Endovascular Interventions A Step-by-Step Approach

A practical and systematic approach to current endovascular surgical techniques

An increasingly popular alternative to open vascular surgery, endovascular intervention offers many advantages, including reduced patient discomfort, smaller incisions, shorter recovery time, and decreased risk of adverse complications. Practitioners and trainees alike require expert guidance on current technologies and up-to-date techniques. Endovascular Interventions provides clinicians with an easy-to-follow guide for minimally invasive treatment of vascular disease. This invaluable resource delivers concise and accurate instructions on a wide range of endovascular interventions, including aorta, renal and mesenteric interventions, lower extremity interventions, venous interventions, and supra-aortic interventions in high-risk patients.

Sequential phases of skill development broaden the reader’s abilities as they progress through each chapter, supplying step-by-step instructions on when each procedure should be used and how it can be safely and effectively performed. This book offers a complete reference to essential techniques and procedures, suitable for both novice and experienced vascular surgeons, cardiologists, and radiologists. Endovascular Interventions also:

• Reinforces comprehension of each procedure with templated chapters, equipment lists and boxed key learning points
• Provides full-color clinical images and detailed illustrations to demonstrate surgical procedures
• Presents authoritative coverage of modern endovascular technologies and techniques
• Written by a team of respected experts and practicing surgeons from internationally recognized hospitals and universities

Suitable for varying skill levels, Endovascular Interventions is a precise, accessible instruction manual for safe and effective endovascular intervention, helping practicing clinicians sharpen their existing abilities and keep pace with the latest surgical technologies while instructing trainees on this innovative approach to vascular surgery.

Jose Wiley MD, MPH, Assistant Professor of Medicine, Cardiology and Radiology, Associate Director of Endovascular Interventions, The Zena and Michael A. Weiner Cardiovascular Institute, The Mount Sinai School of Medicine, New York, NY, USA

Cristina Sanina, MD, Postdoctoral Fellow, Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, USA

George D. Dangas, MD, PhD, Professor of Cardiology and Vascular Surgery, Director of Cardiovascular Innovation, Mount Sinai Medical Center, New York, NY, USA

Prakash Krishnan, MD, Associate Professor of Cardiology, Instructor, Radiology, The Mount Sinai School of Medicine, New York, NY, USA

List of Contributors: Endovascular Interventions “A Step-by-Step

Approach” xiv

1 Innominate & Carotid Artery Intervention in High-Risk Patients 1

Tyrone J. Collins

Introduction  1

Innominate Interventions in High-Risk Patients 2

     Catheter-based Therapy for An Innominate (Brachiocephalic) Stenosis 2

Carotid Artery Intervention in High-Risk Patients 5

     Endovascular Treatment of A Carotid Stenosis 5

     Catheter-based Therapy for Carotid Stenosis 6

Conclusions 10

References 13

2 Subclavian Artery Intervention: Catheter-Based Therapy 15

Saadat Shariff, Isabella Alviz, Cornelia Rivera, Michelle Cortorreal,

and Tyrone J. Collins

Introduction 15

Endovascular Versus Open Surgical Revascularization 16

Endovascular Revascularization Techniques 16

Conclusion 18

References 19

3 Vertebral Artery Intervention: Catheter-Based Therapy 20

Tamunoinemi Bob-Manuel and James S. Jenkins

Introduction 20

Preprocedural Considerations 21

Step 1. Procedural Planning with Diagnostic Angiography 21

Step 2. Vertebral Artery Intervention (Percutaneous Transluminal Angioplasty) 24

Step 3. Vertebral Artery Intervention (Stenting) 25

Management of Potential Complications 27

Postprocedural Care 28

References 29

4 Endovascular Repair of Thoracic Aortic Aneurysms: Catheter-Based

Therapy 30

John Denesopolis, Patricia Yau, and Aksim G. Rivera

Introduction 30

Relevant Anatomy 31

Aortic Anatomy 31

Crawford Classification for TAA/TAAA 31

Landing Zones 31

Implication of Aortic Anatomy on Spinal Perfusion 32

Indications/Contraindications to Procedure 33

Indications 33

Asymptomatic TAA/TAAA 33

Blunt Aortic Injury (BAI) 33

Acute Aortic Syndromes 33

Contraindications/Caveats 34

Available Endografts 34

Preoperative Evaluation 40

Positioning and Intraoperative Monitoring Needs 41

Procedural Steps 42

Postoperative Course/Surveillance 46

Monitored Setting 46

Spinal Drain 46

Blood Pressure Control 47

Arm Ischemia Symptoms 47

CTA Surveillance/Endoleak Types 48

References 49

5 Endovascular Abdominal Aortic Aneurysm Repair (EVAR) 50

John Futchko, Katie MacCallum, and Aksim G. Rivera

Introduction  50

Patient Selection 50

Preoperative Imaging and Measurements 51

Graft Selection 51

Graft Sizing 52

Neck Length 52

Neck Diameter 53

Branch Vessels 53

Aortic Length Measurements 54

Step 1. Vascular Access 54

Percutaneous 54

Open 55

Iliac Disease and Conduits 55

Step 2. Imaging 56

Equipment 56

Neck Angulation 57

Renal Arteries 57

Step 3. Wires 57

Step 4. Delivery and Deployment 57

Main Body 57

Graft Orientation 57

Proximal Landing Zone 58

Contralateral Gate Cannulation 59

Limb Deployment 59

Step 9. Completion Angiogram 60

Step 5. Troubleshooting 60

Endoleaks 60

Inadvertent Coverage of Renal Arteries 61

Iliac Artery Considerations 61

Conclusion 62

References 62

6 Severe Renal Artery Stenosis: How to Intervene 64

Mohammad Hashim Mustehsan, Cristina Sanina, and Jose D. Tafur

Introduction 64

Background and Clinical Significance 65

Epidemiology 65

Clinical Manifestations 65

Patient Selection: Who to Screen for RAS 66

RAS Assessment 66

Noninvasive RAS Assessment 66

Invasive RAS Assessment 68

Indications for Revascularization 68

Intervention 70

References 72

7 Mesenteric Ischemia: Chronic and Acute Management 74

David A. Hirschl

Introduction 74

Chronic Mesenteric Ischemia 74

Step 1. Vascular Access and Sheath Selection 75

Step 2. Diagnostic Angiography 76

Step 3. Vessel Selection 77

Step 4. Selective Angiography 77

Step 5. Placement of a Working Wire 78

Step 6. Stent Placement 78

Step 7. Posttreatment Angiography 79

Step 8. Revision 79

Complications 80

Follow-Up and Outcomes 81

Acute Mesenteric Ischemia 81

Step 1. Arterial Vascular Access and Sheath Selection 83

Step 2. Selection of the SMA 83

Step 3. Aspiration Embolectomy 84

Step 4. Angiogram 85

Step 5. Thrombolysis 85

Step 6. Infusion and Follow-Up 87

Mesenteric Venous Thrombosis 87

Follow-Up and Outcomes 87

References 88

8 Aorto-Iliac Interventions 91

Michael S. Segal, Sameh Elrabie, and Rajesh K. Malik

Introduction 91

Preoperative Workup 91

Noninvasive Studies 92

Computed Tomographic Angiography 92

Ultrasound Duplex 92

Magnetic Resonance Angiography 93

Invasive Imaging 93

Angiography 93

Classification of Lesion and Planning of Intervention 93

TransAtlantic InterSociety Consensus II Classification (TASC II) 93

Planning for the Intervention 93

Step 1. Patient Factors 93

Step 2. Vascular Access 94

Step 3. Crossing the Lesion 95

Step 4. Intervention 96

Step 5. Closure 98

Step 6. Complications 99

Rupture 99

Embolization 99

Access Complications 99

Cases 100

Case 1 100

Case 2 100

References 103

9 Femoropopliteal Arterial Interventions in the Claudicant 104

Sahil A. Parikh, Joseph J. Ingrassia, and Matthew T. Finn

Introduction 104

Patient Evaluation and Indications for Treatment of Femoropopliteal Arterial Pathology 104

Indications for Revascularization Femoropopliteal Claudication 105

Vascular Imaging in Endovascular Treatment 105

Contrast Angiography 105

CO2 Angiography 106

Steps to CO2 Angiography 106

Extravascular and Intravascular Ultrasound 106

Steps to IVUS Use 107

Vascular Access and Lesion Crossing Techniques 109

Steps for Crossover “Up and Over” technique 109

Radial 110

Tibio-Pedal Approach 111

Antegrade Femoral Access 111

Working Wire Size and Changing Between Systems 112

Lesion Preparation 113

Plain Old Balloon Angioplasty 113

Focal Force Balloons for Optimal Lumen Gain 116

Drug-Coated

Balloons 116

Atherectomy 117

Laser 117

Excimer Laser Use Steps 118

Rotational Atherectomy 119

Rotational Atherectomy Steps 120

Directional Atherectomy 120

Orbital Atherectomy 122

Embolic Protection 123

Troubleshooting Embolic Protection Devices 126

Troubleshooting a “Full” Filter 126

Distal Embolization or “No Reflow” 126

Stenting for Femoropopliteal Disease 127

Bare-Metal Stents 127

Drug-Eluting Stents (DES) 127

Alternative Stent Technologies 128

Covered Stents 128

Tacks 128

Final Efficacy Assessment 128

Conclusions 128

Acknowledgments 129

References 129

10 Tibial Interventions in Patients with Critical Limb-Threatening Ischemia 134

Raman Sharma, Roberto Cerrud-Rodriguez, and Prakash Krishnan

Introduction 134

Indications and Goals of Endovascular Revascularization 134

Considerations for Access Site 135

Single Versus Multitibial Artery Revascularization 136

Antegrade Tibial Artery Intervention 137

Retrograde Access for Retrograde Lesion Crossing and Wire Externalization with Antegrade Revascularization 139

TAMI Retrograde Revascularization 140

Reentry and Externalization Devices 142

Deep Venous Arterialization (DVA) 142

References 143

11 Acute Limb Ischemia: Endovascular Approach 147

Shunsuke Aoi and Amit M. Kakkar

Introduction 147

Procedure Planning, Equipment, and Considerations 147

References 157

12 Pedal Reconstruction 158

Ehrin Armstrong and Rory Brinker

Introduction 158

Pedal Arch Reconstruction 158

Indications for Pedal Revascularization 162

Technical Considerations 162

Access 163

Lesion Crossing 163

CTO Lesion Subtype 163

Special Considerations of the Pedal Intervention 164

Troubleshooting 165

Summary 165

References 169

13 Endovascular Management of Access Site Complications 171

Manaf Assafin, Robert Pyo, Pedro Cox-Alomar, and Miguel Alvarez-Villela

Introduction 171

Complications Related to Common Femoral Artery Access 172

Access Site Bleeding 172

Crossover Technique 175

BalloonTamponade, Endovascular Coiling, and Covered Stent Placement 175

Femoral Pseudoaneurysms 176

Ultrasound-Guided Compression Repair 178

Ultrasound-Guided Thrombin Injection 179

Covered Stent Placement 180

Other Techniques 180

Arteriovenous Fistulas 181

Vascular Closure Device Related Complications 182

Radial Artery Related Complications 183

Radial Artery Spasm 184

Radial Artery Occlusion 185

Bleeding Complications 186

References 187

14 Acute Deep Vein Thrombosis 192

Vishal Kapur and Sagar Goyal

Introduction 192

Treatment Strategy 193

Initial and Long-Term Treatment of VTE 196

Oral Anticoagulants 196

Thrombolysis 196

Vena Cava Filters 197

Compression Stockings 198

Cancer-Associated VTE 198

Isolated Distal DVT 198

Extended Treatment 198

Unprovoked VTE 198

Oral Anticoagulants 199

Conclusion 199

References 200

15 Lower-Extremity Venous Stenting 203

Asma Khaliq, Sandrine Labrune, and Cristina Sanina

Introduction 203

Follow-Up 209

References 210

16 Intervention for Pulmonary Embolism 211

Seth I. Sokol, Wissam A. Jaber, and Yosef Golowa

Introduction 211

Pulmonary Angiography 211

Vascular Access 211

Injection and X-Ray Detector Positioning 212

Catheter-Directed Thrombolysis 212

EKOS™ Catheter-Directed Thrombolysis 212

Preparation of System 213

Access 214

Mechanical Disruption 216

Catheter Fragmentation of Clot 216

Large Catheter Aspiration 216

FlowTriever™ 216

Access 217

Penumbra 221

AngioVac 223

Patient Selection and Central Venous Access 223

AngioVac Circuit Setup and Thrombus Aspiration 225

AngioVac for Pulmonary Embolus 227

AngioVac for Clot-in-Transit 228

AngioVac for Right Heart Vegetation 228

Patient Selection and Approach 228

Technique 229

References 230

17 Catheter-Based Therapy for Varicose Veins 232

Juan Terre and Nelson Chavarria

Introduction 232

Thermal Techniques 232

Radiofrequency (RF) Ablation 233

Follow-Up 235

Endovenous Laser Ablation (EVLA) 235

Nonthermal Techniques 236

Mechanico-Chemical Ablation (MOCA) 237

Limitations 238

Summary 239

References 239

Index 000

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