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