Diapositiva 1

Curso de Tratamiento
Endovascular en Patología
Ileo-Femoral e Infra-patelar
15 -16 de marzo, 2012
Angioplastia Infra-patelar…
¡Algunos conceptos!!
Ernesto M. Torresani
SANATORIO MODELO QUILMES
Quilmes – Buenos Aires - Argentina
Dormandy J et al. Fate of the patient with chronic leg ischemia.
Evolución – Enfermedad Vascular Miembros Inferiores
2/3
Estables
1/3
Empeoran
1 - 5% AMPUTACIÓN
J Cardiovasc Surg (Torino) 1989; 30: 50–57
Criqui et al. Mortality over a period of 10 years in patients with PAD.
Evolución – Enfermedad Vascular Miembros Inferiores
N Engl J Med 1992; 326 : 381 – 386.
Hirsch AT et al. ACC/AHA Practice Guidelines of PAD 2005.
Pronóstico del Miembro
• Extensión de la enfermedad vascular
• Tiempo de instalación / evolución de isquemia
• Posibilidad / velocidad en restablecer el flujo al pié
• Trastornos tróficos
ACC – www.acc.org
AHA – www.americaheart.org
Pentecost MJ et al. Guidelines for Peripheral Percutaneous Transluminal
Angioplasty of the Abdominal Aorta and Lower Extremity Vessels.
Indicaciones Clínicas – Revascularización
Claudicación invalidante
Isquemia de reposo
Trastornos tróficos
J Vasc Interv Radiol 2003; 14:S495-S515
Motarjeme A. PTA and Thrombolysis in Leg Salvage.
Objetivos Clínicos – Revascularización
Cicatrización de heridas
Alivio del dolor
Deambulación
J Endovasc Surg 1994; 1:81-87.
Bakal CW et al. PTA of the infrapopliteal arteries: results in 53 patients.
Objetivos Hemodinámicos – Revascularización Infrapatelar
... improving inflow to collaterals
by angioplasty in the absence of
straight-line flow to the foot will
not help most limb salvage patients...
AJR 1990; 154:171-174.
Considerations:
1) Direct flow along the entire
length of ONE Tibial artery is usually
necessary to promote ulcer healing.
2) Direct flow along TWO Tibial
arteries represents the most
favorable condition for
ulcer
healing.
3) In the majority of cases, obtaining
direct flow along a solitary Peroneal
artery, provides little improvement
of TcPO2 measurement, due to lack
of collaterals to the foot.
BASAL
FINAL
Lanfroi Graziani, PCR 2003
Biamino G. Below the knee disease.
TCT 2003
Bendick PJ et al. Progression of Atherosclerosis in Diabetics.
Topografía / Diabéticos – Enfermedad Vascular Miembros Inferiores
1/3 Aorto-Ilíaca o Femoro-poplítea
1/3 Infrapatelar aislada
1/3 Enfermedad difusa
Surgery 1983;93:834-838.
2/3
TASC - INFRAPATELARES
Tipo A. Estenosis única < 1cm en Tibiales o Peronea.
Tipo B. Estenosis múltiple < 1 cm en Tibiales o Peronea.
1 ó 2 Estenosis < 1 cm en la trifurcación tibial
Estenosis en Tibiales ó Peronea c/ ATP en Fem.Sup.
Tipo C. Estenosis 1- 4cm.
Oclusiones 1- 2 cm en Tibiales ó Peronea.
Estenosis extensa en la trifurcación Tibial.
Tipo D. Oclusiones > 2cm en Tibiales ó Peronea.
Enfermedad difusa en Tibiales ó Peronea.
Management of PAD. TASC. J Vasc Surg 2000(31),Supp
Angioplastia Infra-patelar – Vías de Abordaje
Angioplastia Infra-patelar – Vías de Abordaje
Check Flo Performer Introducer
5.5F - 6F - 7F- 8F
40 cm
• 64 años, femenino
• Tabaquista
• Histerectomía por Ca Útero
• Radioterapia Pelviana
• By Pass Femoro-Peroneo
• Claudicación Invalidante
Angioplastia Infra-patelar – Vías de Abordaje
Super Arrow Flex
• 70 años, masculino
• Tabaquista
• HTA
• By Pass Femoro-Peroneo
*Aneurisma Poplíteo
• Oclusión Intra-quirúrgica
Dorros G et al. The Acute Outcome of Tibioperoneal Vessel Angioplasty
in 417 Cases With Claudication and Critical Limb Ischemia.
Vía de abordaje – ATP Infrapatelar
... The ipsilateral retrograde anterior tibial
or posterior tibial artery access, through
cutdown or percutaneous entry, enabled
success in 3 selected cases when antegrade
approach had failed to cross the occluded
segment…
3/417 = 0.7%
Cathet Cardiovasc Diag 1998; 45:251-256.
Bypass vs angioplasty in severe ischaemia of the leg (BASIL):
multicentre,randomised controlled trial. Lancet 2005;366:1925-34.
452 pts – 27 Hospitales (Reino Unido)
(agosto 1999 – junio 2004)
Isquemia Severa de Miemb. Inf. por enf. infra-inguinal
Cirugía 228pts
ATP 224pts
Objetivo primario: Sobrevida libre de amputación.
Bypass vs angioplasty in severe ischaemia of the leg (BASIL):
multicentre,randomised controlled trial. Lancet 2005;366:1925-34.
Amputation-free survival
Vivos s/ amputación
Vivos c/ amputación
Óbito s/ amputación
Óbito c/ amputación
All-cause mortality
248 pts (55%)
38 pts (8%)
130 pts (29%)
36 pts (8%)
Bypass vs angioplasty in severe ischaemia of the leg (BASIL):
multicentre,randomised controlled trial. Lancet 2005;366:1925-34.
Interpretation: In patients presenting with severe limb ischaemia
due to infra-inguinal disease and who are suitable for surgery and
angioplasty, a bypass-surgery-first and a balloon-angioplasty-first
strategy are associated with broadly similar outcomes in terms of
amputation-free survival, and in the short-term, surgery is more
expensive than angioplasty.
We saw no difference in health-related quality of life between the
two strategies, but for the first year the hospital costs associated
with a surgery-first strategy were about one third higher than those
with an angioplasty-first strategy.
TASC - INFRAPATELARES
Tipo A. Estenosis única < 1cm en Tibiales o Peronea.
Tipo B. Estenosis múltiple < 1 cm en Tibiales o Peronea.
1 ó 2 Estenosis < 1 cm en la trifurcación tibial
Estenosis en Tibiales ó Peronea c/ ATP en Fem.Sup.
Tipo C. Estenosis 1- 4cm.
Oclusiones 1- 2 cm en Tibiales ó Peronea.
Estenosis extensa en la trifurcación Tibial.
Tipo D. Oclusiones > 2cm en Tibiales ó Peronea.
Enfermedad difusa en Tibiales ó Peronea.
Management of PAD. TASC. J Vasc Surg 2000(31),Supp
Faglia E. et al. Peripheral Angioplasty as the First-choice Revascularization
Procedure in Diabetic Patients with Critical Limb Ischemia: Prospective Study
993 Consecutive Patients Hospitalized and Folowed Between 1999 and 2003.
Eur J Vasc Endovasc Surg 2005;29:620-627.
2 Diabetic Foot Centre (Italia)
(junio 1999 – diciembre 2003)
1909 hospitalizados
por úlcera en pié o dolor isquémico de reposo
1191 Angiografía
Descartados
Obstrucción <50%
3pts ( 0.25%)
Oclusión calcificada
195pts (16.37%)
ATP 993pts (83.37%)
Faglia E. et al. Peripheral Angioplasty as the First-choice Revascularization
Procedure in Diabetic Patients with Critical Limb Ischemia: Prospective Study
993 Consecutive Patients Hospitalized and Folowed Between 1999 and 2003.
Eur J Vasc Endovasc Surg 2005;29:620-627.
Iliac/femoral/popliteal axis
67pts (6.7%)
Infra-politeal axis
316pts (31.8%)
Femoropopliteal + Infra-politeal axis
610 pts (61.4%)
Faglia E. et al. Peripheral Angioplasty as the First-choice Revascularization
Procedure in Diabetic Patients with Critical Limb Ischemia: Prospective Study
993 Consecutive Patients Hospitalized and Folowed Between 1999 and 2003.
Eur J Vasc Endovasc Surg 2005;29:620-627.
Faglia E. et al. Peripheral Angioplasty as the First-choice Revascularization
Procedure in Diabetic Patients with Critical Limb Ischemia: Prospective Study
993 Consecutive Patients Hospitalized and Folowed Between 1999 and 2003.
Eur J Vasc Endovasc Surg 2005;29:620-627.
Arteria
Estenosis
Múltiple o > 4cm
E.P.
Oclusión
Múltiple o > 2cm
E.P.
Ilíaca
65
29 (44.6%)
65 (100%)
6
3 (50.0%)
6 (100%)
F. Prof.
31
16 (51.6%)
25 (80.6%)
6
1 (16.7%)
5 (83.3%)
F. Sup.
343
266 (77.6%)
341 (99.4%)
185
123 (66.5%)
142 (76.8%)
Poplítea
221
92 (41.6%)
215 (97.3%)
86
47 (54.7%)
77 (89.5%)
T. Ant.
235
188 (80.0%)
215 (91.5%)
589
530 (90.0%)
142 (24.1%)
T. Post.
218
164 (75.2%)
185 (84.7%)
725
679 (93.7%)
83 (11.4%)
Peronea
337
241 (71.5%)
284 (84.3%)
342
257 (75.1%)
88 (25.7%)
Faglia E. et al. Peripheral Angioplasty as the First-choice Revascularization
Procedure in Diabetic Patients with Critical Limb Ischemia: Prospective Study
993 Consecutive Patients Hospitalized and Folowed Between 1999 and 2003.
Eur J Vasc Endovasc Surg 2005;29:620-627.
Major Amputation 17pts (1.7%)
Minor Amputation 478pts (48.1%)
*Toe amputation 55pts (5.5%)
* Ray amputation 232 (23.3%)
*Tarsal-metatarsal amputation 191 (19.2%)
Surgical care without amputation 171pts (17.2%)
(bone substraction, ulcerectomy, skin transplantation)
Local care with dressing 202 (20.3%)
Faglia E. et al. Peripheral Angioplasty as the First-choice Revascularization
Procedure in Diabetic Patients with Critical Limb Ischemia: Prospective Study
993 Consecutive Patients Hospitalized and Folowed Between 1999 and 2003.
Eur J Vasc Endovasc Surg 2005;29:620-627.
• 62 años, masculino
• Ex-tabaquista
• HTA
• Dislipemia
• Obesidad
• Sedentarismo
• IRC en Diálisis
• Diabetes
• Claudic. Int. Prog.
* < 100mts (MIDcho)
BASAL
FINAL
Osamu Iida et al. Importance of the Angiosome Concept for
Endovascular Therapy in Patients with Critical Limb Ischemia
Cathet Cardiovasc Interven 2010; 75:830–836
Lanfroi Graziani, LINC 2005
• 64 años, femenino
• Tabaquista
• Histerectomía por Ca Útero
• Radioterapia Pelviana
• By Pass Femoro-Peroneo
• Claudicación Invalidante
BASAL
Recoil
Stent Coronario
Stent
FINAL
• 70 años, masculino
• Tabaquista
• HTA
• By Pass Femoro-Peroneo
*Aneurisma Poplíteo
• Oclusión Intra-quirúrgica
BASAL
Recoil
Stent
FINAL
Stent Auto-expandible
Lanfroi Graziani, LINC 2005
Giuseppe G.L. Biondi-Zocai, et al. Infragenicular Stent Implantation for
Below-the-Knee Atherosclerotic Disease: Clinical Evidence From an
International Collaborative Meta-Analysis on 640 Patients.
J ENDOVASC THER 2009;16:251–260
Giuseppe G.L. Biondi-Zocai, et al. Infragenicular Stent Implantation for Below-the-Knee
Atherosclerotic Disease: Clinical Evidence From an International Collaborative MetaAnalysis on 640 Patients. J ENDOVASC THER 2009;16:251–260
Giuseppe G.L. Biondi-Zocai, et al. Infragenicular Stent Implantation for Below-the-Knee
Atherosclerotic Disease: Clinical Evidence From an International Collaborative MetaAnalysis on 640 Patients. J ENDOVASC THER 2009;16:251–260
Andrej Schmidt et al. First Experience With Drug-Eluting Balloons in
Infrapopliteal Arteries. Restenosis Rate and Clinical Outcome .
J Am Coll Cardiol, 2011; 58:1105-1109
104 pts – 109 miembros
Isquemia Crítica (82.6%) o Claudicación severa (17.4%)
Longitud media de las lesiones 176
REESTENOSIS a 3 meses
>50%
Oclusiones
88 mm
27.4%
19.1%
8.3%
(en todo el segmento tratado 9.5% resto segmentaria)
Seguimiento 378
65 días
1 pts perdido
17 óbitos
83 (91.2%) con mejoría clínica
Cicatrización completa en 74.2%
Amputación mayor 4 pts
Salvataje del miembro 95.6%
Conclusions: The early restenosis rate of long-segment infrapopliteal disease is significantly lower after
treatment with DEBs compared with historical data using uncoated balloons. Randomized trials are required
to show whether this difference will lead to improvement in clinical outcomes.
Tratamiento Endovascular – ATP Infrapatelar
¿Cuál es la táctica mas apropiada?
BALÓN
Cutting Balón?
Aterectomía?
LASER?
Stent?
. DES?
. Autoexpandibles?
. Biodegradables?
Crioplastia?
...
Dotter CT, Judkins MP. Transluminal Treatment of Arteriosclerotic
Obstruction. Description of a New Technic and a Preliminary Report of
Its Aplication.
Circulation. 1964 Nov;30:654-70.
Mark Inglis
Monte Everest
marzo de 2006