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Interventions 64
Scott L. Stevens, Chandler A. Long, and Sagar S. Gandhi
Contents Introduction
Introduction ................................................................................... 797
Considering the increasing incidences of peripheral arterial
Treatment of Failing Lower-Extremity Grafts ........................... 797
disease (PAD), the need for vascular intervention will expand
Discussion....................................................................................... 800 and the number of repeat interventions will grow. As endo-
Contour Balloons (Cutting and Sculpting) ..................................... 800
vascular techniques and tools advance, this less-invasive
Stents ............................................................................................... 800
Graft Surveillance Protocols and Thresholds for Intervention ....... 800 approach will continue to be increasingly used to repair
Treating Failed Grafts ..................................................................... 800 bypass grafts. The average cost for a lower-extremity (LE)
References ...................................................................................... 802 bypass is $19,331 $5,300. The average cost for elective
treatment of a duplex-identified stenosis is $13,003 $5,935
for surgical graft revision and $3,623 $445 for endovascu-
lar repair. After graft thrombosis, the salvage cost is $18,519
$8,267 with thrombectomy and $22,532 $4,750 with
endovascular thrombolysis. The most expensive is major
amputation which costs $36,273 $9,336 [1, 2].
Case 1
This patient is a 49-year-old diabetic and heavy smoker.
He had a femoropopliteal bypass using the autogenous
saphenous vein for severe claudication 18 months
prior. At the follow-up office visit, he reported a return
of claudication and was noted to have decreased distal
pulses. Surveillance duplex evaluation demonstrated
low graft flow (less than 40 cm/s) and an arteriogram
was performed. Demonstrated were focal, high-grade
S.L. Stevens, MD (*)
Division of Vascular/Transplant Surgery, Department of Surgery,
stenoses immediately distal to the outflow anastomo-
University of Tennessee Medical Center, sis. Treatment of all three tibial origins was successful
1924 Alcoa Highway Box U-11, Knoxville, using an endovascular approach (Figs. 64.1 and 64.2).
TN 37920, USA 1. Obtaining access: When addressing failing grafts,
C.A. Long, MD S.S. Gandhi, MD our first choice is retrograde femoral cannulation.
Department of Surgery, University of Tennessee Medical This provides a forehand approach for easier cath-
CenterKnoxville,
1924 Alcoa Highway Box U-11, Knoxville,
eter and wire manipulation.
TN 37920, USA
If surgery is required, a contralateral femoral cannu- iliac vessels, or distal lesions, an antegrade approach is
lation preserves the ipsilateral surgical side from hema- used. Once an antegrade common femoral access is
toma- and access-related complications. Retrograde achieved, a long sheath can be fixed to the lower
access facilitates accurate puncture directly over the abdominal wall with a sticky drape to simulate a retro-
femoral head, especially in obese patients. grade femoral access (Figs. 64.3 and 64.4).
Key points: In patients who require anticoagulation or Brachial access is rarely used due to the risk of ves-
lytic therapy, successful graft intervention is predicated sel and nerve injury. Also, the long working distance
on accurate femoral cannulation. The femoral head is from the brachial artery to the lesion makes graft inter-
routinely marked with fluoroscopy and a hemostat. Next ventions from this approach difficult to accomplish.
the artery is punctured at the 12 oclock position using a 2. Wires, sheaths, and catheters for lower-extremity graft
micro system and ultrasound guidance. Care is taken to interventions: After access is gained, an atraumatic
avoid back wall arterial puncture and to minimize the 0.35 wire is advanced under fluoroscopic guidance
risk of hematoma. Pre-cannulation fluoroscopy often to the mid-descending thoracic aorta. Next a 4 F
gives important clues that impact access strategy, such as sheath is placed and a Soss multi-side-hole catheter is
vascular calcifications, prior stents, or hardware. positioned at the L1L2 junction. After a diagnostic
For patients who have had previous aortic grafts, run demonstrates aortic and iliac inflow anatomy, the
stents at the aortic bifurcation, anatomically difficult aortic bifurcation is crossed with the same Soss flush
Fig. 64.1 Failing saphenous vein graft with critical stenoses in Fig. 64.3 Adhesive drape used to fix long sheath to lower abdomi-
region of distal anastomosis nal wall
Fig. 64.2 Failing saphenous vein graft after correction of outflow Fig. 64.4 Long sheath fixed to the abdominal wall to simulate a
stenoses using directional atherectomy retrograde femoral access
64 Lower-Extremity Arterial Bypass Graft Interventions 799
catheter, and contralateral femoral position is achieved complicated, we turn to a re-dosing cocktail of rtPA,
using a telescoping maneuver. nitroglycerin, and heparin to avoid procedure-related
Key points: Prior to intervention, the sheath must be thrombus and vasospasm. Antiplatelet agents are rou-
upsized to a 6 or 7 F sheath over a 0.35 wire. We typi- tinely used for lower-extremity graft interventions.
cally use a 45 cm sheath over the aortic bifurcation and 5. Crossing the lesion: The lesion is typically addressed
into the proximal femoral artery. Parking the tip of the and crossed with a 0.014 wire.
sheath in the common femoral artery prevents it from Key points: A 0.014 wire is used to decrease the risk of
obturating and obstructing flow in the superficial femoral causing an intimal flap or dissection with a 0.035 wire.
artery. If the lesion is at the distal portion of the graft, we Crossing the lesion without vessel injury is of paramount
occasionally use a 55 cm sheath to decrease friction points importance. When crossing the lesion, back-and-forth
and to allow better torque control of catheters and wires. torque is placed on the wire which causes the tip to rotate
3. Injecting contrast: Site-specific contrast rates and vol- as it is advanced across the lesion. This allows the tip of
umes are listed below (Table 64.1). the wire to seek the true lumen. If the wire tip engages the
Key points: Since our patient had renal insufficiency, vessel wall and starts to bend in a J configuration, it is
nephrotoxicity of the contrast was a concern. To mini- withdrawn slightly to prevent dissection. Torque devices
mize renal insult, we used half-strength contrast. If an are used when multiple friction points make wire control
ipsilateral femoral pulse is crisply palpable, we con- difficult. When an expanded reach for the wire tip is
clude that there is no hemodynamically significant needed, angled catheters are telescoped over the wire. It is
proximal disease, and we minimize contrast dose by important to use magnified DSA images and orthogonal
avoiding abdomen and pelvic runs. We then cross the views to characterize lesion anatomy.
bifurcation and land the catheter in the target femoral 6. Treating the lesion: This patient had para-anastomotic
artery by brail (i.e., radiographic landmarks and lesions secondary to neointimal hyperplasia, and an
pulse). In addition, we place the catheter as close to the atherectomy was performed over a 0.014 wire. A
lesion as possible and always use digital subtraction 3 mm Spider (ev3) distal protection filter was deployed
angiography (DSA) for contrast imaging. to decrease embolic risk. Cuts were taken at cardinal
4. Pharmacotherapy: Once the lesion has been identified and ordinal directions with frequent contrast injections
and an intervention is planned, unfractionated heparin in orthogonal views to assess effectiveness.
is injected on a weight-based protocol (100 units/kg) Key points: To minimize the risk of dissection and to
and the sheath is upsized. remove lesion bulk, we used a directional atherectomy
Key points: In our shop, the administration of heparin is catheter. A contour (cutting or sculpting) balloon is also
linked to upsizing the access sheath. This helps prevent appropriate for these focal, fibrous lesions. We use distal
intervening without anticoagulation. If heparin-induced protection filters selectivelywhen stakes are high
thrombocytopenia is suspected, we use bivalirudin (The (e.g., a single-vessel runoff), subacute thrombus is sus-
Medicines Company). By having the anesthetist repeat pected (the wire drops effortlessly through a total occlu-
back the medication and dose and also notify us when sion) or the lesion appears embologenic (ulcerative,
2 min have elapsed, a dialogue is created that helps avoid shaggy, or calcified). To simplify deployment we back
interventions without anticoagulation. To prevent proce- load the distal protection filter into the catheter rather
dural medication errors, syringes on the back table are stan- than use the traditional, double monorail technique.
dardized for content by size and morphology of plunger. Once the lesion is treated, the filter can be retrieved
For lower-extremity interventions, nitroglycerin is through a 0.35 catheter without uncrossing the lesion.
used liberally to minimize vasospasm (300600 mcg 7. Assessing efficacy: DSA and intravascular ultrasound
doses titrated to blood pressure). Papaverine is seldom images are used to confirm successful intervention.
used because it causes discomfort and precipitates Before the patient is transferred off of the table, the
patient movement. When cases become prolonged or treated foot is inspected, palpated, and, if necessary,
insonated to confirm treatment efficacy.
Table 64.1 Site-specific settings for contrast injector Key points: Information about the lesion is key to
Flow (cc per second) Total volume success. Pre-case planning should include a review of
Bifurcation 8 12 all available prior vascular images (CT, MR, or prior
Iliac 4 8 catheter based). Adjuncts include magnification, use of
Femoral 5 10 digital subtraction imaging, orthogonal views, and
Popliteal/trifurcation 8 12 intravascular ultrasound (IVUS). IVUS allows 360
LE runoff 33 0 imaging at any given point up and down the axis of the
800 S.L. Stevens et al.
vessel. IVUS is useful when fluoroscopic images do Key points: If the patient requires postoperative
not completely define the lesion or when radiation or anticoagulation or is noncompliant to bed rest, there
contrast dose is of particular concern. is a need for shortened bed rest, or there is increased
8. Closure: A Starclose (Abbott) device was deployed risk of bleeding, then we consider a vessel closure
under fluoroscopic guidance to close the arteriotomy. device.
4. Tools to treat: Once the lesion is crossed, a catheter- Persistent bleeding around a sheath is usually remedied
directed Alteplase (Genentech) is used. Four milligrams by upsizing the sheath. Important, refractory bleeding
in 100 cc saline is laced into the thrombus using the requires discontinuation of therapy and coagulopathy cor-
Angiojet and pulse spray technique. Once laced, the rection. A keen eye is needed to minimize systemic reper-
Alteplase is allowed to marinate in the thrombus for fusion complications and compartment syndrome. We
20 min. Mechanical aspiration of the thrombus is then keep this group of patients well hydrated and anticipate
performed with the Angiojet traveling about 1 mm/s. metabolic acidosis and hyperkalemia. Disproportionate
Other tools available to enhance lysis include Trellis pain, pain on passive muscle motion, and pain over the
(Bacchus Vascular), which isolates the lytic between involved compartment all point toward compartment syn-
inflated balloons, and the EKOSonic (EKOS Corp) sys- drome. A tense compartment with wood-like character
tem, which uses ultrasound energy to drive the lytic agent allows the diagnosis to be made with confidence. Because
into the thrombus. sensory nerves are most sensitive to ischemia, two-point
5. Imaging: Contrast is then hand injected and areas of the discrimination and vibratory sensation are diminished.
residual thrombus are treated with focused mechanical The anterior compartment of the leg is most commonly
aspiration. involved and presents early with the superficial peroneal
Key points: The goal is to lyse the acute clot and to nerve manifestation of numbness between the first two
expose the underlying mechanical failure point. Once the toes. In patients who do not yield a true exam, those with
culprit lesion is pinpointed, it is treated according to the an altered mental status, compartment pressures are help-
same criteria as a failing graft (see above). The usual cul- ful, and we consider pressures greater than 3035 mmHg
prits are perianastomotic hyperplasia and retained valves. diagnostic. In this arena, errors of omission are devastat-
6. Recalcitrant thrombus: Incomplete or suboptimal therapy ing and a low threshold for fasciotomy is important. If
(residual thrombus or distal embolization) is addressed by clinical signs and symptoms of compartment are present,
spanning the thrombus with a side-hole drip catheter. we proceed directly to fasciotomy and bypass compart-
Lytic success is improved by positioning the drip catheter ment pressures.
such that a few centimeters of proximal side holes are
above the thrombus (i.e., in the CFA for a fem-pop throm-
bus) and the distal side holes traverse most of the throm-
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