Ischemia critica degli arti inferiori

Trattamenti endovascolari

Claudio Bianchini Massoni

Chirurgia Vascolare

DPT di Medicina e Chirurgia

Università Parma

AORTO-ILIACO

FEMORO-POPLITEO

SOTTOGENICOLARE

Vascular Surgery - University of Parma

Agenda

Quando trattamento endovascolare?

Linee guida

Casi clinici

Risultati

AORTO-ILIACO

FEMORO-POPLITEO

SOTTOGENICOLARE

Vascular Surgery - University of Parma

Agenda

Quando trattamento endovascolare?

• ESVS 2011

Eur J Vasc Endovasc Surg. 2011;42 Suppl 2:S43-59.

• SICVE 2015

It J Vasc Endovasc Surg. 2015;22(3 Suppl 2):25-68

• SVS 2016

J Vasc Surg 2016;63:3S-21S

AORTO-ILIACO

FEMORO-POPLITEO

SOTTOGENICOLARE

ESVS 2011

• Endovascular treatment can be considered a successful primary

strategy for patients with aorto-iliac lesions… Its major advantage

is its less invasiveness, characterized by a lower operative

morbidity-mortality. (Level 3; Grade C)

• …re-interventions may be performed percutaneously. (Level 5;

Grade D)

Vascular Surgery - University of Parma

Linee guida – Aorto-iliache

AORTO-ILIACO

FEMORO-POPLITEO

SOTTOGENICOLARE

SICVE 2015

• Nel paziente con ischemia critica cronica, arteriopatia obliterante

aorto-iliaca… il trattamento endovascolare è preferibile in caso di

lesioni non estese ed anatomia favorevole. Tuttavia in pazienti

con lesioni trofiche avanzate, anche in lesioni aorto-iliache

estese, un primo approccio endovascolare può essere indicato ai

fini di salvataggio d’arto immediato.

Vascular Surgery - University of Parma

Linee guida – Aorto-iliache

AORTO-ILIACO

FEMORO-POPLITEO

SOTTOGENICOLARE

Self-expandable stent

8x80mm

+ post-dilation (7x60mm)

TASC II: B

Vascular Surgery - University of Parma

Caso clinico - #1

AORTO-ILIACO

FEMORO-POPLITEO

SOTTOGENICOLARE

Kissing stent

(self-expandable 9x60mm)

+ kissing ballon

TASC II: C

Vascular Surgery - University of Parma

Caso clinico - #2

AORTO-ILIACO

FEMORO-POPLITEO

SOTTOGENICOLARE

ESVS 2011

• Endovascular treatment of aorto-iliac occlusive disease in a hybrid

fashion offers an acceptable alternative treatment in patients with

aorto-iliac disease and concomitant common femoral artery

disease that requires open surgery. (Level 3b; Grade C).

Vascular Surgery - University of Parma

Linee guida – Aorto-iliache

AORTO-ILIACO

FEMORO-POPLITEO

SOTTOGENICOLARE

Stent

EV3 Protege

10x40mm

8x60mm

8x40mm

Vascular Surgery - University of Parma

Caso clinico - #3

AORTO-ILIACO

FEMORO-POPLITEO

SOTTOGENICOLARE

A comparison between aortobifemoral bypass and aortoiliac

kissing stents in patients with complex aortoiliac obstructive

diseaseDorigo W et al. J Vasc Surg 2017;65:99-107

• Multicenter, retrospective study

• TASC II C and D lesion

• Group 1 (G1): ao-bif bypass; Group 2 (G2): endovascular

G1 open

N=82

G2 endo

N=128P

Technical failure - 2 (1.5%) .3

Intraoperative complication - 2 (1.5%) .3

Local complication 7 (8.5%) 6 (5%) .03

Major morbidity 10 3 .006

Mortality 1 (1%) -

Vascular Surgery - University of Parma

Aorto-iliaco - Risultati

AORTO-ILIACO

FEMORO-POPLITEO

SOTTOGENICOLARE

P=.07 P=.1

P=.6 P=.3

Dorigo W et al. J Vasc Surg 2017;65:99-107

Mean follow-up: 38.1 months (range 1-96)

A comparison between aortobifemoral bypass and aortoiliac

kissing stents in patients with complex aortoiliac obstructive

disease

Vascular Surgery - University of Parma

Aorto-iliaco - Risultati

FEMORO-POPLITEO

SOTTOGENICOLARE

AORTO-ILIACO

SICVE 2015

Vascular Surgery - University of Parma

Linee guida – Femoro-poplitee-tibiali

Chirurgia

• complessità anatomica

• lesioni steno-occlusive lunghe,

specie calcifiche

• paziente non ad alto rischio

chirurgico(Classe I, Livello B)

Endovascolare

• stenosi o occlusioni

segmentarie (no AFC

e ostio della AFS e

AFP)

• … è indicata la rivascolarizzazione secondo il modello angiosomico

con tecnica endovascolare o chirurgica o ibrida scelta in base alla

valutazione del rischio operatorio, dell’aspettativa di vita, della

topografia della malattia steno-ostruttiva, della qualità delle

lesioni steno-ostruttive, dello stadio delle lesioni trofiche, del

patrimonio venoso autologo. … (Classe I, Livello A)

• … L’orientamento più accreditato è quello di scegliere, nei pazienti in

cui possono essere proponibili sia la tecnica endovascolare che quella

chirurgica, la terapia endovascolare nei pazienti con elevato

rischio chirurgico e ridotta aspettativa di vita.

FEMORO-POPLITEO

SOTTOGENICOLARE

AORTO-ILIACO

SVS 2016

• It is presently unclear for which patients EVT is preferable to open

bypass. There are data suggesting that the outcomes of EVT for

TransAtlantic Inter-Society Consensus type D femoropopliteal

lesions are poor in patients with diabetes.

• …the choice of intervention likely depends on the degree of

ischemia, the extent of arterial disease, the extent of the wound,

the presence or absence of infection, and the available

expertise.

Vascular Surgery - University of Parma

Linee guida – Femoro-poplitee-tibiali

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

ESVS 2011

• Short SFA lesions (<5cm) are preferably treated with angioplasty.

Stenting of short lesions should only be performed when suboptimal

results are obtained with PTA alone (Level 1a; Grade B).

• The preferred treatment of intermediate SFA lesions (5-15 cm) is

PTA with primary bare nitinol stenting (Level 1b; Grade B)

• In long SFA lesions (>15 cm) endovascular treatment (intraluminal

or subintimal) with a stent graft seems acceptable when the

patient’s condition precludes an open procedure. … (Level 3b;

Grade C)

Vascular Surgery - University of Parma

Linee guida – Femoro-poplitee

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

Vascular Surgery - University of Parma

Caso clinico - #1

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

Vascular Surgery - University of Parma

Caso clinico - #2

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

Vascular Surgery - University of Parma

Caso clinico - #3

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

PTA6x60mm

Vascular Surgery - University of Parma

Caso clinico - #4

7-8 cm

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

OUTBACK® LTD™

Re-Entry Catheter

Vascular Surgery - University of Parma

Caso clinico - #5

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO Stent Protege

6x150mm

Gore Viabahn

6x50mm

Vascular Surgery - University of Parma

Caso clinico - #5

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

Rutherford 4

Vascular Surgery - University of Parma

Caso clinico - #6

FEMORO-POPLITEO

AORTO-ILIACO

SOTTOGENICOLARE

Vascular Surgery - University of Parma

Infrainguinal multilevel TASC D

Open surgery as first-line treatment of infrainguinal multilevel

TASC D arterial disease with critical limb ischemia Abualhin M, et al.

Oral Presentation at European Society for Vascular Surgery 31st Annual Meeting

62 patients (mean age: 72years, male: 76%)

Revascularization Technique N (%)

CFA Endarterectomy +

Fem-pop Bypass (BTK)10 (16)

Femoro-Tibial/Pedal Bypass 48 (77)

CFA Endarterectomy +

Femoro-Tibial/Pedal Bypass4 (7)

Survival Limb salvage

77%

. .82%

Mean follow-up: 24.6 months

2-y primary p: 55%

2-y assisted p: 69.2%

2-y secondary p: 78%

Patencies

Technical success: 98%

+

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

ESVS 2011

• Hybrid procedures are the preferred treatment modality

irrespective of lesion length in high-risk patients not suitable for

open bypass surgery or when no suitable vein is available if

minimally open revascularization is mandated, such as CFE (Level

2b; Grade B).

Vascular Surgery - University of Parma

Linee guida – Femoro-poplitee

AORTO-ILIACO

FEMORO-POPLITEO

Vascular Surgery - University of Parma

Caso clinico - #7

SOTTOGENICOLARE

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

A meta-analysis of endovascular versus surgical reconstruction

of femoropopliteal arterial disease.

Antoniou GA et al. J Vasc Surg 2013;57:242

• 4 randomized trials; 6 observational studies

• 2817 patients CLI: 74%

Endovascular

Endovascular: 1430 Surgery: 1387

30-d morbidityTechnical failure

SurgeryEndovascular Surgery

Vascular Surgery - University of Parma

Femoro-popliteo - Risultati

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

A meta-analysis of endovascular versus surgical reconstruction

of femoropopliteal arterial disease.

Antoniou GA et al. J Vasc Surg 2013;57:242

Vascular Surgery - University of Parma

Femoro-popliteo - Risultati

AORTO-ILIACO

FEMORO-POPLITEO

SOTTOGENICOLARE

ESVS 2011

• Endovascular treatment of infrapopliteal arteries has the potential to

achieve similar limb salvage rates with less procedural

morbidity and mortality than surgical bypass. Angioplasty as the

first-line therapeutic modality for patients with CLI and

infrapopliteal lesion is reasonable in the majority of cases,

considering that the interventional procedure should not

preclude future surgical intervention. (Level 4; Grade C).

Vascular Surgery - University of Parma

Linee guida –Tibiali

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

Vascular Surgery - University of Parma

Caso clinico - #1

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

POBA 2.5mm in diameter

Vascular Surgery - University of Parma

Caso clinico - #2

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

Vascular Surgery - University of Parma

Caso clinico - #3

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

Vascular Surgery - University of Parma

Caso clinico - #4

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

Vascular Surgery - University of Parma

Tibiali - Risultati

What’s next after optimal infrapopliteal angioplasty ?

Clinical and ultrasonografic results of a prospective single-center study.

Gargiulo M e t al. J Endovasc Ther 2008;15:363-369

37.9%

87 limbs

Months

Primary patency

1-y restenosis rate

62.1%

Endovascular Surgery

AORTO-ILIACO

Percutaneous Transluminal Angioplasty in Patients With

Infrapopliteal Arterial Disease: Systematic Review and Meta-

Analysis. Mustapha JA et al. Circ Cardiovasc Interv. 2016 May;9(5):e003468.

• 52 studies (65% retrospective; 35% prospective)

• 6769 patients; 9399 lesions

CLI: 97%

SOTTOGENICOLARE

FEMORO-POPLITEO 1-y primary patency:

63.1% 1-y repeated

revascularization:

18.2%

1-y major amputation:

14.9%

Vascular Surgery - University of Parma

Tibiali - Risultati

1 year

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

Wu R et al. J Vasc Surg. 2014;59(6):1711.

Limb salvage

6 months 6 months

1 year

Primary patency

Percutaneous transluminal angioplasty versus primary

stenting in infrapopliteal arterial disease: a meta-analysis of

randomized trials.

Vascular Surgery - University of Parma

Tibiali - Risultati

AORTO-ILIACO

SOTTOGENICOLARE

FEMORO-POPLITEO

Wu R et al. Int J Surg. 2016;35:88

1-y target lesion

revascularization1-y binary restenosis

Drug-eluting balloon versus standard percutaneous

transluminal angioplasty in infrapopliteal arterial disease: A

meta-analysis of randomized trials.

1-y late lumen loss

Vascular Surgery - University of Parma

Tibiali - Risultati

AORTO-ILIACO

FEMORO-POPLITEO

SOTTOGENICOLARE

Endovascolare >>> chirurgia

• Stenosi, occlusioni corte o di media lunghezza

• Non calcificazione

• Elevato rischio operatorio, ridotta aspettativa di vita,

lesioni trofiche poco estese, assenza di patrimonio

venoso autologo

• Trattamento endovascolare come primo approccio

nella maggior parte dei casi, purché non precluda

un successivo trattamento chirurgico

Vascular Surgery - University of Parma

CLI – Trattamento endovascolare

Quando trattamento endovascolare?