Peripheral Overview

Learning objectives

• Understand common causes and clinical presentation of leg ulcers

• Update on advances in:– endovenous treatment of superficial venous disease– endovascular management of critical limb ischaemia

Peripheral Overview

Ulcer

An ulcer is a defect with loss of epidermis and at least part of the dermis

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Causes of lower limb ulceration

• Venous insufficiency (45-60%)• Arterial insufficiency (10-20%)• Diabetes – neuropathic (15-20%)• Lymphoedema• Vasculitis• Infection• Malignancy• Trauma• Drugs• Skin conditions – pyoderma gangrenosum

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Pathophysiology Venous ulcer

• Venous ulceration is the end result of sustained ambulatory venous hypertension acting on a dermal microcirculation designed to operate in the presence of low venous pressure

Macrovascular• Valvular reflux

– primary incompetence (elastin/collagen) – Secondary incompetence – post thrombotic

• Muscle pump dysfunction– ageing, MSK and neurological pathologies

• Venous obstruction

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Pathophysiology Venous ulcer

Microvascular•Venous stasis and hypoxia•White cell trapping•Pericapillary fibrin cuff – leakage of fibrinogen through pericapillary spaces forms oxygen diffusion barrier•Trapping of growth factors

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Pathophysiology Arterial Ulcer

Microvascular•High blood viscosity•Platelet plugging•Endothelial swelling

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Pathophysiology Diabetic foot ulcer

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Clinical assessment of leg ulcers

FEATURES VENOUS ARTERIAL NEUROPATHICSITE Gaiter area,

commonly medialCircumferential

Pre-tibial, lateral malleolusToes, heel

Pressure areas

PAIN Painless or mild, relieved by elevation

Severe, relieved by dependency

Painless

CHARACTERISTICS Large, irregular marginShallow, sloping edgeSlough with granulation tissue in baseModerate to heavy exudate

Small, irregular shapePunched-out, deepShallow base with necrotic tissueLow exudate unless infected

Regular margins Deep, can probe to bone/sinusSloughy base

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Clinical assessment of leg ulcers

FEATURES VENOUS ARTERIAL NEUROPATHICASSOCIATED

FINDINGSHaemosiderin stainingDry skin, eczemaVaricose veins, oedemaPedal pulses present

Thin, shiny, dry skinReduced or no hair on lower legPallor on leg elevationAbsent or weak pedal pulsesDelayed capillary refill

Callous formationLoss of sensation, vibrationWarm foot

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Diagnostic testingInvestigation• Punch biopsy• ABI

Imaging modalities• Duplex Ultrasound

• Computerized Tomography Angiography (CTA)

• MR Angiography (MRA)

• Angiogram

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ADVANCED VENOUS TREATMENT

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Endovenous ablation

• https://youtu.be/JwWlLTzXtdo

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Sclerotherapy

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Combination endovenous treatment

Advantages•Walk-in, walk-out procedure•Avoid general anaesthetic•Minimal discomfort•Faster return to normal activity•Significantly reduced morbidity

Complications•Saphenous neuralgia•DVT, Heat induced thrombosis•Recurrence•Extravasation of sclerosant•Burn to skin

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Mechanicochemical Ablation

Advantages• No need for tumescent anaesthesia• Short procedure time• No chance of nerve injury

• https://youtu.be/ruMuWMQ_HrE

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Venaseal

https://youtu.be/IBxtKvG20f0

Medical adhesive for closure of the saphenous vein

Advantages•No sedation required•No need for tumescent anaesthesia•Short procedure time•No chance of nerve injury or burn•No need for compression stockings

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ADVANCED ENDOVASCULAR TREATMENT

Common iliacCommon iliac

Internal iliacInternal iliac

ProfundaProfunda

Popliteal arteryPopliteal artery

Posterior tibialPosterior tibial

External iliacExternal iliac

SFASFA

Tibioperoneal trunkTibioperoneal trunk

Anterior tibialAnterior tibial

Peroneal (fibular)Peroneal (fibular)

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Diagnostic Test- Angiography

Angiography:• Gold Standard

• X-ray images of blood vessels

• Use of catheters

• Use of contrast agents

• Femoral artery access is common

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Extension / ContractionExtension / Contraction1.

TorsionTorsion

2.

CompressionCompression

3.FlexionFlexion 4.

Forces Exerted on SFA

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Lesions in SFA

Focal lesionFocal lesion Short proximal nubShort proximal nub

Occlusive diseaseOcclusive disease

Diffuse diseaseDiffuse disease

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Popliteal Artery

Note the flexionpoint

occurs above knee

joint not right at joint

location

Knee FlexionKnee Extension

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Lesion Types – TASC Guidelines 2007TASC Type A• Single stenosis ≤10 cm in length• Single occlusion ≤5 cm in length

Endovascular therapy is treatment of choiceTASC Type B• Multiple lesions each ≤5cm (stenosis or occlusions)• Single stenosis or occlusion ≤15 cm not involving the infrageniculate popliteal artery• Single or multiple lesion in the absence of continuous tibial vessel to improve

inflow for a distal bypass• Heavily calcified occlusion ≤5 cm long• Single popliteal stenosis

Endovascular therapy is preferred treatmentTASC Type C• Multiple stenoses or occlusions totally >15 cm in length, with or without heavy calcification• Recurrent stenoses or occlusion that need treatment after two endovascular interventions.

Surgery is preferred treatment for good risk patientsTASC Type D• Chronic total occlusion of the common femoral artery or SFA >20 cm in length

involving the popliteal artery• Chronic total occlusion of popliteal artery and proximal trifurcation vessels

Surgery is treatment of choice

Norgen L. Hiatt WR, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).Eur J Vasc Endovasc Surg. 2007:33(suppl1);558-559.

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Surgery results

• Gold standard of treatment for TASC C and D• Autologous infrainguinal bypass 60-80% 4 yr patency• Tibial bypass 60% 2 yr patency• Complication 10-15%• Mortality 2-5%• Surveillance required for minimum of 5 yrs for best results

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Interventional Procedure

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Interventional Procedure Basic Steps

• Vascular access

• Catheter/sheath inserted

• Wire inserted and advanced across lesion

• Balloon Angioplasty

• Stent implantation

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Tool Chest for Treatment

Diagnostic

• Sheath– Short– Intermediate – Contralateral

• Wires– 0.035” for catheter

placement– Avoid hydrophillic wires

• Diagnostic catheter – 4-5 fr.– IMA, JR4, AR1, AL1

commonly used

Intervention

• Wires– 0.014”– 0.035” for catheter

placement• Guide Catheter- optional• Balloons

– Low profile– Undersized for pre-dilation

• Stents– BES - iliac– SES- Iliac & SFA

• Alternative Therapies

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Arterial Access

Femoral artery – sheath placement Brachial artery – sheath placement

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Guide Catheters

DoubleCurve

ShephardsCrook

Single Curve

HockeyStick

Multipurpose

Sizes: 6-7 Fr. Various sizes and shapes used

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Treatment: Balloon AngioplastyAngioplasty Balloon• Dilation of narrowed area

• 1:1 balloon size ratio

– Pre-dilation with undersize balloon

Cutting Balloon• 3-4 athertone blades

• Cuts and scores plaque

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Treatment: Balloon AngioplastyDrug eluting balloon• Initially developed to treat restenosis

• Emerging evidence for first line use

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Treatment: Stents

• Balloon Expandable (BE) Stent

• Self-Expanding (SE) Stents– 1-2 mm larger than the reference balloon diameter– Self tapering

• Covered Stents

Stent selection:

The lesion location influences selection stent

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Stent TypesBalloon-expandable:• Stainless Steel

• Cobalt Chromium

• Platinum/Tantalum

Self Expandable:• Nitinol

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Iliac Procedure – Ipsilateral Approach

Sheath insame side as lesion. Wire

crosses lesion

Ballooninflation

Stent deployed Stent implanted

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Arterial access on the opposite side of the body

as the lesion

Guide catheter guide “up-and-over”

the bifurcation.Wire cross lesion

PTA balloon inserted

and inflated

Stent inserted and deployed

Contralateral Approach

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Kissing Balloon technique

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Kissing Balloon Technique At Aorto-iliac Bifurcation

AfterBefore Kissing balloon inflation

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Pre Post

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Infrainguinal angioplasty and stenting

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Infrainguinal angioplasty and stenting

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Long Term ResultsIliac

Result of PTA + Stenting 98% immediate clinical success

Increase in lumen diameter Abolition of pressure gradient across lesion

90%+ primary patency at 1 year 70%+ primary patency at 4 years

PTA only – restenosis rates ~24-40%

SFA PTA alone has restenosis rate of ~40-50%

PTA + Stenting has restenosis rate of ~20-50% Patency 80% at 12 months, but restenosis rates between 40-50% at

2 yrs. DEB patency >80% at 12 months

Surgical Graft Patency is 60-80% – autogenous at 5 years

Palmaz et al. Cardiovasc Interv RadioloI. 1992:15:291-297.

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Potential Procedure Complications

Procedure Related• Access site complications

• Dissection

• Perforation/rupture

• Distal embolisation

• Late aneurysm formation

Device Related• Stent thrombosis

• Stent crush/fracture

• Stent embolization