Endovascular interventions.

Diseases of the mesenteric

arteries.

LÁSZLÓ BENKŐ MD., PH.D.

UNIVERSITY OF PÉCS, DEPARTMENT OF VASCULAR SURGERY
Vascular surgery has undergone a major paradigm shift of the
past years from open surgical techniques to minimally invasive
techniques - so- called endovascular surgery.

Because these endovascular technologies are less invasive than

older procedures, they are attractive to both patients and
referring physicians. In addition, because they are gratifying to
perform and often less morbid for patients, they have been
embraced by vascular surgeons and other interventional
specialists
The term endovascular refers to the treatment of
blood vessel disorders from inside the vessel using
balloons, stents and other devices.

Endovascular surgery is a form of minimally

invasive surgery that was designed to access many
regions of the body via major blood vessels.
 Seldinger technique
The Seldinger technique is a medical procedure to obtain safe access to blood vessels and other hollow organs. It is
named after Dr. Sven-Ivar Seldinger (1921-1998), a Swedish radiologist, who introduced the procedure in 1953.

A sheath can be used to introduce catheters or other devices to perform endoluminal procedures, such as
angioplasty. Fluoroscopy may be used to confirm the position of the catheter and to manoeuvre it to the desired
location. Injection of radiocontrast may be used to visualize organs. Interventional procedures, such as
thermoablation, angioplasty, embolisation or biopsy, may be performed.
 History
On 16 January 1964, Charles Dotter (who was then chairman of Radiology at the University of Oregon
Medical School) performed the first recorded angioplasty in the world when he used progressively larger
catheters to dilate a distal superficial femoral artery stenosis. The patient was an elderly woman with rest
pain and gangrenous toes who had only been offered amputation of her foot. After successful dilation of
the stenosis with a guide wire and coaxial Teflon catheters, the circulation returned to her leg. The dilated
artery stayed open until her death from pneumonia two and a half years later.

Charles Dotter is commonly known as the "Father of Interventional

Radiology" and was nominated for the Nobel Prize in medicine in 1978.
1977 – the first coronary angioplasty on an awake patient was performed by German cardiologist Andreas Grüntzig
Coronary angioplasty (PTCA)

1985 - Palmaz et al. Introduced the use of balloon mounted stents in peripherial arteries

1986 - Schatz et al. modified the Palmaz stent, which led to the development of the first commercially successful
stent, the Palmaz– Schatz stent.

1986 - Puel & Sigwart were the first to implant a stent in humans they used a self expanding mesh device.
 Angioplasty
Angioplasty is the technique of mechanically widening a narrowed or obstructed blood vessel, typically as a
result of atherosclerosis. An empty and collapsed balloon on a guide wire, known as a balloon catheter, is
passed into the narrowed locations and then inflated to a fixed size using water pressures some 75 to 500
times normal blood pressure (6 to 20 atmospheres). The balloon crushes the fatty deposits, so opening up
the blood vessel to improved flow, and the balloon is then collapsed and withdrawn.
 Stenting
A stent is a tiny wire mesh tube mad of nitinol. When a stent is used, it’s collapsed and put over the
balloon catheter. It’s then moved into the area of the blockage. When the balloon is inflated, the stent
expands, locks in place and forms a scaffold. This holds the artery open. The stent stays in the artery
permanently and holds it open. Stents are used depending on certain features of the artery blockage.

Reclosure of the blood vessels from blood clotting, even long after surgery, is an important complication. To help
prevent this complication, and repeat surgery, a tiny expandable metal mesh tube (stent) is often used along with
angioplasty.
 Endovascular fields
• Carotid stenosis
• Subclavian stenosis
• Thoracic aortic aneurysm
• Abdominal aortic aneurysm
• Iliac stenosis/occlusion
• PAD stenosis/occlusion
• Popliteal aneurysm
 Carotid artery stenting
Carotid artery stenting (CAS) is most
commonly performed for symptomatic or
asymptomatic high-grade (>70 %) internal
carotid artery stenosis. Carotid
endarterectomy (CEA) remains the
preferred treatment for most patients with
symptomatic carotid atherosclerosis.

Based upon the available data, we suggest CAS rather than CEA, for select patients with recently symptomatic
carotid stenosis of 70 to 99 percent who have any of the following conditions:

• A carotid lesion that is not suitable for surgical access

• Radiation-induced stenosis
• Restenosis after endarterectomy
• Clinically significant cardiac, pulmonary or other disease that greatly increases the risk of anesthesia and surgery
 Subclavian steal syndrome
Physical exam:
• Decreased arm power
• Blood pressure differential >=20mmHg
• 2-3x more common on the left
• Embolic phenoma to hands
Diagnosis:
Duplex ultrasonography
• Reversal blood flow within vertebral
• Monophasic waveforms in subclavian a.
• High-frequency blood flow pattern
CTA, DSA
TAA - Endovascular intervention (TEVAR)

Advantages
- lower mortality and morbidity
- lower risk for neurologic complications
- no need for GA
- shorter surgery time
- less blood loss

Drawbacks
- longlife CT follow-up
- more reinterventions
 Endovascular aneurysm repair (EVAR)
Abdominal aortic aneurysms are most often found when a
physician is performing an imaging test, such as an
ultrasound, Hip X-RAY, CT scan, or MRI, for other
conditions. The procedure involves the placement of an
expandable stent graft within the aorta to treat aortic
disease without operating directly on the aorta.

Indications for EVAR:

• AAA diameter > 5,5 cm
• Suitable anatomy

EVAR is preferred for older, high risk patients, because EVAR

has shown a reduction in 30-day mortality relative to that
achieved with open repair.
Contraindications for EVAR:

• Short of proximal neck

• Thrombus present in proximal landing zone
• Conical proximal neck
• Greater than 120º angulations of the proximal
neck
• Critical inferior mesenteric artery
• Significant iliac occlusion
• Torture of iliac vessels
 Iliac artery angioplasty
Percutaneous transluminal angioplasty (PTA) with or without stent placement for the management of iliac
artery occlusive disease is indicated in patients presenting with disabling claudication, limb-threatening
ischaemia, rest pain or tissue loss, vasculogenic impotence, and to treat a haemodynamically obstructive
lesion prior to a distal revascularization procedure or for the salvage of a distal bypass graft at risk.
 PAD angioplasty
SFA, PFA and Below Knee Interventions

• Minimal invasive approach

• Limb salvage
• Better wound/ulcer healing

Different balloons and wires:

• Low profile and longer (8-21cm) balloons

• Higher pressure (13-20 atm)
• Longer inflation time (3-5min)
 Popliteal aneurysms

Diameter greater than 2 cm is often

stated as being an indication for
elective operation in asymptomatic
popliteal aneurysms.
 In the 21th century…

• Drug eluting balloons (Sirolimus)

To prevent restenosis
• Drug eluting stents (Sirolimus)
• Cutting balloons Laser atherotomy
• Directional atherotomy
• Cryoplasty
• Fenestrated stent graft
 Diseases of the meseteric arteries
The mesenteric arteries supply blood to the large and small intestines. When one or more of the
mesenteric arteries narrow or becomes blocked, blood flow is restricted and the intestines fail to
get enough oxygen. This is called ischemia - an inadequate blood supply (circulation) to an organ
due to blockage of blood vessels in the area.

Mesenteric ischemia can be acute or chronic. In acute mesenteric ischemia, symptoms come on
suddenly and a serious health crisis may result. With chronic mesenteric ischemia, symptoms
develop gradually over time, but can rapidly progress to an acute crisis without warning.
I. Acute mesenteric ischaemia

• Relatively uncommon
• Difficult diagnosis
• High complication rate
• High mortality rate > 65-70 %
Clinical presentations

• Abdominal pain (severe, sudden, diffuse)

• Few physical exam finding early
• Peritoneal signs and acidosis late
• Vomiting
• Diarrhoea
• Occult rectal bleeding
Etiology

• Mesenteric artery occlusion (2/3)

- 1/3 embolic
- 1/3 thrombotic
• Non occlusive mesenteric disease (1/3)
• Mesenteric venous thrombosis (rare)
Treatment
• Limited role for endovascular surgery
- thrombolysis
- PTA/stenting
• Operative
- Laparotomy
- Revascularization (thrombectomy/embolectomy)
- Determine viability
- Bowel resection
- Second look after 24 hours!
II. Chronic mesenteric ischaemia

Mesenteric ischemia is a medical condition in which inflammation and injury of the small
intestine occurs due to inadequate blood supply. Causes of the reduced blood flow can
include changes in the systemic circulation or local factors such as constriction of blood
vessels or a blood clot.
Symptoms
 Severe pain in the abdomen occurring within an hour of eating, lasting for 60 to 90 minutes.
 Weight loss (patients cut back on eating due to the pain)
 Diarrhea
 Nausea
 Vomiting
 Flatulence
 Constipation
Epidemiology
4:1 - Female:male
60.7 y/o +/- 10 years
16% do not have classic symptoms
◦ nausea, vomiting, diarrhea, constipation

17.4 mo. +/- 12.2 mo delay in diagnosis

◦ 50% have had some form of abdominal operation
Etiology
Near 100% have occlusion or high grade stenosis of the SMA
70% have disease of all 2-3 mesenteric vessels
20-30% have disease of the SMA or celiac alone ????
Atherosclerosis
◦ FMD, Arteritis, Median arcuate ligament
Diagnosis
• DSA

• MRA

• CTA

• Duplex ultrasonography
Intervention Indications
Symptomatic patients with appropriate angiography
◦ Negative wokup for other sources of pain

Asymptomatic patients at time of aortoiliac reconstruction with SMA stenosis/occlusion

◦ SMA alone
◦ SMA and celiac
Interventions
 Transaortic endarterectomy
 Antegrade bypass
 Retrograde bypass
 Vein patch angioplasty
 Interpostion graft
 PTA
 PTA/Stent
PTA
Poor surgical candidates
1980 - Furrer
Poor results with “orificial” lesions
Symptomatic relief 80% at 3 year
◦ 5% mortality, 20% failure, 15 % - 50% need recurrent therapy
◦ 40% recurrent sx at 1 year

Better outcome if oversized balloons used

Symptomatic relief not related to the pressure drop, may be related to overdilation
◦ Southampton Hospital 1988 (Odurny)
◦ Baylor 1996 (Allen)
PTA with Stent
Orificial stenosis

Better outcomes

Lower restenosis rate

Lower complication rate, morbitity

Easy to perform reinterventions

Thank you for the attention!