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Specialist of Vascular Surgery ,Endovascular Surgery and Diabetic Foot mangement National Institute Of Diabetes and Endocrinology Cairo - Egypt Tele : 0113437474 2010 0106011656
Dr . Moustafa Abd Elhamid Elshal
In the name of ALLAH the almighty and merciful
Review of Literature # Surgical anatomy of lower limb arteries.
# Equipments for angioplasty. # Techniques of tibial angioplasty. # Transluminal versus subintimal angioplasty. # Causes and mechanisms of restenosis after angioplasty. # Surgery versus angioplasty in treatment of tibial arteries diseases.
1- Femoral Artery:
Is a continuation of the external iliac. It begins behinnd the inguinal ligament, midway between the anterior superior iliac spine and the pubic symphysis, enters and passes through the adductor (subsartorial) canal, and becomes the popliteal artery as it passes through an opening in adductor magnus near the junction of the middle and distal thirds of the thigh. (Gray and Lewis , 2004)
2 - Profunda femoris artery (deep femoral artery) : I a l rg e b ra n ch th a t s a a ri s l te ra l y fro m th e se a l fe m o ra l a rte ry 3 . 5 cm d i l to sta th e i gui al n n l g a m e n t a n d i th e m a i i s n su p p l to th e a d d u cto r, y exte n so r and fl exo r m u scl s; e i t al so a n a sto m o se s wi th th e i te rn a l a n d exte rn a l i i c n la a rte ri s a b o ve a n d th e e p o p l te a l a rte ry b e l w i i o t g i s th re e ve p e rfo ra ti g n b ra n ch e s, and th e p ro fu n d a i l b e co m e s tse f th e fo u rth p e rfo ra to r. ( Williams et al. , 1999 ) .
3-Popliteal artery : I th e co n ti u a ti n s n o o f th e fe m o ra l a rte ry , cro sse s th e p o p l te a l i fo ssa . T h e a rte ry i s re l ti l ti h te n e d a t a ve y g th e a d d u cto r m a g n u s h i tu s a n d a g a i d i l y a n sta l b y th e fa sci re l te d to a a so l u s . i d i d e s i to th e e t vi n a n te ri r a n d p o ste ri r o o ti i l b a a rte ri s e ( Valentine and Wind , 2 0 0 3 ).
4 - Anterior Tibial Artery : I a b ra n ch o f th e s p o p l te a l a rte ry th a t a ri s i se a t th e d i l b o rd e r o f sta p o p l te u s i D e sce n d i g n a n te ri rl o y on th e i te ro ssi u s m e m b ra n e a t n o th e a n kl i i m i w a y e t s d b e tw e e n th e m a l e o l , a n d l i co n ti u e s o n th e d o rsu m n o f th e fo o t a s th e d o rsa l s i pedi s a rte ry ( Sinnatamby , 2000 ) .
5 - Posterior Tibial Artery : B e g i s a t th e d i l n sta b o rd e r o f p o p l te u s, i b e tw e e n th e ti i a n d b a fi u l . b a I t d e sce n d s m e d i l y i th e fl al n exo r co m p a rtm e n t and di des vi m i w ay d b e tw e e n th e m e d i l a m a le o l s l u and th e m e d i l tu b e rcl o f th e a e ca l n e u s, ca i to n th e m edi l and a l te ra l a p l n ta r a a rte ri s e ( Williams et al. , 1 9 9 9 ).
6 - PERONEAL ARTERY : Arises from the posterior tibial artery 2.5 cm distal to popliteus and passes obliquely to the fibula. Distally it is overlapped by flexor hallucis longus ( Valentine and Wind , 2003 ).
EQUIPMENTS FOR ANGIOPLASTY
1-Choosing an imaging system: E xce l e n t i a g i g i th e ke y to e n d o va scu l r th e ra p i s . B o th l m n s a e p o rta b l C -a rm a n d a n a n g i su i i a g i g u n i h a ve sp e ci l ze d e o te m n t ai fu n cti n s th a t a re co m m o n l u se d d u ri g i te rve n ti n s . D e sp i o y n n o te th e si n i ca n t te ch n i l i p ro ve m e n ts i th e cu rre n t m o d e l o f C g fi ca m n a rm syste m s, th e i a g e q u a l ty re m a i s sl g h tl i fe ri r to th a t m i n i y n o o b ta i e d fro m th e a n g i su i . A sta n d a rd i a g i g su i i a g e n o te m n te m i te n si e r i 1 5 i ch i d i m e te r. ( Yao and Pearce , 2002 ). n fi s n n a
2 - Im a g in g ta b le :
A re lc b **Fixed tables: co n stru cte d o f a n o n m e ta l i ca rb o n -fi e r su p p o rte d u su a l y a t o n l o n e e n d T h e se ta b l s a re re l ti l l y e a ve y fra g i e a n d d o n o t su p p o rt o b e se p a ti n ts. (Yao and l e Pearce , 2002). l ti n e n zo * * Movable tables : A l o w p o si o n i g o f th e p a ti n t i th e h o ri n ta l p l n e . T h e y co m e w i a se t o f b e d si e co n tro l th a t a th d s al so p e rm i se l cti n o f th e ra d i g ra p h i se tti g s t e o o c n i cl d i g n u n ro ta ti n , i a g e i te n si e r l ca ti n a n d o m n fi o o ta b l h e i h t e g (Yao and Pearce , 2002).
3 - P o w e r in je cto r: co n tra st:
T h e re a re tw o m e th o d s fo r d e l ve ri g i n
# H a n d i j cti n w i a syri g e Fo r m o st sm a l ve sse la n d se l cti n e o th n l e ve a n g i g ra p h y , h a n d i j cti n i a d e q u a te . o n e o s # E l ctro n i l y ca l b ra te d p o w e r i j cti n fo r o p ti a lo p a ci ca ti n o f e ca l i n e o m fi o h i h -fl w b l o d ve sse l l ke th e a o rta g o o s i ( Kluge and R a u b e r e t a l. , 2 0 0 3 ) .
4 - E q u ip m e n ts o f v e sse l p u n ctu re : A - The single - wall puncture needle : is most familiar to surgeons and the one most commonly used. It is a bevel-tipped 16or 18-gauge hollow needle that accommodates a 0.035 inch guide wire. B - The Double - wall puncture needles: which are two component systems that combine a blunt-tipped hollow needle with a bevel-tipped stylet that projects slightly out the end of the needle
and Hodgson , 2005 ).
5 - S h e a th s : # Sheaths are essentially access to the vascular system placed at the time of initial vascular access is achieved and removed after completion of the diagnostic study or intervention. # Diameters most commonly used are in the 5- to 6-French range (1 French = 0.33 mm or 0.013 inch). # Placement of stents requires the use of sheaths in the 6F . # The size designation denotes the internal diameter (ID) of the sheath, as opposed to catheters which are sized in French by their outer diameters (OD).
( Kluge and Rauber et al ., 2003 ).
6 - W ire s : # Major classification is often by size, grouping 0.035 inch and 0.014/0.018 in diameter wires. # Access wires for the femoral approach and for diagnostic angiography of large and medium-sized vessels are usually 0.035 inches in diameter. # Hydrophilic wires are essentially used in tortuous vessels, recanalization work, are more difficult to handle potentially more traumatic, and should not be used as routine access . # 0.014/0.018-in systems are super tools for intervention on smaller vessels These wires generally have a shapeable tip that is visible under fluoroscopy. They are less traumatic than thicker wires and are conveniently paired with low-profile balloons and stents that easily cross tight lesions.
and Scott et al ., 2000 ).
7 - B a llo o n s :
# Angioplasty balloons Made with a thin wall of materials such as polyethylene terephthalate or nylon, they tend to maintain their shape and size under high inflation pressure (typically 8-20 atm and sometimes as high as 30 atm). # Of these 2 materials, polyethylene terephthalate is stronger and the balloon can have a thinner wall and lower profile . # Compliance refers to the relationship between changes in volume and pressure Balloon compliance is also important when expanding a stent . # The following equation defines the stress on a typical angioplasty balloon: Radial (hoop) stress = (pressure × radius)/(2 × thickness) #Cryoplasty balloons produce a cold thermal injury to the vessel by inflating with liquid nitrous oxide that turns to gas. These balloons have recently received considerable attention in the media, but their superiority remains unproven . # Cutting balloons have blades that are brought into contact with the vessel wall during inflation and are useful in resistant lesions.
d ru g -e l ti g ca th e te r d e si n e d sp e ci ca l y to tre a t a th e ro scl ro si i u n g fi l e s n a rte ri s l ca te d b e l w th e kn e e . A p ro p ri ta ry co a ti g th a t fre e s a n d e o o e n se p a ra te s p a cl ta xe l m o l cu l s a n d fa ci i te s th e i a b so rp ti n i to th e i e e l ta r o n w a l f th e a rte ry. lo
8 - S te n ts : # Vascular stents are metal frameworks that support the lumen from within. # Stents work well to prevent acute recoil after angioplasty, maximize lumen diameter, and “tack down” dissection flaps. # Earlier stents were stainless steel, with newer designs favoring cobalt-chromium alloys. The most biocompatible material has yet to be determined. Magnesium-based and other absorbable stents are under investigation. # Drug-eluting stents and newer stent designs have lower restenosis rates. # Stents may be broadly classified as balloon- expandable or selfexpanding * Balloon - Expandable Stents Balloon-expandable stents rely on inflation of an angioplasty balloon to expand the stent from its collapsed configuration and push it into contact with the vessel wall * Self - Expanding Stents As the name implies, self-expanding stents are released from their constraining delivery mechanism and expand within the vessel until the stent reaches its predetermined maximum diameter or is constrained by the vessel wall.
La b o ra to ry , re fe rri g to th e co m p o n e n ts o f th e a l o y a n d th e si o f i n l te ts d i ve ry i 1 9 6 1 . sco n # N i n o lste n ts a re a p p e a l n g b e ca u se th e y re ve rt to th e i o ri i a l ti i r g n sh a p e w h e n w a rm e d to b o d y te m p e ra tu re . T h i a l o w s b o th a co m p a ct s l d e l ve ry syste m a n d a n o u tw a rd ra d i l fo rce i th e ve sse la fte r i a n p l ce m e n t. T h e ste n ts a re M R I sa fe , fl b l , a n d fo re sh o rte n l ttl . A n d a exi e i e u su a l y h a ve m a rke r d o ts a t b o th e n d s. l ( Ayerdi a n d H o d g so n , 2 0 0 5 ) .
Other Types of Stents :
“stent grafts” 1 - Covered Stents Are terms loosely used to describe metal stents that are either covered or lined with fabric (usually polytetrafl uoroethylene). Benefits include the ability to treat aneurysms and perforations while maintaining lumen patency. 2 - Drug - Eluting Stents The most recent and dramatic advance in stent design is the drug-eluting stent. These stents provide local release of a drug to prevent restenosis. Agents used include the anti-proliferative drugs (paclitaxel). However, they are expensive, and patients must remain on clopidogrel for 6 months after placement to prevent thrombosis
( Ayerdi and Hodgson ,
TECHNIQUES OF TIBIAL ANGIOPLASTY
Endovascular therapy for infrapopliteal vascular disease is gaining acceptance as there is growing evidence demonstrating its safety and effectiveness Indications and Patient Selection : # Indication for PTA of infrapopliteal vascular disease is in limb salvage patients with (CLI). This patient often has limited surgical options. # Extending the indications for endovascular interventions on the tibial arteries to include lifestyle altering claudication. # Technical and more importantly clinical success depends on the ability to select cases which are most suitable for endovascular therapy. # The ideal lesions for tibial angioplasty are focal stenoses with good distal runoff. # The necessity of establishing straight-line flow to the foot is another key feature in tibial angioplasty for limb salvage.
( Lofberg and Karacagil et al ., 2000 ).
Te ch n iq u e s 1 -Im a g in g : A high-quality digital subtraction angiography. Use of road-mapping greatly aids in performing the procedure. The preferred contrast agent for lower extremity arteriography is low-osmolar, nonionic contrast material. ( Kougias and Nguyen et al ., 2006 )
2 - A cce ss :
Through an antegrade puncture of the ipsilateral common femoral artery. This provides the greatest control to direct catheters and wires .
( Kougias and Nguyen et al ., 2006 ) : 3 - Balloon Angioplasty # To cross infrapopliteal stenoses, 0.018-inch hi-torque floppytipped guide wires are ideal. For difficult occlusions, hydrophilic guide wires are useful.
# PTA of infrapopliteal lesions are best accomplished using highprofile small vessel balloons catheters ranging from 2.5 to 4.0 French. # Inflation times of 5 to 10 seconds are usually adequate a balloon is positioned in each one of the two vessels arising from the bifurcation. This will protect both vessels from intimal dissection or embolization. #In performing infrapopliteal PTA it is usually best to treat the proximal lesions before the distal lesions for Prevention of thrombosis around the proximal stenoses and better manipulation of the catheter and guide wire when treating the distal lesions. ( Pearce and Matsumura et al ., 2000 ).
4 - S te n ts : stents have not been widely used in the infra-popliteal vessels. The primary reason is because of the small caliber and slow flow in these vessels. Currently, stents are only typically used below the knee when PTA fails, such in the case of a flow limiting dissection or elastic recoil ( Lipsitz and Veith et al ., 2005 ). : 5 - Postprocedure Care includes bed rest, monitoring observation for complications. : 6 - Pharmacologic Agents of vital signs, hydration, and
Antispasmodics : use of intra-arterial nitroglycerin (100 microgm.) either once vasospasm is seen. Thrombolytics : catheter directed thrombolysis with urokinase is appropriate. Anticoagulation Agents : intravenous bolus of heparin (5,000 to 7,000 U) after vascular assess is obtained. An additional 5,000 units may be needed during the procedure postprocedure heparin may be continued overnight. The routine use of postprocedure warfarin is not indicated ( Anand and Creager , 2000 ).
A n tip la te le t A g e n ts : # Aspirin is by far the most commonly used of the antiplatelet agents available. # Recently, clopidogrel (Plavix) has gained increased acceptance as an antiplatelet agent .Clopidogrel has been shown to be superior to aspirin in reducing the rates of all types of vascular occlusive events.
( Clark and Groffsky et al ., 2001 ) . 1 - Laser :
laser athermic catheters and saline infusion techniques can minimize thermal injury and significantly reduce arterial dissection. Excimer laser is a pulsed laser system working at a wavelength of 308 nm, which ablates or vaporizes the lesion material ( De Sanctis , 2001 ).
New approaches to infrapopliteal angioplasty
2 - C o a te d ste n ts Recently stents coated with a thin and highly adherent film of Carbonfilm , a material which shows excellent high haemocompatibility and mitigation of inflammatory response (high biocompatibility) (De Sanctis , 2001).
3 - Absorbable stents
Recently a magnesium alloy absorbable stent has been used in focal infrapopliteal stenoses in patients with CLI. ( Muradin and Bosch et al ., 2003 ).
TRANSLUMINAL VERSUS SUBINTIMAL ANGIOPLASTY
# Important determinants of successful percutaneous transluminal angioplasty (PTA) are lesion location, length, plaque composition, and morphology. #Pooled results of infrapopliteal PTA indicate 1, 3 and 5-year primary patency rates of 65% to 77%, 48% to 66%, and 42% to 55%, respectively. # Subintimal angioplasty, described by Bolia in 1989, is a variant of PTA that allows the treatment of long occlusions when intraluminal wire crossing is not possible. an extraluminal dissection is created and pass the occlusion, with re-entry into the true lumen distally. Technical failure is mainly due to an inability to re-enter the true lumen. 90% of the subintimal angioplasties were performed in TASC D lesions, with skin ulceration or necrosis. Clinical success and limb salvage at 2 years was 72% and 88%, respectively.
( Perera and Lyden ,
Subintimal angioplasty of Peroneal artery
F a cto rs A ffe ctin g P a te n cy o f S u b in tim a l A n g io p la sty in P a tie n ts w ith C ritica l L o w e r L im b Isch e m ia :
# The most important are the number of patent run-off vessels after the procedure and the length of angioplasty. # Neither gender nor any risk factor of atherosclerosis such as diabetes mellitus, arterial hypertension, coronary artery disease and history of smoking, affect the outcome. # the patency rate of SIA with more than one run-off vessels at 12 months is 81% compared to the 25% of SIA with one run-off vessel. # None of the factors predisposing to atherosclerosis was found to affect the SIA outcome. Arterial hypertension has been reported to increase the risk of occlusion in claudicant patients . # Smoking is not related to the angioplasty outcome but the continuation of smoking after the procedure is related to a higher reocclusion rate.
( Lazaris and Salas et al .,
CAUSES AND MECHANISMS OF RESTENOSIS AFTER ANGIOPLASTY
lular events in response to endovascular interventions : logical response to balloon angioplasty : The objective of the balloon angioplasty is to exert a dilating force on the endoluminal surface of a vessel at the desired location. This causes desquamation of endothelial cells (ECs) and histological damage proportional to the diameter of the balloon and the duration of the inflation. The predominant effect of balloon angioplasty in enlarging vessel lumen is by stretching the elastic components of the arterial wall. Inelastic portion of the plaque fracture or tear results in a definite arterial wall dissection histologically evident arterial dissection is nearly present in all diseased vessels following balloon angioplasty procedures.
( Kougias and Nguyen et al ., 2006 ).
The oxidative stress that follows angioplasty, invasion of neutrophils, macrophages and T-lymphocytes, mobile vascular smooth muscle cells (SMCs) which migrate close to the site of injury all these events favor restenosis, or intimal hyperplasia. Biological response to intraluminal stenting : within 15 min following stent implantation, there is an accumulation of red blood cells and platelets on the stent surface. At 24 h. , this cellular layer is replaced by a layer of fibrin strands oriented in the direction of blood flow as the positive electrical potential of the metallic stents attracts the negatively charged circulating proteins on the stent surface. ( Kougias and Nguyen et al . , 2006 ). Stents placed into the venous system exhibit a faster rate of endothelialization than do intra-arterial stents.( Kougias and Nguyen et al . , 2006 ). Soon after the intra-arterial stent deployment, the positive electrical potential of the metal attracts the negatively charged circulating proteins to form a thin layer of fibrinogen strands on the stent surface. The proteins neutralize the stent surface and decrease thrombogenicity ( Lee and David et al ., 2004 ).
Severe angiographic restenosis (arrow) is seen within a Anterior tibial artery stent. 4 months following implantation of a stent. ( Kougias and Nguyen et al . , 2006 ).
Ideally, stents should be deployed in such a way that the metal ends are embedded deep enough into the vessel wall The achievement of this ideal deployment is dependent on multiple factors: the ratio of the diameter of the stent to that of the blood vessel, the depth of penetration of the struts into the vessel wall, thickness of the struts, and the composition and integrity of the intimal surface. Stent struts will be embedded adequately if the final stent diameter is 10 – 15 % larger than the diameter of the adjacent vessel .
( Lee and David et al .,
M e ch a n ism s o f R e ste n o sis : # Three mechanisms are responsible for the development of restenosis: elastic recoil, intimal hyperplasia, and late vascular constriction. # Restenosis is seen mainly in small-sized and medium-sized arteries. Vessel remodeling :
( Sidawy and Weiswasser et al ., 2002 ).
#Refers to a pattern of chronic over weeks or months the structure of the vessel wall that follows injury.
# The factors linked to remodeling after angioplasty include hemodynamic changes in blood pressure, flow rates, patterns of sheer stress, and changes in extracellular matrix composition. # Production, deposition, or organization of collagen is impaired under the influence of growth factors, cytokines, and matrix metalloproteinases with resultant increased extracellular matrix deposition .
( Kougias and Nguyen et al ., 2006 ).
N e o in tim a l h y p e rp la sia :
# Represents a chronic structural change in the blood vessel that leads to formation of a thickened fibrocellular layer between the endothelium and the inner elastic lamina of the arterial wall. # Responsible for 20 – 50 % of the clinical failures of all vascular interventions.
( Kougias and Nguyen et al ., 2006 ). Cellular and molecular mechanisms of neointimal hyperplasia : # Neointimal hyperplasia after vascular injury involves three phases: medial SMC proliferation (first wave), medial SMC migration into the intima (second wave) and intimal SMC proliferation and extracellular matrix production (third wave). ( Lazaris and Salas et al ., 2006 ).
C lin ica l stra te g y fo r re ste n o sis : Pharmacologic approach 1 - Antiplatelet drugs : Low dose Aspirin has documented efficacy for prevention of rethrombosis in the early phase of balloon angioplasty and should be administered 2 h before the procedure . ( Gorelick and Born et al ., 2005 ).
2 - Anticoagulants : Heparin is important because: (1) It reduces the risk of thrombosis .
(2) Heparin has anti-SMC proliferative activity.
( Gorelick and Born et al ., 2005 ). 3 - Essential fatty acids: Attenuate free radical generation and modify the body’s inflammatory response to tissue injury ( Ferns and Avades , 2000 ). 4 - Gene therapy : Involves overexpression of genes that are considered protective or blockade of genes that are involved in the pathogenesis of the intimal hyperplasia achieved through the use of nucleic acids known as antisense oligodeoxynucleotides (ODN). ( Kougias and Nguyen et al ., 2006 ).
E n d o v a scu la r stra te g y fo r re ste n o sis :
Drug - eluting stent design principles : Drug-eluting stents are composed of a three-dimensional complex. The stent-based drug delivery system can be accomplished through application of thin layers of a drug-polymer solution to the stent surface.
The key component of using any biopolymer is that the polymer is a non inflammatory inert non thrombogenic component. Unfortunately, without a polymer to aid in drug delivery, 40% of the drug can be lost during stent placement, and after placement, the remainder of the drug will completely elute in 1– 2 weeks. An alternative approach for drug delivery is direct application of the drug to a bare stent or incorporation of the drug into microscopic fenestration in the stent. This approach is currently being used for the paclitaxel-eluting stents.
( Grube and Silber et al ., 2003 ).
D ru g e lu tin g a g e n ts :
The basic function is to create an antiproliferative environment around the stent in order to prevent luminal stenosis and neointimal hyperplasia. The drug should have a reasonably long half-life of at least 4 weeks postprocedure since this is the time during which the greatest endothelial injury and reactivity to stent placement occurs
( Grube and Silber et al ., 2003 ).
SURGERY VERSUS ANGIOPLASTY IN TREATMENT OF TIBIAL ARTERIES DISEASES
The technical success rate of angioplasty is often reported to be in the range of 90%. The initial hemodynamic success defined as an increase in the ABIs or PVRs at the ankle for infrgenicular PTA. Percutaneous transluminal angioplasty (PTA) has been proposed as a safe, effective, less expensive alternative to lower extremity arterial bypass graft surgery for treating limb-threatening ischemia and claudication. The effectiveness of PTA in the treatment of tibial occlusive disease is well established, with good long-term patency achieved. Early success with PTA in the treatment of focal stenoses in the tibial arteries led us to expand the indications for PTA to include longer, more distal lesions with less favorable runoff, particularly in high-risk patients and those whose surgical options are less promising.
( Perera and Lyden ,
M e d i I d ex M e m b e r cs n C o n tri u ti n b o
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