Vascular Intervention (T/F)

• Vascular surgery interventions address Peripheral Artery Disease (PAD).
• The approach to PAD includes indication, imaging, and interventions.

Angiogram

• An angiogram is a common, invasive procedure providing detailed anatomical information about a patient's arteries.
• Angiograms aid in planning open revascularization or can be converted into a therapeutic procedure for leg revascularization.

Angiogram with Intervention: Endovascular Surgery

• Utilizes angiography to open occluded or stenotic arteries from the inside.
• Endovascular revascularization surgery options:
  • Balloon angioplasty with or without antirestenosis drug.
  • Stent placement with or without antirestenosis drug.
  • Atherectomy using plaque removal devices.
• Typically, a small puncture over the common femoral artery is the only incision needed.

Angiogram: General Considerations

• Performed with local anesthesia and sedation, assuming the patient can lie on their back.
• Contraindications include:
  • Acute kidney injury or chronic kidney disease near dialysis, which carries the risk of permanent renal failure.
  • Untreatable contrast allergy.
  • Uncontrolled coagulopathy, indicated by an INR greater than 1.5-2.

Angiogram: Basic Equipment

• Essential equipment includes:
  • Fluoroscopy table
  • C-arm or fixed imaging system
  • Lead aprons, thyroid shields, and barriers
  • Puncture needle, access wire, and sheath
  • Wires and catheters
  • Contrast and heparinized saline
  • Balloons and sheaths
  • Intravenous heparin

Angioplasty vs. Stent

• Endovascular therapy is most effective for short segment treatment of large arteries.
  • Iliac arteries benefit from a high likelihood of sustained improvement.
  • Femoropopliteal arteries have a good chance of sustained benefit.
  • Tibial arteries show low rates of long-term patency, but short-term therapy can improve blood flow for wound healing.
• Stents provide improvement over balloon angioplasty for longer lesions in the iliac, femoral, or popliteal arteries, however there are no benefits below the knee.

Angiogram: Postoperative Care

• Requires sheath removal and puncture closure via direct compression or a closure device.
• Patients must remain on bedrest for 4-6 hours, monitored for hematoma or pseudoaneurysm at the puncture site.
• If the puncture site remains clean after 4-6 hours, the patient may ambulate and potentially go home.

Open Surgery

• Involves two main techniques:
  • Endarterectomy: Plaque is removed from the artery.
  • Bypass surgery: A substitute vessel creates a new route around an occluded artery.
• Procedure names often indicate the surgical site:
  • Common femoral endarterectomy involves plaque removal from the common femoral artery.
  • Aorto-femoral bypass reroutes blood flow from the aorta to the femoral artery.
  • Femoral-popliteal bypass creates a bypass from the femoral to the popliteal artery.

Bypass Grafts

• A single-segment vein conduit has the best results for infrainguinal bypass surgery.
  • The great saphenous vein is often used.
  • Cephalic or basilic veins from the arms are other options.
• Prosthetic bypass grafts like PTFE or Dacron work well above the inguinal ligament.
• They have inferior outcomes when used below the inguinal ligament.

Importance of Inflow

• Occlusion of the aorta, iliac, or common femoral arteries reduces blood flow to the entire leg.
• The leg relies on collateral circulation.
• Restoring inflow provides the most benefit.

Patterns of PAD Risk Factors

• PAD patterns vary by risk factor, including age, gender, diabetes, hypertension, hypercholesterolemia, and smoking.

Case Study 1: Femoral Endarterectomy

• A 67-year-old male with hypertension presented with left foot ischemic rest pain and an ulcer between their 3rd and 4th toes.
• The exam showed an absent left femoral pulse.
• A CTA revealed extensive left femoral plaque.
• A palpable PT pulse was present after said endarterectomy.
• The patient recovered well, the ulcer healed, and ischemic rest pain resolved.

Vascular Surgeon Saying

• For CLTI return a palpable pulse to the foot.

Case Study 2: Chronic Limb Threatening Ischemia

• A 60 year old male active smoker with left non-healing hallux wound.
• A patient with diabetes had palpable femoral pulses and was taken to the OR for an angiogram.
• The decision was made to perform a left femoral PT bypass.
• There was a 20+ cm occlusion of the left SFA with occlusion of the tibioperoneal trunk.
• Incision made, and the great saphenous vein from the left leg was harvested.
• The vein was sewn in a non-reversed configuration to the common femoral artery and then the posterior tibial artery.
• In order to allow flow through the vein, the valves were cut with a Mills valvulotome.
• A completion angiogram was performed.
• There was a palpable left PT pulse at the ankle
• Remember that in chronic limb threatening ischemia, wound healing requires the three critical components wound care/offloading, treatment of ischemia, and treatment of infection.
• The patient’s hallux wound healed

Case Study 3: Ischemic Rest Pain (CLTI)

• 71 year old female that has hypertension, coronary artery disease, and diabetes.
• The patient’s intermittent claudication has progressed over several months to ischemic restpain.
• The femoral pulses are palpable.
• The decision was made to make an angiogram via a right common femoral artery puncture.
• A 20 cm segment of the left SFA is occluded.
• There is significant stenosis of the tibialperoneal trunk, the posterior tibial artery is patent onto the foot.
• The anterior tibial and dorsalis pedis arteries occur distally and are chronically occluded.
• An endovascular treatment was selected an dthe patient had a balloon angioplasty and stenting of the SFA as well as a balloon angioplasty of the popliteal and tibioperoneal trunk.
• There was a palpable left PT pulse at the ankle.
• Rest pain and intermittent claudication resolve

Conclusions for Vascular Interventions

• The goal of revascularization is to provide sufficient foot perfusion for wound healing.
• Open and endovascular approaches have advantages and disadvantages; therefore the choice of a procedure must be tailored to a suitable patient.
• If the patient had at least two years of life expectancy and had a suitable vein, a lower extremity bypass with saphenous vein is the best revascularization procedure.