Peripheral Vascular Intervention, lecture, nicvd

7/27/2019 Peripheral Vascular Intervention, lecture, nicvd

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Peripheral vascular intervention

DR. MIR JAMAL UDDINAssociate Professor of CardiologyNational Institute of Cardiovascular Diseases


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Peripheral vascular intervention

Vascular Access:

1. Common femoral arterial approach

a) Retrograde common femoral artery access

b) Antegrade common femoral artery access

c) Contralateral ileofemoral artery access or cross over approach

d) Biletaral access

2. Popliteal approach

3. Brachial arterial approach

4. Radial arterial approach

5. Direct percuteneous carotid access or short cut down technique in

the neck

6. Axillary approach


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1A. Retrograde common femoral artery access. The most

frequently used vascular access.

Tips of CFA puncture

CFA well below the inguinal ligament is the optimum target for

puncture.

Can identify the head of the femur by fluroscopy.

Can make a nick at the level of the lower border of the femoral head.

Puncture should be 1-2cm below the level of inguinal ligament.

At the level of the middle of head of femur.

Puncture needle with single wall technique is ideal.

Puncture needle should be placed at 450 angle.

Seldinger (double wall) puncture-not suitable

Avoid hydrophilic wire with puncture needle because these wires can

be cut by needle.


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Drawback of higher puncture:

Inadequate hemostasis

Bleeding

Retroperitoneal hematoma

Shock

Drawback of low puncture

Ineffective hemostasis

A-V fistula

Pseudoaneurysm


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1B. Antegarade common femoral artery access

It is slightly more technically demanding than retrograde access

& carry higher complication rate.

Tips to do antegrade common femoral artery

(CFA) access.

It is a essential to identify the femoral head under fluoroscopy.

Skin nicks is made cranial to the centre of the femoral head. After feeling the pulse of CFA at the level of the centre of

femoral head puncture needle is introduced through the skin

nick directed obliqued & caudally towards the centre of the

femoral head.

Once CFA has entered guide wire is advanced under fluroscopy

toward SFA which runs medial to the profunada femoris.

AS in the origin of SFA & PFA there is over lapping in AP view

so if]psilateral 20-400 oblique view should be taken.


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Drawback of too cranial puncture:

Insufficient hemostatasis

Retroperitoneal hematoma

Shock

Drawback of too caudal puncture (>3cm below

the inguinal ligament) to the CFA:

Hematoma

Pseudoaneunysm

A-V fistula


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1C. Centralateral ileafemoral artery access or

crossover approach.

Used for intervention of centralateral ileac, CFA Profunda femoris, SFAparticularly when the lesion is located in the ostium or very proximal

portion of SFA, internal ileac, very distal lesion of external iliac arteries.

Technique:-

Arterial sheath in situ in CFA.

Contralateral ileofemoral system is reached by placing a small

dia 5-6F diagnostic catheter with an acute angle (preferably IMA

catheter or JR cobra, Hook, Shepard- Hook) at the aortic,

bifurcation.

Catheter manipulated so that the tip of the catheter engages

ostium of contralateral common iliac artery.

J tipped 035// soft hydrophilic guide wire is then advanced to the

CFA & diagnostic catheter is positioned to FA.


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Guide wire is then exchanged with stiff exchange wire.

Diagnostic catheter & chordis sheath removed.

Then cross over sheath 6-8 F is advanced over the stiff quide wire &placed in contralateral CFA.

Drawback:

In addition to conventional complication of retrogade CFA

puncture:-

1) Dissection of distal abdominal aorta.

2) Dissection of ostium of common iliac artery.


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1D. Bilateral approach

Both RT & Lt CF A approach.

2. Popliteal approach-

20-30% cases standard technique including cross over & antegrade

approach fail to cross total occlusion of SFA.

Indication-

Long SFA occlusion without visible proximal patent stump.

Prerequisite- Only patent proximal popliteal & distal femoral artery &

sufficient peripheral run off.


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Technique-

4F catheter placed in Ext iliac artery

Patient turned to prone position Popliteal puncture performed with the assistance of roadmap

fluoroscopy after injection of contrast through 4F catheter.

6f sheath introduced into PA.

Disadvantage:

Frequency of puncture site related complication is potentially

higher than with conventional technique.


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Brachial arterial approach

Almost not used now a days.

If severe iliac obstruction of distal abdominal aorta 100%

occlusion then it can be used.

May be used as an alternative approach for intervention of

renal arteries.

Technique- Puncture of the brachial artery should be performed in

its distal part above the antecubital fossa.

sheath usually not exceeding 6f


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Drawback:

Ischemia to the hand

Spasm of the vessel

Hematoma.

Axillary approach:

Abandmd now a days


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Peripheral Vascular Intervention, lecture, nicvd