlusions involving the aortoiliac
segment are shown in Figure 25.1. Aortic occlu-
sions that begin distally and extend into the iliac
arteries can oen be opened. Aortic occlusions
that are ush with the renal arteries are more dan-
gerous due to the risk of expressing compacted
thrombus into the renal arteries or the visceral
arteries. Likewise, for iliac artery occlusion, lesions
that extend into the common femoral artery are
more dicult and riskier to treat. In this case, the
iliac artery recanalization can be combined with
a femoral endarterectomy. If that is not possible,
the limb can be revascularized as the recipient of a
femoral–femoral bypass.
Assessment of iliac artery occlusions
When assessing iliac artery occlusions, it makes a
dierence as to whether these lesions are located
in the common iliac artery alone or the external
iliac artery alone, or whether they involve both the
common and the external iliac arteries. In gen-
eral, results are better with common iliac artery
occlusions than with external iliac artery occlu-
sions. e common iliac artery is a larger, shorter
artery. Results with either common or external
iliac artery occlusions are better than those in
which both arteries are occluded on the same side.
is is true for technical success and for long-term
patency. A patent internal iliac artery is helpful
in recanalizing either a common iliac artery or
an external iliac artery occlusion. e occlusion
usually ends at the origin of the internal iliac
artery. e internal iliac artery maintains ow in
the patent segment juxtaposed to the occlusion. It
can be used to anchor a wire. It can also be used
to assist the operator in directing the wire in the
correct direction to get across an iliac occlusion.
With respect to common or external iliac artery
occlusions, if theproximal end or the distal end
of the artery at the lesion has a beak of patent
vessel leading into the occlusion (as opposed to a
ush occlusion), this will enhance getting into the
occlusion (Figure 25.2). In the case of a common
iliac artery occlusion, the beak or stump can be
used to enter the occlusion, either by coming in
https://t.me/med1917
346 Complex lower extremity revascularization
A B C
D E F
G H
Fig. 25.1 Patterns of aortoiliac occlusive disease. These lesions are arranged in order from those
that are simplest to treat with endovascular intervention to those that are the most complex. (A) Iliac
stenosis is the most favorable situation for use of endovascular techniques. This is the index endovas-
cular case. (B) Unilateral common iliac artery occlusion. These are more challenging when they pres-
ent as a flush occlusion than when they have a beak or stump to help get into the lesion. (C) External
iliac artery occlusion. This is a longer, smaller caliber artery than the common iliac artery. (D) Bilateral
common iliac artery occlusion. (E) Combined common and external iliac artery occlusion. These can
be quite challenging because the operator must enter the occlusion at the optimal location and re-
enter the true lumen at the optimal location, with minimal leeway for variation. (F) Combination of
infrarenal aortic occlusion and bilateral common iliac artery occlusion. (G) Iliac occlusion combined
with common femoral artery occlusion. (H) Iliac artery occlusion combined with extensive infrarenal
aortic occlusion that extends from the level of the renal arteries. In general, the risk of technical
failure and complications increases in managing occlusions that extend up toward the renal arteries
orextend distally into the common femoral arteries.
https://t.me/med1917
Aortoiliac occlusive disease 347
proximally from the brachial artery or by coming
in over the aortic bifurcation from the contralat-
eral side. If there is a ush occlusion of the proxi-
mal end of a common iliac artery occlusion, the
benet of approaching the lesion from a proximal
access is higher. is is because the up-and-over
approach is disadvantaged when approaching a
ush occlusion.
Getting the guidewire in the correct place with
respect to the proximal end of a common iliac
artery occlusion is oen challenging when coming
from below (Figure 25.3). e guidewire oen will
pass into the subadventitial space posterior to the
aortic bifurcation. e distal aorta and proximal
iliac arteries are oen fused together in a continu-
ous cast of calcic plaque. When the subadventi-
tial guidewire comes in from below, it oen will
not be able to break through this calcium in order
to pass back into the true lumen. Because of this,
a higher likelihood of success usually results by
approaching a common iliac artery occlusion from
the proximal end, especially if there is a stump or
beak of open artery that shows the way into the
lesion. Nevertheless, approaching an iliac artery
occlusion retrograde from the lower end of the
occlusion is sometimes successful and oen worth
an attempt (Figure 25.4). When recanalizing com-
mon iliac artery occlusions, it may be necessary
to approach the occlusion from both ends, using
a bidirectional approach. In this case, it is impor-
tant to make the wires meet along the length of
theocclusion and not proximal or distal to it. If the
subintimal planes meet proximal or distal to the
occluded length, the reconstruction will be more
lengthy and an important vessel may be impinged
(contralateral common iliac artery proximally or
internal iliac artery distally).
An external iliac artery occlusion may have
a beak of patent artery proximally or it may be
a ush occlusion. erefore, the principles that
apply to common iliac artery occlusions also apply
to the external iliac artery. External iliac artery
occlusions usually extend to the junction with the
common femoral artery, where the true lumen
is reconstituted by the iliac circumex vessels.
edistal end of an external iliac artery occlusion
A B
Fig. 25.2 Approach to a common iliac artery
occlusion. (A) A common iliac artery occlusion
may be recanalized from a proximal approach,
through a transbrachial or a transradial access.
(B) The other option is an up-and-over approach
from the contralateral femoral artery.
Fig. 25.3 Passing a guidewire retrograde
through a common iliac artery occlusion. It is
usual for the guidewire to enter and progress
through the lesion from a retrograde approach.
However, after the wire enters the subintimal
plane, it may be challenging to re-enter the true
lumen proximally. This is a hit and miss process.
This is especially the case when there is a
substantialatherosclerotic disease burden of the
aortic bifurcation or severe calcification of the
infrarenal aorta. If you select this approach and
the wire stays in the subintimal plane, set a time
limit and move on to an alternative approach.
https://t.me/med1917
348 Complex lower extremity revascularization
is oen a ush occlusion. It is usually subopti-
mal to approach an external iliac artery from its
distal end because there is not enough working
room from the ipsilateral common femoral artery.
If a retrograde approach is absolutely necessary,
consider accessing the supercial femoral artery
(SFA) if it has an acceptable lumen. At the distal
end of an external iliac artery occlusion, a smooth
junction between the external iliac artery and the
common femoral artery must be created when
performing a reconstruction. is requires true
lumen re-entry precisely at the junction of the
external iliac and common femoral arteries. ere
is also a limitation to the use of stents at the re-
entry zone, because it is undesirable to place stents
that extend too far into the common femoral
artery. Re-entry into the common femoral artery
distal to an external iliac artery occlusion can be
facilitated by a re-entry catheter. is is discussed
in more detail below.
e aortoiliac segment should be assessed based
on preoperative imaging so that plans can be made
ahead of time. ese procedures may be time con-
suming and may involve dierent devices. If stent–
gra relining of the occlusion is anticipated, this
will aect the size of sheath selected. If there is the
possibility of a combined open and endovascular
approach (e.g., adding a femoral endarterectomy
or femoral–femoral bypass), it will inuence the
choice of anesthesia and the sterile eld prepara-
tion. Aortography or CTA may be used for pre-
procedure evaluation. Assess whether there is
any hidden aneurysmal disease, which may have
led to thrombosis of either a common or internal
iliac artery, any signicant tortuosity, or anything
challenging about the aortic bifurcation (e.g., high
placement, calcication). Usually, a preoperative
study can assess whether the common femoral
artery is going to be adequate. e length and cali-
ber of the occluded artery can also be estimated.
A B C
D
E
Fig. 25.4 Common iliac artery recanalization from the distal end. (A) A sheath is placed to provide a
platform. (B) A braided, angle tip catheter is placed and a Glidewire
®
advanced through it to probe
the lesion. (C) Using the catheter and the sheath for support, the guidewire is pushed into the most
promising location and the wire buckles. Once the wire is anchored, the catheter is advanced into the
lesion. (D) The guidewire loop progresses through the subintimal space and re-enters the true lumen.
(E) The catheter is advanced over the guidewire to gain access to the true lumen.
https://t.me/med1917
Aortoiliac occlusive disease 349
Technique of iliac artery recanalization
Needle access is usually obtained into the contra-
lateral groin, assuming a unilateral occlusion. If
there is bilateral occlusion, needle access is usu-
ally obtained at the brachial artery. If the com-
mon iliac artery is occluded but the external iliac
and common femoral arteries are patent, needle
access may be gained on either the contralateral
or the ipsilateral side. A guidewire is advanced
under uoroscopic guidance and a 6-Fr sheath
placed. Frequently, there is iliac artery occlusive
disease, either stenosis or occlusion, that is contra-
lateral to the iliac artery that requires treatment,
and frequently guidewire passage will require
some eort or extra steps. Once the guidewire is
in the infrarenal aorta, a ush catheter is placed
over the wire. e patient is given systemic antico-
agulation with heparin. In the setting of extensive
occlusive disease, ow in the aortoiliac segment
may be slow and this observation should prompt
more aggressive systemic anticoagulation during
the procedure.
An aortoiliac arteriogram is obtained with
delayed lming so that reconstitution on the side
of the occlusion can be imaged. Recanalizing an
occlusion requires setting up an adequate treat-
ment platform, which includes placement of a
sheath. If the lesion is an external iliac artery
occlusion or a common iliac artery occlusion that
has a decent beak of artery at its origin, place a
longer sheath (30–45 cm, 6-Fr) into the iliac artery.
Besure the sheath tip has a radiopaque marker. e
sheath tip is advanced to the proximal common
iliac artery. In the case of a common iliac artery
occlusion, a hook-shaped or U-shaped catheter is
placed through the sheath over the aortic bifurca-
tion in the same way as you would to go over the
aortic bifurcation for routine contralateral cath-
eterization (Figure 25.5). e closer the occlusion
initiates to the bifurcation, the more a sti, hook-
shaped catheter is needed. Catheters to consider
for this include a RIM catheter, a Sos Omni
®
cath-
eter, an Amir Motarjeme
®
catheter, or any variety
of hook-shaped visceral catheter. Once the cath-
eter tip is engaged in the beak of a patent artery,
a Glidewire
®
is advanced into the occluded artery.
Sometimes, this is a relatively short distance and
the guidewire tip will remain straight and resist
going into the occlusion and will attempt to push
the catheter out of the bifurcation every time for-
ward pressure is placed on the wire. Sometimes, it
forms a loop as it goes into the subintimal space. If
the loop will not form in the subintimal space or
it tries to push the catheter out with each applica-
tion of forward pressure, there are other options.
One is to use a catheter with a stier tip to sup-
port the wire better. Another option is to approach
the occlusion from the brachial artery and push
straight into the occlusion. Yet another option is to
puncture the common femoral artery ipsilateral to
the occlusion and pass the guidewire and catheter
retrograde. Once the guidewire digs into the lesion,
the catheter is advanced to anchor it into the lesion.
Sometimes, it also helps to advance the sheath a
little bit for maximum support (Figure 25.5).
A B C
Fig. 25.5 Common iliac artery recanalization from the proximal end. (A) A sheath is placed so that its
tip is in the proximal common iliac artery. (B) A hook-shaped catheter is placed so that the tip of the
catheter is pointing inferiorly and directly into the occlusion. (C) A wire is gently advanced, so that it
does not kick the catheter out of position. The wire forms a loop and is advanced.
https://t.me/med1917
350 Complex lower extremity revascularization
Aer the loop forms and there are several to
many centimeters of guidewire and catheter on
the contralateral side, a 6-Fr sheath can frequently
be advanced over the aortic bifurcation directly
over the guidewire and catheter combination. is
step helps to provide additional support for push-
ability in the direction of the occlusion. e loop
of Glidewire
®
is advanced and oen it will pop
back into the true lumen distal to the occlusion.
Another option, other than a looped subintimal
hydrophilic guidewire, is to use a low-prole 0.018-
inch or 0.014-inch compatible, sti tip exchange
catheter (Quick-Cross
™
Support catheter). is is
a microcatheter with a sti tip that can be passed
directly through a 5-Fr angiographic catheter and,
combined with a sti, low-prole guidewire, fre-
quently is enough to push across an occlusion.
When treating a common iliac artery occlusion,
it may be of value to perform an ipsilateral retro-
grade approach, especially if there is no success
coming from the proximal end or some reason why
this approach should be avoided. Just remember
that when an artery access site is created distal to
an occlusion, if the reconstruction is not success-
ful and pressure at the access site remains low, the
opportunity for puncture site thrombosis to occur
is increased. Ipsilateral retrograde access can be
performed using a micropuncture needle under
uoroscopic guidance. e micropuncture needle
can be entered into the artery in several ways.
Sometimes with a common iliac artery occlusion,
there is still a palpable pulse as pulsatile blood
ows through internal iliac artery collaterals. Also,
injecting contrast into the aorta from some other
route will reconstitute femoral artery and this can
be road mapped. e road mapped image can be
used to puncture with the micropuncture needle.
Ultrasound-guided puncture is helpful and is the
preferred method. e artery may be quite small in
diameter due to hypoperfusion.
In the case of a common iliac artery occlusion
with a patent external iliac artery, there is enough
artery for an acceptable length of guidewire to be
passed retrograde so that a sheath can be placed
from the groin area. is will allow placement of a
short 6-Fr sheath. A 6-Fr sheath with a radiopaque
tip should be used so that the tip of the sheath can
be advanced directly up to just below the occlu-
sion. Most reconstructive options are available
through a 6-Fr sheath. From this position, a couple
of dierent angles are obtained to help see where
the best place is to approach the lesion. ere are
various options for approaching the lesion and
these include passage of a Glidewire
®
and possibly
forming a loop and a subintimal angioplasty, as
described earlier. Another option is to use a Quick-
Cross
™
Support catheter directly from below. is
type of catheter is used with a sti guidewire. e
catheter and guidewire are advanced in a step-
by-step manner, one and then the other, until the
occlusion is crossed. If this is not successful, a re-
entry catheter may be advanced over the guide-
wire through the 6-Fr sheath and a re-entry needle
can be placed just proximal to the origin of the
occlusion.
If the occlusion is near the origin of the com-
mon iliac artery or ush at the origin, with the
bifurcation of the aorta being partly obscured, a
kissing stent should be placed on the contralat-
eral side so that any debris or compacted throm-
bus located at the bifurcation may be caged at this
point and not forced into the patent contralateral
side (Figure 25.6). A common iliac artery occlu-
sion that originates within a few millimeters of the
bifurcation requires bilateral access and will prob-
ably also require kissing stents to reconstruct. If
the occlusion involves the infrarenal aorta to some
degree and the iliac arteries, then an aortic stent
can be placed rst followed by kissing bilateral iliac
stents.
External iliac artery occlusions have some
nuances that make them dierent from common
iliac artery occlusions. ey are almost always
approached in an up-and-over manner because of
the challenge of getting working room when the
ipsilateral side is punctured, as mentioned earlier.
e challenge with an external iliac artery occlu-
sion is getting back in at the appointed location at
the junction between the external iliac and com-
mon femoral arteries. e patient is fully antico-
agulated. e guidewire and catheter system is
advanced into the internal iliac artery. In order to
get enough of an anchor to pass the sheath over the
aortic bifurcation, the sti exchange wire is passed
as far as possible into the internal iliac artery.
A 6-Fr or 7-Fr sheath is passed over the aortic
bifurcation on a sti guidewire, and the sheath tip
can even be advanced all the way into the internal
iliac artery to get as close to the origin of the occlu-
sion as possible. e sti guidewire is removed and
an angle tip catheter is placed into the 6-Fr or 7-Fr
sheath. e sheath is then withdrawn just a little
https://t.me/med1917
Aortoiliac occlusive disease 351
bit and readjusted until a slight movement can be
seen at the tip of the sheath, which indicates that it
has popped from the internal iliac artery and back
into the distal common iliac artery. A couple of dif-
ferent angiographic angles are obtained by inject-
ing contrast through either the catheter or the
sheath, with the catheter pointing directly down
the barrel of the external iliac artery. A contralat-
eral anterior oblique view is usually best for visu-
alizing the common iliac artery bifurcation and
understanding where the proximal external iliac
artery is located. At this point, one has a choice
of either using a Glidewire
®
and forming a loop
and going subintimal through the external iliac
artery, or using a combination of a microcatheter
and a 0.014-inch or 0.018-inch diameter guidewire.
Whichever method is chosen to cross the occlu-
sion, the goal is to have the wire break back into
the true lumen on its own. If there is challenge in
re-entering, this is a good position for placement
of a re-entry catheter and using the needle on the
catheter to enter the true lumen. e location of
thesheath is also perfect because injecting through
the side arm of the sheath will allow reconstitu-
tion of contrast into the location where re-entry is
desired.
Re-entry can also be performed with a re-entry
catheter, most commonly an Outback
®
catheter
or a Pioneer Plus catheter. Both catheters are rela-
tively sti. erefore, if being considered for use
inan up-and-over approach, a 7-Fr sheath is desir-
able. A re-entry catheter can also be used when
passed retrograde from the ipsilateral common
femoral artery and into a common iliac artery
occlusion. is will aid in re-entry into the true
lumen in the distal aorta. In this setting, consider
using an intravenous ultrasound (IVUS)-guided
catheter (Pioneer Plus) to be certain that the wire
is directed in the appropriate direction. ere are
no signicant turns to be made and the puncturing
needle is directed into the location closest to where
the common iliac artery origin is located. Using
IVUS to re-enter proximal to the common iliac
artery occlusion is also helpful to re-enter away
from the patent contralateral iliac artery.
Aer the occlusion has been traversed, whether
it is in the common iliac artery or the external iliac
artery, or both, the operator has a choice of how
to reconstruct the lesion. In general, aer recana-
lizing iliac artery occlusions, most experts advise
stenting the lesion or placing stent–gras. In the
external iliac artery, the entire occluded segment
should be stented using self-expanding stents.
Accurate stent placement is required on the dis-
tal end of the occlusion because stent placement
too far into the common femoral artery should be
avoided. is is facilitated by an over-the-bifurca-
tion approach, because the self-expanding stents
are deployed from the tip end to the hub end. In the
common iliac artery, there is a broader choice of
self-expanding or balloon-expandable stents. If the
aortic bifurcation is heavily calcied and/or there
is a lot of distal aortic disease, balloon-expandable
A
C
B
D
Fig. 25.6 Kissing stents of the aortic bifurcation.
(A) Bilateral guidewires and balloon catheters are
placed. Because the right side has a significant
lesion and because it is also very near the bifur-
cation, both arteries are accessed. (B) Kissing
balloon angioplasty is performed. The balloon
in the left iliac artery is used to “protect” the
ar ter y. (C) There is a substantial residual stenosis
on the right side and the intended stent will
be required to raise the bifurcation to treat the
lesion. (D) Kissing stents are placed to raise the
aortic bifurcation.
https://t.me/med1917
352 Complex lower extremity revascularization
stents are used. Self-expanding stents are a reason-
able choice for longer occlusions or in arteries that
are somewhat tortuous, especially if there is less
aortic disease. If the stents extend intothe aorta,
they must be placed carefully so that they are equal
on the bilateral sides. If there is a fair degree of
disease in the distal aorta and/or the aortic bifur-
cation must be raised a bit, self-expanding stents
do not work as well. It is not uncommon to stent
across the origin of the internal iliac artery with
bare metal stents. is usually does not negatively
aect the patency of the internal iliac artery. Acov-
ered stent across the internal iliac artery would
necessarily exclude it from the circulation and is
generally avoided.
e biggest challenges with iliac artery recana-
lization are:
●
Where you have got through an external iliac
artery occlusion but are unable to enter at the
appropriate location at the external iliac com-
mon femoral artery junction.
●
When disease extends from an occluded exter-
nal iliac artery directly into a heavily calcied
and possibly even occluded common femoral
artery. ese are dicult to treat from an
endovascular standpoint, if not impossible.
●
When there is a combined occlusion of both
the common iliac artery and the external iliac
artery. ese are challenging to cross and oen
require some innovative steps to do so.
●
Recanalizing a common iliac artery but then
nding the distal aorta is so calcied that it is
impossible to break through to get back into
the true lumen. When performing iliac artery
recanalization, the worst scenario other than
rupture (which is rare) is distal embolization.
is is one reason why it is appropriate to cover
the whole occlusion, if possible.
Some operators like to use covered stents or
stent–gras to cover the occlusion. ere is some
evidence to suggest that the long-term patency is
improved by using covered stents for iliac artery
reconstruction. If a stent–gra is selected, some of
the features that must be considered include:
●
A larger sheath may be required depending on
the nished desired diameter of the stent–gra.
●
It is likely that there will be some predilation
required because the stent–gra, no matter
how tightly it is packed on its delivery cath-
eter, is high prole and has some rough edges,
which may catch on the lesion and may not
want to pass.
●
Perfect placement is usually required because
one would not want to cover the collaterals at
the medial and lateral iliac circumex, cover
the internal iliac artery, or extend one end
ofthe stent–gra up into the aortic bifurcation
unless it was met on the contralateral side with
an opposing structure, such as a contralateral
kissing stent–gra.
Managing aortic occlusion
As mentioned earlier, if an infrarenal aortic occlu-
sion extends to the renal arteries, the risks of revas-
cularization are increased due to the potential that
debris from the disrupted occlusion can embolize
into the visceral or renal arteries. In this setting,
some other type of revascularization should be
considered. If it is clear that endovascular recana-
lization and reconstruction is best, consider the
following approach. Use extra anticoagulation so
that thrombus will not propagate in areas of no
ow or slow ow. If wire passage can be achieved
across the aortic occlusion, consider using IVUS
to ensure that the wire is in the true lumen at the
location where the reconstitution is at the level
of the renal arteries. With either no predilation
or minimal predilation, just enough to pass the
stent–gra, consider relining the entire occluded
segment using a self-expanding endovascular gra
similar to what would be used for aortic aneurysm
treatment. is can be done using either a stack of
cus or a series of large diameter extension limbs.
In this manner, the accumulated thrombus should
be excluded. When the reconstruction is nished,
be sure that there is no evidence of thrombus for-
mation in the visceral and renal arteries.
If the aortic occlusion initiates in the middle or
distal infrarenal aorta and there is runo into some
of the lumbar arteries, the risks are much less. In
this setting, a large diameter self-expanding bare
metal stent or covered stent could be used. Note
that in this situation, the inferior mesenteric artery
is frequently patent and it may be desirable to avoid
a covered stent over this area. If the iliac arteries
are also involved, the infrarenal stent is placed rst
and then bilateral wires, and bilateral iliac stents
are placed to complete the reconstruction.
https://t.me/med1917
Femoral–popliteal occlusive disease 353
When the iliac arteries are also diseased and are
included in the planned reconstruction, the wire
must be placed across each one before deciding on
the reconstruction. If one of the iliac arteries cannot
be crossed, the reconstruction will be performed dif-
ferently. For example, a stent may be placed to extend
from the aortic bifurcation into one iliac artery and
then a femoral–femoral bypass performed.
MANAGING HIGHLY CALCIFIED LESIONS
ere are several issues with highly calcied lesions
that should be considered and some maneuvers
that can help work one’s way around them. Highly
calcied lesions pose the risk that the calcium will
not give way and the lesion can be pushed through
the arterial wall if dilated too aggressively and
all at once, causing potentially a localized or free
rupture. e other risk is that the lesion may be
recalcitrant to dilation and it may not be possible
to gain an adequate lumen. In order to avoid this
scenario, the lesion could be gradually dilated to
ensure that a lumen is created. Cutting or scor-
ing balloons can also be used in this situation. If
a patient is experiencing severe pain with dilation,
it usually makes sense to permit some degree of
residual stenosis rather than attempting to achieve
a perfect cosmetic result. When it is likely that a
residual stenosis will be present, it is oen not pos-
sible for a balloon-expandable stent to oppose the
wall both proximal and distal to the location of the
lesion. In this setting, a self-expanding stent with
continued gradual and stepwise poststent dilation
at the location of residual stenosis could be used.
ACCESS SITE MANAGEMENT WHEN
TREATING AORTOILIAC OCCLUSION
Frequently, when dealing with aortoiliac occlu-
sion, there is an access site ipsilateral to and distal
to the reconstruction. In this case, closure devices
have the advantage of continued ow beyond
the access site immediately aer performing clo-
sure. is helps to prevent access site thrombosis.
However, if the artery is quite small (<5 or 6 mm),
closure devices may be a set up for a complication
such as thrombosis. In addition, if there is a stent
that ends near the access site, it may inuence the
choice of closure device. Suture-mediated closure
devices must be passed a signicant distance into
the artery, and this must be done blindly and not
over a wire, and this is not optimal in the set-
ting of a recently placed stent. e local collagen
plug approach is probably best in this setting.
e Mynx
®
Vascular Closure Device permits
closure with the plug material deposited external
to the artery. If the access is simply for passage of
the catheter and guidewire, and the access site is
limited in size, such as a 4-Fr sheath, manual com-
pression should be considered.
HOW TO MANAGE ILIAC DISEASE THAT
EXTENDS DOWN TO THE FEMORAL
ARTERIES
is is covered in more detail in Chapter 27
(Hybrid procedures). If an external iliac artery
lesion extends to the common femoral artery but
ends in the proximal common femoral artery, this
can be stented with an up-and-over approach. If
the entire common femoral artery is included, it
could be used as the recipient for a femoral– femoral
bypass. e challenge in dealing with external iliac
artery occlusion that extends into the common
femoral artery is the lack of working room between
the le common femoral artery and the site of the
stent in the external iliac artery. One other issue
for consideration: if endovascular recanalization
of the common femoral artery is undertaken, every
eort must be made to ensure that both the SFA
and the profunda femoris artery are revascularized.
Whereas the external iliac artery is usually read-
ily treatable with stenting and there is no role for
atherectomy, the common femoral artery is just the
opposite. Some form of plaque debulking is usually
required in the common femoral artery and there is
less of a role for stent placement. If common femo-
ral artery repair is not going to be performed with
endarterectomy, atherectomy should be considered.
FEMORAL–POPLITEAL OCCLUSIVE
DISEASE
When to use each method of
revascularization
ere are multiple competing options for recon-
struction of femoral–popliteal occlusive disease.
ere is a signicant overlap in 6-, 12-, and 24-month
patencies between many of the dierent methods
of revascularization. One of the notable features of
endovascular approaches to the lower extremity
is that we have generally become better at getting
across challenging lesions, but not necessarily better
at keeping these open over the long term.
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана