1. Dr Imran Javed MBBS, FCPS Surgery.
Ex-International Fellow
Arizona Heart Institute / Hospital, Phoenix, AZ, USA.
Ex-Senior Registrar Cardiovascular Surgery
Allama Iqbal Medical College/ Jinnah Hospital
Lahore, Pakistan.
Basic Endovascular Surgery

2. Basic Endovascular Surgery
Basics Instruments
•Needles
•Wires
•Catheters
•Sheaths

3. Basic Endovascular Surgery
• Balloons
• Stents
• Stent Grafts
• Filters
• Thrombolytics
• Closure Devices
• IVUS
Common Interventions

4. Endoluminal Therapy Offers Less Invasive
Approaches, Thereby Justifying Intervention at
Earlier Stages in the Symptom/Disease Complex

5. Classical Surgical Indications to
Treat Intermittent Claudication Are
Obsolete in Many Cases
Endoluminal Treatment
Has Liberalized
Indications For
Intervention

6. Origin of
Endovascular Therapies
Crude…
with only
large shafted
balloons,
inflexible
wires, etc.

7. Indications for Interventional Therapy
Have Forever Changed

8. This is the 21st Century!!!

9. We Are A People On The Move...
Modern Treatment Methods Must
Accommodate Our Life Style

10. Intermittent Claudication
• Absence of pain at rest
• Commencement of pain, tension
weakness after walking has begun;
intensification of condition until
walking becomes impossible
• Disappearance of symptoms after
a period of rest

11. Post-OpPre-Op
ABI 0.56
“Cool”
Laser

12. Interventional
Treatment Should Be
Reserved For The Most
Symptomatic Patients”
William R. Hiatt, M.D.
from Perler & Becker 1998

13. Laser Therapy
Created Excitement

14. Hot Tip Created
Excitement
but
failed.

15. The Atherocath Turned out to
be a Good Biopsy Instrument
But…
Believe it or
not, a new
generation is
forthcoming

16. Single Most
Important Breakthrough!
The Palmaz
Stent for Iliacs

17. The Palmaz
Shatz Stent for
Coronaries
A Second Most
Important Breakthrough!

18. Overnight,
Endoluminal
Approaches
Became the
Standard of
Practice in
Many Arterial
Distributions

19. Subclavian

20. Renal

21. Iliac

22. Aorta

23. and…
SFA

24. Below

25. The Achilles heel
of angioplasty,
including stenting:
Restenosis and
In-stent
Restenosis

26. New stent designs have
decreased profile for
delivery, increased
flexibility, and
provided numerous
alternatives in sizing
-- but all of these
failed to solve the
restenosis problem

27. Researchers are
Seeking Solutions
Cutting Balloon

28. Heparin Coated
Stents
Conclusion:
No angiographic or
clinically related benefit

29. Antibiotic Coated Stents
(Actinomycin-D)
Conclusion:
Trial Halted

30. Naturally
occurring
antibiotic
coated stent.
Sirolimus
Conclusion:
210 day trial, 120 pts,
Coronary
0 InStent Restenosis
24 month trail, 45 pts,
Coronary
0 InStent Restenosis
Cordis Velocity Stent

31. Balanced Effect -
Healing of
Stented Vessel
Inhibition of
Restenosis
The ideal drug has higher potency for smooth muscle cells
(SMCs) and lower potency for endothelial cells (ECs).
Benefit/Risk Relation

32. Investigations
are extending
into the
peripheral
circulation
Mobile Peripheral
Radiation Trial
Sponsored by:
Novoste
Radiation to
Treat Instent
Restenosis

33. 9 Years post-percutaneous deployment
of endoluminal graft

34. THE SILVER HAWK SYSTEM

35. SilverHawk Atherectomy
Remote Endarterectomy

36. Cryoplasty

37. And Cool Laser (Spectranetics)
has Returned
Laser Therapy Only

38. Beyond Occlusive Disease
Endovascular Attack on Aneurysms

39. • The current standard procedure,
endoaneurysmorraphy with intraluminal graft
placement was popularized by Creech,
DeBakey and associates
Abdominal Aortic Aneurysms

41. • Parodi JC, Palmaz JC, Barone, MD
– Transfemoral intraluminal graft implantation for
abdominal aortic aneurysms
Ann. Vasc. Surgery, 1991, Nov.
Endovascular Stent Grafting of
Abdominal Aortic Aneurysms

42. Commercially Available AAA Endografts
2002
Excluder
Gore
2005
PowerLink
Endologix
2003
Zenith
Cook
1999
AneuRx
Medtronic
April 15,
2008

43. If you had this 6cm infrarenal AAA,
would you prefer a 30cm xyphoid to pubis slice,
accompanied by perforations into veins, arteries and
other vital structures with needles, tubes, sheaths,
conduits, urinary catheter, etc?

44. • Completion angiogram shows aneurysm exclusion
• Groins repaired
• Follow-up CTA reveals thrombosis of AAA sac

45. Endoluminal Grafts (ELG’s)
to Correct Aneurysmal Disease

46. Abdominal Aortic
Aneurysm Rupture

47. Current Conclusions:
Excellent results when indications are appropriate

48. Deviations
Yield Failures
Current Conclusions:

49. Aorfix: Angulated Neck

50. The Aptus System
• Venture backed start-up
• Graft with fixation applied via
staples
• Smaller delivery system
• Locking modular limbs
• Unsupported body

51. ELGs have multiple advantages and when
applied properly, results are equal or superior
to classical procedure
Current Conclusions:

52. 8mm Graft
Splenic
Anastomosis

53. Fenestrated and
Branched Endografts:
Courtesy David Hartley
The Next Frontier

55. Thoracic
Endoluminal
Grafts
Another
Important
Application

56. Great Vessel Transposition for Antegrade Delivery of
the TAG Endoprosthesis in the Proximal Aortic Arch
Edward B. Diethrich, MD; Marwan Ghazoul, MD;
Grayson H. Wheatley III, MD; Jeffrey B. Alpern, DO;
Julio A. Rodriguez-Lopez, MD; and Venkatesh Ramaiah, MD
Department of Cardiovascular and Endovascular Surgery
Arizona Heart Institute and Hospital, Phoenix, Arizona, USA
J. Endovas Therapy 2005
Surgical graft for
debranching
Endoluminal
graft
exclusion

58. The Future Is Now!

59. Another Area
of Major
Investigation
Cervical
Carotid Artery

60. Cervical
Carotid
Artery

61. Do or Will Cerebral Protection
Devices Make a Difference in CAS?

62. Refocusing Attention
on Congestive Heart Failure
Major cause for hospital
admission
Multiple Approaches

63. -Medical
-Surgical “patch”, cup, etc
Multiple Approaches
Refocusing Attention
on Congestive Heart Failure

64. But where is
all of this
leading us?

65. Shortly the Entire Human
Genome Will be Available for
Treatment Selection
Risk Assessment
Prognosis

66. Can you imagine the
power of gene
identification for the care
of patients in the future?

67. VEGEF for Peripheral
Vascular Disease

68. Basic Endovascular Surgery
ANATOMY
1. Femoral
2. Brachial
3. Radial
4. Axillary
5. Popliteal

69. Imaging System

70. ACIST
Pressure Injector

71. Basic Endovascular Techniques
CONTRAST MEDIA
1. Ionic
2. Nonionic

72. Basic Endovascular Surgery
CONTRAST MEDIA
Contrast Agents Anion Cation
Ionic Agents
Renografin Diatrizoate Sodium, meglumine, or
Angiovist mixture of both salts
Hypaque
Conray Iothalamate Meglumine, sodium, or both
Low Osmolar Agents
Iohexol (Omnipaque) Nonionic dimer
Iopamidol (Isovue) Nonionic dimer
Ioxaglate (Hexabrix) Ioxaglate Meglumine and sodium

73. Access Related Accessories
• Steering/Torque
devices
• Needles 18/21 GA
• Stopcocks

74. Basic Endovascular Surgery
Diameter Maximum Guidewire Common
Needles (gauge) Diameter (in.) Length
Seldinger 18 0.038 2 ¾ inch
19 0.025
20 0.021
21 0.018
Potts 18 0.038 2 ¾ inch
20 0.021
Amplatz (with 5 Fr Teflon 18 18-gauge 2 ½ inch
sheath over cannula) 20 sheath accepts
0.038
Butterfly 19 0.028 Various
venipuncture 21 0.021
Jelco IV (with Teflon sheath) 18 0.035 Various
20 0.025
NEEDLES

75. Basic Endovascular Surgery
Diameter Maximum Guidewire Common
Needles (gauge) Diameter (in.) Length
Syringe Needles 18 0.025 Various
20 0.021
21 0.018
Percutaneous Transhepatic 22 (black hub) 0.018 20 cm
Cholangiography 23 (green hub)
Sheath Needle 16G sheath 0.038 24 cm
(19-gauge
stylet)
NEEDLES

76. Basic Endovascular Surgery
ACCESS
1. Femoral
2. Brachial
3. Axillary
4. Popliteal
5. Radial

77. Basic Endovascular Surgery
ACCESS
1. Retrograde
2. Antegrade

79. Basic Endovascular Surgery
ACCESS
1. Single Puncture
2. Double Puncture

80. Guidewire Anatomy &
Construction
• Composite construction
• Materials
– Stainless Steel
– Nitinol
– Jacketed Composite
• Tapered grinds

81. • Core
• Stainless Steel
– Used for support
– Stiffness varies based on taper / diameter of core
• Nitinol
– Used for it’s flexibility, memory and kink resistance
• Tip
• Platinum / Gold
– Provides radiopacity
– Atraumatic
– Ribbon formed for shaping tip
Core Material

82. • Core
• Stainless Steel
– Used for support
– Stiffness varies based on taper / diameter of core
• Nitinol
– Used for it’s flexibility, memory and kink resistance
• Tip
• Platinum / Gold
– Provides radiopacity
– Atraumatic
– Ribbon formed for shaping tip
Core Material

83. • Core
• Stainless Steel
– Used for support
– Stiffness varies based on taper / diameter of core
• Nitinol
– Used for it’s flexibility, memory and kink resistance
• Tip
• Platinum / Gold
– Provides radiopacity
– Atraumatic
– Ribbon formed for shaping tip
Core Material

84. Grind & Tip Performance
• Stiff
• Intermediate
• Floppy

85. Variable Tip Grinds & Visibility

86. Variable Grinds & Tip Stiffness

87. Tip Shaping
• Shapeable tips
• Pre-shaped tips

88. Dilators

89. Sheaths
• Sheaths are hemostatic conduits inserted into the
vessel. They allow passage of guidewires, catheters
and interventional devices. The allows these to be
passed in and out of the body without damaging the
vessel and reducing the blood loss.

90. Sheath Construction
Hemostatic Valve
3-Way Stopcock
Sheath Conduit
Dilator (obturator)

91. Sheaths
• Peripheral and coronary sheaths have a universal color code
• Universal color coding
 4 Fr = red
 5 Fr = gray
 6 Fr = green
 7 Fr = orange
 8 Fr = blue
 9 Fr = black
 10 Fr = violet
 11 Fr = yellow
• Sheaths are measured inner diameter in french size (1fr =
.33mm)

92. Basic Endovascular Surgery
CATHETERS
1. Straight
- End holed
- Flush
2. Rim
3. JB2
4. IMA
5. Pig
6. Omni
7. Head Hunter
8. Simmons/VTEK
9. Cobra 2
10. Berenstein
11. Grollman

113. Thoracic Endografting
The Future
Is Now !!!