PRISE EN CHARGE DES LESIONS DISTALES/JAMBIERES

Les techniques endovasculaires très
distales chez le diabétique
Pr E Ducasse, D Midy
Service de Chirurgie vasculaire
CHU Bordeaux
CFPV 19-21 mars 2014
Paris
CLI : definition
Asymptomatic
Mild claudication
Moderate claudication
Severe claudication
Ischemic rest pain
Minor tissue loss
Major tissue loss
Fontaine
class
Rutherford
category
ABI
Symptoms
I
IIa
IIb
IIb
III
IV
IV
0
1
2
3
4
5
6
0.85-1
0.5-0.8
0.5-0.8
0.5-0.8
<0.5
<0.5
<0.5
none
walking distance > 200m
walking distance = 100-200m
walking distance <100
rest pain
minor tissue loss (ulceration)
major tissue loss (gangrene)
Population diabétique
(en millions)
DIABETES : EPIDEMIOLOGY
400
300
Epidémie
de
« DIABESITY »
200
100
2000 2030
Scénario 1 : constant obesity
Scénario 2 : obesity 
+ 114%
+ ???
Wild S, Diabetes Care, 2004
OBESITY : EPIDEMIOLOGY
• Booming of obesity
OBESITY : EPIDEMIOLOGY
• Obesity is equaly dangerous…
EPIDEMIOLOGICAL
NIGHTMARE
• Diabetes + obesity : evolution in the US
CLI : impact for the patient
• ¼ death, 1/3 amputation after 1 year
Hirsch et al. J Am Coll Cardiol 2006; 47: 1239-1312
BTK screening : non invasive
• Exploration : ATK +/- BTK
Duplex 
MRI 
Angio CT  
For all BTK lesions
and clearly now
for SFA lesions…
ENDOVASCULAR OPTION…
IS STILL THE FIRST OPTION…
• Recommandations TASC 2 (F3.2) there is
increasing evidence to support a recommendation for angioplasty in
patients with CLI and infrapopliteal artery occlusion where in-line
flow to the foot can be re-established and where there is medical comorbidity.
Dedicated material
• Stents
– SES and BES
– DES and BSM
• Balloons
–
–
–
–
–
Low-profile balloons
0.014’ and 0.018’
RX and OTW
Dedicated diameter 1.5 to 4 mm
Dedicated length 1 to 200 mm
• And also Wires
– 0.014’ and 0.018’
DEVICES for BTK
• Dedicated stents to BTK lesions
– BES good radial force and good visibility
• 0.014 - OTW
• Ø 2 – 2.5 – 3 – 3.5 – 4 – 4.5 – 5 mm
• L 10,20,30,40 mm
– SES less radial force
over the wire
• 0.018”
• Ø 4 –5 – 6 – 7 mm
• L 20,30,40,60,80 mm
Length up to 200 mm
Diameter from 3 mm
DEVICES : Balloons
• Dedicated balloons
– 0.018 or 0.014’’ balloon
– Dedicated diameter and length
– 0.018’’ – OTW
2 to 4 mm
2 to 220 mm
- 0.014’’ – RX
1.25 to 4 mm
40 to 220 mm – shaft 150 cm
DEVICES
• Example:
Dilation
2.5x150
Pre-op
Post-op
GUIDEWIRES
• Guidewires antegrade way
– 0.035” – 0.032”
• GuideWire (Terumo) 180cm
– 0.018”
• SV Wire (Cordis) 180cm
• V-18 ControlWire (BSci) 180cm
• Cruiser (Biotronik) 195 cm and 300 cm
– 0.014”
• Asahi (Abbott) 180cm / Pilot and Win wires 300 cm
• Cruiser (Biotronik) 190 cm : IDEAL : Chromium enriched Nitinol wire
–
–
–
Coating :
Proximal  PTFE on stainless steel shaft
Distal
 hydrophylic coating
Tip stiffness : high flexible – flexible – medium
Tip shape : straight – Angled
GUIDEWIRES
SUMMARY
• 0.014’’ are dedicated for navigation
– Multistenosed lesions
– In foot lesions
• 0.018’’ are dedicated for recanalisation
– Thrombosis and preocclusive lesions
PERSONAL ATTITUDE
Antegrade approach
Antegrade approach
• Placement of short sheath at puncture
site
– 6F, 11cm or 4F long sheath
In FOOT treatment
• Male 66 years – stage 6 – quikly surgical
debridment on infected diabetic foot
Very distal lesion
Distal navigation
0.014’ wire
Treatment
Balloon 2x20mm
Remaining lesion
Angioplasty + stenting
Now dedicated – 3 mm - SES
BES
2x10mm
10 days after
Excellent pedal pulse
CLINICAL CASE
• 63 years old male –
debridment in an other center
–
BTK lesions
revascularisation
0.018’ wire +
support
catheter
Long angioplasty
Balloon 4x120mm
Remaining lesions
Long stenting
• The solution:
– STENTING using SES 5x120 mm
SES: 5x120mm
Primary results
Further lesions on TAA
Balloon 2.5x20mm
In stent recanalisation
0.014 wire +
2.5mm balloon
angioplasty
Result – remaining lesion
Additional stent
BES
3x10mm
Final result
Clinical follow-up at D 6
Clinical FU at 3 weeks
Clinical FU at 4 months
Stenting SUPPORT
Stenting Angioplasty
DEB 3 mm
Final control
Clinical FU at 6 months
• Patient working, no pain, stop of antibiotic
medication
ACCESS
FOCUS
• In more than 80% of case, when there is
only one remaining BTK artery this is the
peroneal artery
• If antegrade recanalisation impossible:
PERONEAL ACCESS
PERONEAL ACCESS
PERONEAL ACCESS
PERONEAL ACCESS
• Retrograde access:
same technique, same tools
CONCLUSION
• Matériel dédié
– 0.014’’ et 0.018’’ guides
– Support cathéter
– Ballon dédiés – diamètre et longueur
• Strategie adaptée à l’aspect clinique
• Aucune hésitation à être agressif en
accord avec l’aspect clinique
CONCLUSION 1
• With a good technique and dedicated
material:
– large and dedicated stenting
– Dedicated balloon
– Adapted guide wire
– No fear for exotic access
• nothing impossible
CONCLUSION 2
• Most advanced endovascular treatment for
BTK lesions is efficient
BEFORE
AFTER