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Arterial Revascularization

Arterial revascularization is one of the cornerstones to treatment for peripheral arterial disease. These patients and their procedures can range in scope, complexity and level of difficulty. Understanding key concepts will help an interventionist begin to dive into this complex topic.

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Ep 118 Treating Acute Limb Ischemia with Dr. Donald Garbett

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Pre-Procedure Prep

Indications

• Peripheral vascular disease - including focal or long segment stenoses and/or chronic total occlusions.

Contraindications

• Uncorrectable bleeding diathesis
• Stenotic/occlusive disease with high thromboembolic risk
• Renal failure
• Extreme vessel tortuosity

Things To Check

• History and Physical
• Patient anticoagulation status
• Creatinine, coagulation profile
• Any prior imaging - Vascular ultrasound, CTA, MRA
• Lower extremity pulses

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Procedure Steps

Procedural Steps

• Access common femoral artery of contralateral leg using micropuncture needle under US
• Advance wire centrally
• Place a 5, 6 or 7 Fr sheath (depending on the potential atherectomy device).

Angiography

• Advance flush catheter over the wire into the aorta.
• Perform AP aortogram - 15 mL/sec for 30 mL.
• Pull flush catheter back into the distal aorta
• Perform iliac artery arteriogram - 10 mL/sec for 20 sec.
• Keep catheter in distal aorta and perform lower extremity runoff arteriography - 8 mL/sec for 80 mL

Evaluate Lesion(s)

• Exchange for a selective catheter and catheterize target artery.
• Position catheter proximal to lesion.
• Administer heparin bolus prior to crossing lesion (2500-5000 U)
• Gently advance guidewire across stenosis.
• If resistance is met - avoid dissection and retract wire. Redirect catheter and readvance wire until successful passage.
• Direct guidewire through central canal of lesion. Advance selective catheter over wire across the lesion
• Angiogram following lesion crossing to confirm position
• Exchange crossing guidewire for a 0.014" guidewire.

Treatment

• Many options from balloon angioplasty to atherectomy
• Introduce atherectomy device over guidewire; perform atherectomy across lesion
• Inject contrast through sheath or catheter to evaluate progress. Determine if further intervention is needed. May need balloon angioplasty, or stent placement if dissection occurs.
• Remove access sheath and close arteriotomy site - closure device or manual pressure.

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Post-Procedure

Obtain Hemostasis

• Supine bedrest for 3 hours with closure device. 6 hours with manual pressure

Complications

• Arterial injury - dissection, rupture, hematoma, distal embolization, thrombosis.
• Groin complications

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References

[1] Mittleider D, Russell E. Peripheral Atherectomy: Applications and Techniques. Tech Vasc Interv Radiol. 2016;19(2):123‐135. doi:10.1053/j.tvir.2016.04.005
[2] Wilkins LR, Sabri SS. Strategies to Approaching Lower Limb Occlusions. Tech Vasc Interv Radiol. 2016;19(2):136‐144. doi:10.1053/j.tvir.2016.04.006
[3] BackTable, LLC (Producer). (2017, August 16). Ep 9 - #StopTheChop [Audio podcast]. Retrieved from https://www.backtable.com/shows/vi

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