POSTGRADUAAT ASO 2021 - Bast

POSTGRADUAAT ASO 2021

Vaatheelkunde

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SPREKERS

09.00 – 09.30 Prof. Aerden Critical Limb Ischemia

09.30 – 10.00 Dr. Kerselaers Symptomatische Carotisstenose

10.00 – 10.30 Prof. Debing Buikaneurysma

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CRITICAL LIMB ISCHEMIA

08-02-17

Titel van de presentatie

3

Definition

A limb with chronic, end-stage arterial occlusive disease, that is expected to

require amputation UNLESS successful revascularisation is performed.

- end-stage peripheral arterial disease (atherosclerotic disease)

- Fontaine 3-4 (restpain-tissue loss), or Rutherford 4-5-6 (restpain-minor/major tissue

loss)

- slow progression (years)

- usually uncontrolled CRF

- long history of revascularisations

- long occlusions (stenosis exclusively), multilevel disease (iliac/fem/pop/BTK),

collaterals+++, calcifications (CNI, DM, +80y)

- Ankle-Brachial Index <0.4

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CAVE: CLI VS ACUTE ISCHEMIA VS DF

08-02-17


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‘It’s all occluded arteries’

Acute ischemia CLI DF + PAD

pulselessness +++ +++ ++ (BTK)

pain +++ +++ 0

palor ++ + (<>Buerger test) 0

poikilothermia +++ + 0

paralysis +++ + 0

par/an-esthesia ++ 0 +++

non-healing wound 0 +++ (spontanous) +++ (trauma, neuropathy)

timing hours (acute) years weeks

flow interuption trombus, (plaque rupture) lesions lesions

trauma/aneurysm/embolism atherosclerosis (severe)

atherosclerosis

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CRITICAL LIMB ISCHEMIA ≠ DIABETIC FOOT ULCERATION!

Burn victim

25 sept

Progressive infection

3d3d

I2/23/2021 6

Archetype:dry, circumferential necrosismultiple area’s affectedsurroundings = nl‘far from the heart’

I1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025

IKED-voet2003

M.E. Edmonds1986

Specialised diabetic foot clinic

Brewster1978

Aneurysm repair with synthetic graft

D.G. Armstrong1997

Charcot arthropathy

J. Kunlin1951

Autologous vein grafting

K. Van Acker2000

DFC in Belgium

Best & Murray1940

Heparin purification & use

J.C. Dos Santos1946

First endarterectomy

M. DeBakey1950

First carotidendarterectomy

B. Lipsky1991

Diabetic foot infections

C. Attinger2001

Foot angiosomes

C. Dubost1951

Aneurysm repair with homograft

Cassarella1988

BTK angioplasty

Mullan1980

First Carotid stenting

A. Bolia1990

Subintimal angioplasty

A. Boulton1986

Total Contact Cast

A. Grüntzig1977

First coronary angioplasty

Burke1986

PTFE prothese

L. Graziani2003

Endovascular feasibility in DF

J. Parodi1991

Aneurysm exclusion with endograft

C. Dotter1964

First PTA

E. Faglia2005

Endovascular First for DF

St. Vincent Declaration1989

Reduce Major Amputation by 50%

V.A. Alexandrescu2008

Angiosome-guided revascularization

Open, Reconstructive Vascular Surgery

Endovascular Techniques

Diabetic Foot Pathofysiology

2/23/2021 7

I

RECENT CLI STUDIES

Biagioni RB, Nasser F, Matielo MF, Burihan MC, Brochado Neto FC, Ingrund JC, Sacilotto R.

Comparison of Bypass and Endovascular Intervention for Popliteal Occlusion with the

Involvement of Trifurcation for Critical Limb Ischemia. Ann Vasc Surg. 2020 Feb;63:218-226

Altreuther M, Mattsson E. Long-Term Limb Salvage and Amputation-Free Survival After

Femoropopliteal Bypass and Femoropopliteal PTA for Critical Ischemia in a Clinical Cohort.

Vasc Endovascular Surg. 2019 Feb;53(2):112-117

Dayama A, Tsilimparis N, Kolakowski S, Matolo NM, Humphries MD. Clinical outcomes of

bypass-first versus endovascular-first strategy in patients with chronic limb-threatening

ischemia due to infrageniculate arterial disease. J Vasc Surg. 2019 Jan;69(1):156-163

Mustapha JA, Katzen BT, Neville RF, Lookstein RA, Zeller T, Miller LE, Nelson TR, Jaff MR.

Propensity Score-Adjusted Comparison of Long-Term Outcomes Among Revascularization

Strategies for Critical Limb Ischemia. Circ Cardiovasc Interv. 2019 Sep;12(9)

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Bypass vs Endovascular revascularization

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ENDOVASCULAIR VS OPEN HEELKUNDE

Endovasculair Open heelkunde

+ - + -

anesthesie locale algemene- of locoregionale

incisies geen wondinfectie en littekens

bloed verlies geen onvermijdelijk

contrast allergienefrotoxisch

bestraling

minimaal

patency goed (iliacaal) matig (SFA)slecht (BTK)

goed (ATK)matig (BTK)

slecht indien langebypass en prothese

bypass geen vene PTFE/Dacron

hospitalizatie kort lang

arteriëlesegmenten: multiple of onbereikbaar

ja nee

redo gemakkelijk moeilijk (distalerelandingszone)

2/23/2021 11

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ENDOVASCULAIR VS OPEN HEELKUNDE

Endovasculair Open heelkunde

+ - + -

anesthesie locale algemene- of locoregionale

incisies geen wondinfectie en littekens

bloed verlies geen onvermijdelijk

contrast allergienefrotoxisch

bestraling

minimaal

patency goed (iliacaal) matig (SFA)slecht (BTK)

goed (ATK)matig (BTK)

slecht indien langebypass en prothese

bypass geen vene PTFE/Dacron

hospitalizatie kort lang

arteriëlesegmenten: multiple of onbereikbaar

ja nee

redo gemakkelijk moeilijk (distalerelandingszone)

DM = immunosuppressieulcus = ingangspoort voorinfectie (CAVE prothese)

patency loss ≠ ulcer recurrencewondgenezing ± 3-6 maand

multilevel disease: meerderearteriële segmenten kunnentegelijkertijd behandeld worden

ulcus recidieven zijn ZEER frequent

Femoro-distale bypass: 1m lange vene zeldenbeschikbaar

2/23/2021 12

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OPEN/BYPASS SURGERY

- low surgical/anesthesiological risk (‘the fit elder’)

- maximalization of patency required

- large tissue defect (wound): months of healing required

- rest pain: patency loss = reoccurance of pain

- involvement of common femoral and deep femoral artery

- multi-level disease, long occlusions of SFA and popliteal P2-3

- excellent landing/receptor arterial segment with outflow to correct angiosome

- venous conduit available

- all other: ENDOVASCULAR FIRST/ONLY (+ REDO)

08-02-17


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when is open surgery the optimal revascularization mode?

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COMPOUND PATENCY

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SFA - Full Metal Jacket

10/6/2020

1/2/2021

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ENDOVASCULAR REVASCULARIZATION

- minimal invasive (morbidity, mortality)

- local anesthesia

- minimal blood loss

- no surgical wounds

- multiple target vessels (BTK), simultaneous revascularization

- redo perfectly doable (patency bypass > PTA = false debate)

- low(er) patency = acceptable (small wounds) (DCB/DES to the rescue?)

- ankle and foot arteries (bypass = no option)

- full occlussions (no landing zone required) (bypass = no option)

08-02-17


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when is endovascular the optimal revascularization mode?

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ENDOVASCULAR

08-02-17


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Emerging technologies• Paclitaxel

• Cryotherapy

Intima Hyperplasia

• Intravascular Lithotripsy

• Scoring Balloons

Plaque Rupture

• Arterectomy devices

• Laser

Tunnelisaztion

• Biodegradable

• DES

• Sirolimus

• Paclitaxel

Stents

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PACLITAXEL / DCB

IMPACT- DEEP BTK trial

Konstantinos Katsanos: meta-analysis of 2018 (28 RCTs*) and 2019 (8 RCTs):

‘higher mortality and limb loss, dose dependant’

FDA: stop!

initial industry response: suspicious

08-02-17


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*Katsanos K, Spiliopoulos S, Kitrou P, Krokidis M, Karnabatidis D. Risk of Death Following Application of Paclitaxel-Coated Balloons and Stents in the Femoropopliteal Artery of the Leg: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc. 2018 Dec 18;7(24)

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MEDIACALCINOSIS (ARTERIAL WALL CALCIFICATION)

2/23/2021 18

diabetesrenal failureoctogenarians

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CLI REVASCULARISATION

1. ‘Aorta+Iliac/Femoral/FemPop/2xTibial+Peroneal’

Ankle and Foot arteries are equally important

CT-angio protocol irrelevant when foot pulses are ABSENT

2. ‘Indirect revascularization of wrong angiosome =

OK’

Direct revascularization

3. ‘First: repair inflow (iliac, femoral)’

Flow-limiting leasions are usually BTK

4. ‘Incomplete opening of full length occlusion =

collateral recruitment’

Provide pulsatile flow towards wound region (inflammatory

blush)

08-02-17


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Misconceptions / New Insights

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OK’







blush)



08-02-

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Titel van de presentatie2

0

BTK:- Diabetics- Octogenarians- Renal Failure

I08-02-17


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OK’







blush)

08-02-17


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“An angiosome is a block of tissue

that is fed by one source artery”

Taylor GI, Palmer JH. The vascular territories

(angiosomes) of the body: experimental study and clinical

applications. Br J Plast Surg. 1987;40(2):113–141.

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OK’







blush)

08-02-17


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art. peronealis

art. tibialis posterior

art. tibialis anterior

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OK’







blush)

08-02-17


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2/23/2021 24

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BTK ARTERIAL SEGMENTS ARE PREDOMINANTLY

AFFECTED

2/23/2021 25

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OK’







blush)



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SPREKERS




Carotispathologie: indicaties en behandeling

Laura Kerselaers, kliniekhoofdVaatchirurgie UZ Brussel

Vrijdag 12 februari 2021ASO's 4de en 5de opleidingsjaar Algemene Heelkunde

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BEROERTE MAJEUR GEZONDHEIDSPROBLEEM

1ste

oorzaak verworven handicap volwassenen

3de

oorzaak overlijden

Burden of stroke in Belgium (2015-SAFE):

Incidentie: 10.000 per jaar (↑ 39% te verwachten 2015-2035)

Kost: ong 400 miljoen/jaar

Ong 50 % overlijdt binnen het jaar

Ong 1/3 blijvende handicap

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BEROERTE PLOTSE VERSTORING BLOEDVOORZIENING IN DE HERSENEN

Herseninfarct -ischemisch

(85%)

Hersenbloeding -hemorrhagisch(15%)

Klinisch geen onderscheid: beeldvorming nodig

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BE FAST REMINDER OF STROKE SIGNS

B - BalanceIs the person suddenly having trouble with balance or coordination?

E – Eyes Is the person experiencing suddenly blurred or double vision or a sudden loss of vision in one or both eyes?

F - Face DroopingDoes one side of the face droop or is it numb? Ask the person to smile.

A- Arm Weakness Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?S - Speech DifficultyIs speech slurred, are they unable to speak, or are they hard to

understand? Ask the person to repeat a simple sentence like, “The sky is blue.” Is the sentence repeated correctly?T - Time to call 9-1-1If the person shows any of these symptoms, even if the symptoms go away,

call 9-1-1 and get them to the hospital immediately

Source: American Stroke Association

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2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in

collaboration with the European Society for Vascular Surgery (ESVS). Document covering

atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper

and lower extremity arteries. Endorsed by: the European Stroke Organization (ESO).

Eur J Vasc Endovasc Surg (2018) 55, 305e368

Questions and Answers on Diagnosis and Management of Patients with Peripheral

Arterial Diseases: A Companion Document of the 2017 ESC Guidelines for the Diagnosis

and Treatment of Peripheral Arterial Diseases, in collaboration with the European

Society for Vascular Surgery (ESVS) Endorsed by: the European Stroke Organisation

(ESO).

Eur J Vasc Endovasc Surg (2018) 55,

457e464

Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical

Practice Guidelines of the European Society for Vascular Surgery (ESVS). A.R. Naylor a,

J.-B. Ricco a, G.J. de Borst a, S. Debus a, J. de Haro a, A. Halliday, et al.

Eur J Vasc Endovasc Surg (2018) 55, 3e81

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AETIOLOGY OF CAROTID TERRITORY ISCHAEMIC STROKE

The principal causes of ischaemic, carotid territory stroke are

thromboembolism from ICA or MCA (25%),

small vessel intracranial disease (25%),

cardiac embolism (20%),

other specified rarer causes (5%),

and unknown causes despite investigation (25%).

Overall, about 10 -15% of all strokes follow thromboembolism

from a previously asymptomatic ICA stenosis >50%.

ICopyrights apply

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CASE 1

A 76-year-old male is referred 48 hours after a transient ischaemic attack in the territory of the left carotid artery.

He presented a recurrent episode of transient aphasia two hours prior to admission. He is not currently taking any medication. The duplex ultrasound scan (DUS) reveals a 60% stenosis of the left internal carotid artery (ICA) and non-stenotic plaques in the right ICA.

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CASE 1

Onderscheid symptomen carotisstenose:

–> asymptomatisch vs symptomatisch (< 6ma)

Onderscheid symptomatologie:

-> AF (ipsi) – TIA – stroke (contra)

Q1. Do you plan any further carotid imaging?

>DUS – CTA - MRA

>CAS –> aortic arch

Q2. How would you manage the patient?

>CEA? - CAS? – BMT?

>Timing?

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METHODS FOR MEASURING CAROTID ARTERY STENOSIS SEVERITY.

23-2-202138

I11/10

/201239

PreSSUB

Stroke = Time is brain

Neurologist: IVTL < 4,5u after onsetInterventional radiologist: Trombectomy major vesselocclusion <24h

Goals: door to needle: < 30 min (< 15 min bij de routines)door to groin: < 60 min

CEA – CAS - BMT = Prevention of strokeremove – cover – stabilize plaque

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TIMING CEA

Stroke-in-evolution, Crescendo TIAs : urgent

TIA, minor stroke: asap (within 2 weeks)

Patients with a significant neurological deficit (modified Rankin > 3), with an area

of infarction exceeding one-third of the MCA territory and those who have altered

consciousness should not undergo CEA until significant neurological improvement

has occurred.

11/10

/2012PreSSUB 40

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CASE 3

A 62-year-old man is referred for a left carotid bruit. He is asymptomatic and smokes tobacco regularly. DUS found a 70% left ICA stenosis. His medical history includes a transient ischaemic aphasia seven years earlier and a thyroidectomy complicated by right recurrent laryngeal nerve (RLN) palsy.

Further investigations reveal that the left carotid lesion is predominantly echolucent and there is evidence of an old ‘silent’ infarction in the left parietal hemisphere.

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CASE 3

Q6. Should the 70% asymptomatic left ICA stenosis be treated?

• Optimal medical therapy

• Smoking cessation and assistance.

• Carotid revascularization

Q7. What should be the revascularization strategy: CEA or CAS?

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I11/10

/201244

PreSSUB

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TREATMENT CEA : PLAQUE REMOVAL

Type anesthesia

- AA vs LRA

23-2-202146

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Fixatie hoofd en bovenste

ledematen

Arteriële bloeddrukmonitoring

Monitoring contralaterale

motoriek

Monitoring hogere

hersenfuncties (tellen)

Installatie Locoregionale anesthesie

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Type anesthesia

Classic vs eversion endarterectomy

23-2-202148

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KLASSIEKE CEA

08-02-17 49

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EVERSIETECHNIEK - RAITHEL

08-02-17 50

Indicaties:

• Kinking ACI

Voorwaarde Raithel:

• Geïsoleerde ACI aantasting

Nadeel:

• Shunting moeilijker

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EVERSIE ENDARTERECTOMIE

08-02-17 51

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Type anesthesia


Anteromediaal vs retrojugulair

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ANTEROMEDIAAL VS RETROJUGULAIR

Beasley et al.

Ann R Coll Surg

Eng 2008

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Type anesthesia



Patch vs primary closure

23-2-202154

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Type anesthesia



Patch vs primary closure

Shunt? No – routine - indication

- no shunt (?) when: stump-pressure, frontal lobe monitoring (EEG, NIRS), LRA

- circulus of Willis ok? Contralateral occlusion?

- shunt complications: dissection, air- of blood clot embolism

- increases operation difficulty

- false sense of security (no flow)

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CAROTID ARTERY STENTING : PLAQUE COVERING

• EPD (embolic protection device)

• Compared to CEA: more minor stroke perioperative, equal results at long term

• Indications

> hostile neck (redo surgery, tracheo, radiation neck, cervical kyphosis/obesity)

> Contralateral vocal cord paralysis

> lesion out-of-reach (under mandibula), or concomitant lesions in CCA

> unfit for anesthesia: very rare indication

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TECHNIEK – CAS (1/3)

26-04-2018

Techniek van carotid artery stenting

57

Via AFC

- Retrograad aanprikken AFC

- Plaatsen korte 7Fr. Sheat

- 0.035 voerdraad en catheter om ACC te catheteriseren tot ACE

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- Exchange naar stijve guidewire

- Opvoeren lange sheat tot in ACC

- Angiografie

- 0,014 voerdraad met Embolic Protection

Device op gemonteerd

- Voorzichtig tot voorbij letsel passeren

- Catheter terug trekken, EPD ter plaatse,

ruim voorbij stenose

26-04_2018

Techniek van carotid artery stenting

58

Via AFC

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- Zo nodig predilateren

- Stent positioneren en vrijzetten

- Postdilatereren, zacht niet

aandringen

- Controle angiografie

- Verwijderen van EPD nadat dit

terug dicht getrokken wordt in

catheter

- Verwijderen sheat mits closure

device of manuele compressie

08-02-17


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Via AFC

IBest medical therapy

6023-2-2021

BEST MEDICAL THERAPY : PLAQUE STABILISATION

In secundaire preventie van CVA/TIA wordt aanbevolen:

Een geleidelijk te bereiken maar strikte

bloeddrukcontrole, waarbij ACEI en ARB de voorkeur

genieten.

Een absolute rookstop.

Een strikte controle van diabetes mellitus.

Toediening van een statine, ook bij borderline normale

cholesterolemie.

IBest medical therapy

6123-2-2021

BEST MEDICAL THERAPY : PLAQUE STABILISATION

Anti-aggregerende medicatie :

• Aspirin 75 à 160 mg/d bij asymptomatische stenose

• Aspirine + Clopidogrel 75mg bij TIA/minor stroke, na 3 weken

Clopidogrel in monotherapie verder

Anticoagulantia

• Bij voorkamerfibrillatie of cardiale emboligene pathologie

• In monotherapie !

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QUESTION #1

SHOULD WE CONSIDER ANY INTERVENTION (CEA / CAS)

FOR ASYMPTOMATIC CAROTID PATIENTS?

ASYMPT STENOSE: REVASC VS BMT:

ECST-2, CREST-2

QUESTION #2

CEA VS CAS IN ASYMPT PATIENTS?

ACST-2

GUIDELINES: 2022

Two BIG questions in carotid research:

VRAGEN?

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SPREKERS




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CASUS

65

23-2-2021

Vrouw van 74 jaar vertoont sinds enkele weken vage abdominale pijnen en af en toe messtekende pijnen ter hoogte van de rug

Medische voorgeschiedenis Hysterectomie en ovariectomie Appendicectomie

Cardiovasculaire risicofactoren Actief tabagisme AHT hypercholesterolemie

Thuismedicatie Exforge 10/160mg 1x/dag Crestor 10 mg 1/dag

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FYSIEK ONDERZOEK

66

23-2-2021

BD 135/85

Hartritme:102 per minuut, regelmatig

Normale vulling en hydratatie

BMI 28

Aa carotis +/+, geen souffle

Cor: S1 S2, geen souffle

Longen: zuivere auscultatie

Abdomen: pulsatiele massa, pijnlijk bij diepe palpatie

Pulsaties te voelen ter hoogte van arterie femoralis communis, poplitea,

dorsalis pedis en tibialis posterior

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BIJKOMENDE ONDERZOEKEN

68

23-2-2021

Duplex

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BIJKOMENDE ONDERZOEKEN: CTA

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23-2-2021

Diameter: 7,2 cm

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Diagnose:

Symptomatisch infrarenaal aorta

abdominalis aneurysma (contained

rupture)

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BEHANDELING - INDICATIE

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23-2-2021

Vrouw ≥ 5 cmMan ≥ 5,5 cmSnelgroeiende (≥ 1 cm/jaar)SacculairSymptomatische aneurysma

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RUPTUUR

72

23-2-2021

Contained rupture Retroperitoneale bloeding Intraperitoneale bloeding

Pijn

HD stabiel

Normaal Hb

Pijn

Tachycardie

Normo- tot hypotensief

Daling Hb

Tachycardie

Hypotensief

Hypovolemische shock

Extreem laag Hb

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BEHANDELING

73

23-2-2021

Ervaren team

Bloed en plasma bestellen

Cell saver

Hypotensieve hemostase

Anesthesie inductie start wanneer chirurgen steriel staan en patiënt afgedekt is

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OPEN HERSTEL

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ENDOLEAKS

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TYPE Ia Endoleak

Predictor = outside IFU

Ititel9023-2-2021

VASCULAR TEAM UZB

Documents

POSTGRADUAAT ASO 2021 - Bast