2. WHY SO IMPORTANT?
• PAD is often present in patients with
established CAD
• PAD may be the first and/or only
manifestation of atherothrombosis in
several pts
• Peripheral complications during PCI
or other cardiac interventions are
not rare
4. Before the Battle
• Be prepared (for the worst)
• Be carefull (misleading journals &
articles)
• Be well trained surgeon
5. Before the Battle
• Endovascular setting is Surgical setting
• Blood – OR team – Fasting – Consent –
Surgical field preparation.
• Radiation knowledge
• Access problem = BIG problems
9. Garcia et al, Catheter Cardiovasc Interv 2009;74:27-36
COMMON ACCESS SITES FORCOMMON ACCESS SITES FOR
PERIPHERAL=FOR CORONARYPERIPHERAL=FOR CORONARY
10. Garcia et al, Catheter Cardiovasc Interv 2009;74:27-36
LESS COMMON ACCESS SITESLESS COMMON ACCESS SITES
FOR PERIPHERAL≠FORFOR PERIPHERAL≠FOR
CORONARYCORONARY
11. Vascular Access sites
Retrograde Common Femoral Artery Access
•Common access site used for
peripheral diagnostic angiography
and intervention
•Prevent injury to the less diseased
extremity
12. Vascular access sites
•Contralateral femoral retrograde
access :
•Internal iliac stenoses are best
treated from a contralateral approach
•SFA,PFA- lesions located within the
CFA/involve SFA/PFA ostium –
•Proximity to arterial puncture site,
Bifurcation anatomy of CFA
•Also allows treatment B/L disease
with a single arterial puncture
13.
14. Vascular Access site
Antegrade Common Femoral Artery Access:
•Required for infrainguinal proced
•Approx 3cm CFA lies betw
ligament & FA bifurcation
•Inorder to access CFA, skin entry-
prox to ing ligm
•Access too close to F bifurc –
inadeq working room to
selectively cath SFA
18. Modified TASC Morphological Classification of
Femoral-Popliteal Lesions
•A. Endovascular treatment of choice:
• Single <3-cm stenosis (unilateral/bilateral)
•B. Endovascular more often used:
• Single 3- to 5-cm stenosis
• Heavily calcified stenoses ≤3 cm
• Multiple lesions each ≤3 cm (stenoses or occlusions)
• Single or multiple lesions, in the absence of continuous tibial
runoff, to improve inflow for infrageniculate bypass
•C. Endovascular if possible:
• Single stenosis or occlusion 5 to 10 cm
• Multiple stenoses or occlusion, each 3 to 5 cm
•D. Surgery preferred, endovascular considered on case-by-case basis:
• Complete occlusion of CFA or SFA or popliteal and proximal
crural arteries
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society Consensus for the
Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007; 45: S5–S67
SFA and Popliteal Artery Disease
24. TAKE HOME MESSAGES
• Peripheral intervention skills must be
mastered by all endovascular surgeon for
bail-out indications
• Motivated endovascular surgeons can
pursue further improvements by focusing
on district-specific indications, anatomy,
and devices
• Team work
emonstrated no difference at 1 year for angioplasty or surgery
There was no difference in limb salvage or patient survival at 5 years.. But patency etc
Darah daftar puasa konsul inform consent sio cukur… psiapa op lengkap dg graft
Akses.. Open or puncture
DM, renal failure, koagulopathy, tua(CV, kalsifikasi)
Complication.. To outcome
Medical therapy, intervention, and surgery have been compared in several trials in symptomatic patients with femoral-popliteal disease. A meta-analysis that compared PTA with exercise therapy in patients with intermittent claudication reported similar quality-of-life outcomes at 3 and 6 months but also found that functional capacity (ABI) improved more with endovascular therapy than with exercise.49 Cost-effectiveness and quality-of-life outcomes favor the performance of percutaneous therapy whenever feasible as a more effective treatment than exercise alone.50 A matched-cohort study of 526 patients with intermittent claudication found significant advantages for a revascularization strategy (surgery or PTA) compared with medical therapy.51 Revascularization was more effective than medical therapy for improvement in physical function, bodily pain, and walking distance. Patients with the greatest improvement in their ABI results had the best clinical improvement, which indicates that the degree of revascularization was related to a successful outcome. If the 5-year patency rate is estimated to be ≥30%, the authors concluded that percutaneous therapies would be superior to surgery.52
Clinical success in patients with SFA lesions depends on a durable, long-lasting procedure. Multiple clinical trials in small numbers of patients had previously failed to show any advantage for stents compared with PTA (Table 4).1 A meta-analysis did, however, demonstrate better patency at 3 years for stents than for PTA in the most severely affected patients, those with occlusions and CLI.53 A recent randomized controlled trial demonstrated a better outcome for primary SFA stent placement than a strategy of provisional stent placement. Not only was restenosis significantly lower in the stent group at 6 and 12 months, but there was also better functional improvement (ABI) and walking distance in the primary stent group (Figure 7).54 An interesting observation was that stent fractures, which have been associated with restenosis in SFA lesions,55 were only reported in 2% of the stents (Dynalink/Absolute, Abbott Vascular) used in this trial. There are differences regarding stent fracture among SFA stents that are presumably related to their composition and architecture. A recently published series found fracture rates of 28% for the SMART stent (Cordis), 19% for the Wallstent (Boston Scientific), and 2% for the Dynalink/Absolute stent (Abbott Vascular).56 The issue of stent fracture is a complex one, with attendant restenosis being greater in the fracture territory and the length of lesion/presence of multiple overlapping stents also being an apparent contributing factor