A practical and systematic approach to current endovascular surgical techniques

An increasingly popular alternative to open vascular surgery, endovascular intervention offers many advantages, including reduced patient discomfort, smaller incisions, shorter recovery time, and decreased risk of adverse complications. Practitioners and trainees alike require expert guidance on current technologies and up-to-date techniques. Endovascular Interventions provides clinicians with an easy-to-follow guide for minimally invasive treatment of vascular disease. This invaluable resource delivers concise and accurate instructions on a wide range of endovascular interventions, including aorta, renal and mesenteric interventions, lower extremity interventions, venous interventions, and supra-aortic interventions in high-risk patients.

Sequential phases of skill development broaden the reader's abilities as they progress through each chapter, supplying step-by-step instructions on when each procedure should be used and how it can be safely and effectively performed. This book offers a complete reference to essential techniques and procedures, suitable for both novice and experienced vascular surgeons, cardiologists, and radiologists. Endovascular Interventions also:

Reinforces comprehension of each procedure with templated chapters, equipment lists and boxed key learning points
Provides full-color clinical images and detailed illustrations to demonstrate surgical procedures
Presents authoritative coverage of modern endovascular technologies and techniques
Written by a team of respected experts and practicing surgeons from internationally recognized hospitals and universities
Suitable for varying skill levels, Endovascular Interventions is a precise, accessible instruction manual for safe and effective endovascular intervention, helping practicing clinicians sharpen their existing abilities and keep pace with the latest surgical technologies while instructing trainees on this innovative approach to vascular surgery.


Jose M. Wiley, MD, MPH, Sidney W. and Marilyn S. Lassen Chair in Cardiovascular Medicine, Professor of Medicine, Chief, Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA


Cristina Sanina, MD, Interventional Cardiology Fellow, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA


George D. Dangas, MD, PhD, Professor of Medicine-Cardiology and Vascular Surgery, Director of Cardiovascular Innovation, Icahn School of Medicine at Mount Sinai, New York, NY, USA


Prakash Krishnan, MD, Professor of Medicine-Cardiology, Director of Endovascular Services, Icahn School of Medicine at Mount Sinai, New York, NY, USA


List of Contributors: Endovascular Interventions A Step-by-Step
Approach


1 Innominate & Carotid Artery Intervention in High-Risk Patients 1

Tyrone J. Collins

Introduction 1
Innominate Interventions in High-Risk Patients 2
Catheter-based Therapy for An Innominate (Brachiocephalic) Stenosis 2
Carotid Artery Intervention in High-Risk Patients 5
Endovascular Treatment of A Carotid Stenosis 5
Catheter-based Therapy for Carotid Stenosis 6
Conclusions 10
References 13
2 Subclavian Artery Intervention: Catheter-Based Therapy 15

Saadat Shariff, Isabella Alviz, Cornelia Rivera, Michelle Cortorreal, and Tyrone J. Collins

Introduction 15
Endovascular Versus Open Surgical Revascularization 16
Endovascular Revascularization Techniques 16
Conclusion 18
References 19
3 Vertebral Artery Intervention: Catheter-Based Therapy 20

Tamunoinemi Bob-Manuel and James S. Jenkins

Introduction 20
Preprocedural Considerations 21
Step 1. Procedural Planning with Diagnostic Angiography 21
Step 2. Vertebral Artery Intervention (Percutaneous Transluminal Angioplasty) 24
Step 3. Vertebral Artery Intervention (Stenting) 25
Management of Potential Complications 27
Postprocedural Care 28
References 29
4 Endovascular Repair of Thoracic Aortic Aneurysms: Catheter-Based Therapy 30

John Denesopolis, Patricia Yau, and Aksim G. Rivera

Introduction 30
Relevant Anatomy 31
Aortic Anatomy 31
Crawford Classification for TAA/TAAA 31
Landing Zones 31
Implication of Aortic Anatomy on Spinal Perfusion 32
Indications/Contraindications to Procedure 33
Indications 33
Asymptomatic TAA/TAAA 33
Blunt Aortic Injury (BAI) 33
Acute Aortic Syndromes 33
Contraindications/Caveats 34
Available Endografts 34
Preoperative Evaluation 40
Positioning and Intraoperative Monitoring Needs 41
Procedural Steps 42
Postoperative Course/Surveillance 46
Monitored Setting 46
Spinal Drain 46
Blood Pressure Control 47
Arm Ischemia Symptoms 47
CTA Surveillance/Endoleak Types 48
References 49
5 Endovascular Abdominal Aortic Aneurysm Repair (EVAR) 50

John Futchko, Katie MacCallum, and Aksim G. Rivera

Introduction 50
Patient Selection 50
Preoperative Imaging and Measurements 51
Graft Selection 51
Graft Sizing 52
Neck Length 52
Neck Diameter 53
Branch Vessels 53
Aortic Length Measurements 54
Step 1. Vascular Access 54
Percutaneous 54
Open 55
Iliac Disease and Conduits 55
Step 2. Imaging 56
Equipment 56
Neck Angulation 57
Renal Arteries 57
Step 3. Wires 57
Step 4. Delivery and Deployment 57
Main Body 57
Graft Orientation 57
Proximal Landing Zone 58
Contralateral Gate Cannulation 59
Limb Deployment 59
Step 9. Completion Angiogram 60
Step 5. Troubleshooting 60
Endoleaks 60
Inadvertent Coverage of Renal Arteries 61
Iliac Artery Considerations 61
Conclusion 62
References 62
6 Severe Renal Artery Stenosis: How to Intervene 64

Mohammad Hashim Mustehsan, Cristina Sanina, and Jose D. Tafur

Introduction 64
Background and Clinical Significance 65
Epidemiology 65
Clinical Manifestations 65
Patient Selection: Who to Screen for RAS 66
RAS Assessment 66
Noninvasive RAS Assessment 66
Invasive RAS Assessment 68
Indications for Revascularization 68
Intervention 70
References 72
7 Mesenteric Ischemia: Chronic and Acute Management 74

David A. Hirschl

Introduction 74
Chronic Mesenteric Ischemia 74
Step 1. Vascular Access and Sheath Selection 75
Step 2. Diagnostic Angiography 76
Step 3. Vessel Selection 77
Step 4. Selective Angiography 77
Step 5. Placement of a Working Wire 78
Step 6. Stent Placement 78
Step 7. Posttreatment Angiography 79
Step 8. Revision 79
Complications 80
Follow-Up and Outcomes 81
Acute Mesenteric Ischemia 81
Step 1. Arterial Vascular Access and Sheath Selection 83
Step 2. Selection of the SMA 83
Step 3. Aspiration Embolectomy 84
Step 4. Angiogram 85
Step 5. Thrombolysis 85
Step 6. Infusion and Follow-Up 87
Mesenteric Venous Thrombosis 87
Follow-Up and Outcomes 87
References 88
8 Aorto-Iliac Interventions 91

Michael S. Segal, Sameh Elrabie, and Rajesh K. Malik

Introduction 91
Preoperative Workup 91
Noninvasive Studies 92
Computed Tomographic Angiography 92
Ultrasound Duplex 92
Magnetic Resonance Angiography 93
Invasive Imaging 93
Angiography 93
Classification of Lesion and Planning of Intervention 93
TransAtlantic InterSociety Consensus II Classification (TASC II) 93
Planning for the Intervention 93
Step 1. Patient Factors 93
Step 2. Vascular Access 94
Step 3. Crossing the Lesion 95
Step 4. Intervention 96
Step 5. Closure 98
Step 6. Complications 99
Rupture 99
Embolization 99
Access Complications 99
Cases 100
Case 1 100
Case 2 100
References 103
9 Femoropopliteal Arterial Interventions in the Claudicant 104

Sahil A. Parikh, Joseph J. Ingrassia, and Matthew T. Finn

Introduction 104
Patient Evaluation and Indications for Treatment of Femoropopliteal Arterial Pathology 104
Indications for Revascularization Femoropopliteal Claudication 105
Vascular Imaging in Endovascular Treatment 105
Contrast Angiography 105
CO2 Angiography 106
Steps to CO2 Angiography 106
Extravascular and Intravascular Ultrasound 106
Steps to IVUS Use 107
Vascular Access and Lesion Crossing Techniques 109
Steps for Crossover Up and Over technique 109
Radial 110
Tibio-Pedal Approach 111
Antegrade Femoral Access 111
Working Wire Size and Changing Between Systems 112
Lesion Preparation 113
Plain Old Balloon Angioplasty 113
Focal Force Balloons for Optimal Lumen Gain 116
Drug-Coated
Balloons 116
Atherectomy 117
Laser 117
Excimer Laser Use Steps 118
Rotational Atherectomy 119
Rotational Atherectomy Steps 120
Directional Atherectomy 120
Orbital Atherectomy 122
Embolic Protection 123
Troubleshooting Embolic Protection Devices 126
Troubleshooting a Full Filter 126
Distal Embolization or No Reflow 126
Stenting for Femoropopliteal Disease 127
Bare-Metal Stents 127
Drug-Eluting Stents (DES) 127
Alternative Stent Technologies 128
Covered Stents 128
Tacks 128
Final Efficacy Assessment 128
Conclusions 128
Acknowledgments 129
References 129
10 Tibial Interventions in Patients with Critical Limb-Threatening Ischemia 134

Raman Sharma, Roberto Cerrud-Rodriguez, and Prakash Krishnan

Introduction 134
Indications and Goals of Endovascular Revascularization 134
Considerations for Access Site 135
Single Versus Multitibial Artery Revascularization 136
Antegrade Tibial Artery Intervention 137
Retrograde Access for Retrograde Lesion Crossing and Wire Externalization with Antegrade Revascularization 139
TAMI Retrograde Revascularization 140
Reentry and Externalization Devices 142
Deep Venous Arterialization (DVA) 142
References 143
11 Acute Limb Ischemia: Endovascular Approach 147

Shunsuke Aoi and Amit M. Kakkar

Introduction 147
Procedure Planning, Equipment, and Considerations 147
References 157
12 Pedal Reconstruction 158

Ehrin Armstrong and Rory Brinker

Introduction 158
Pedal Arch Reconstruction 158
Indications for Pedal Revascularization 162
Technical Considerations 162
Access 163
Lesion Crossing 163
CTO Lesion Subtype 163
Special Considerations of the Pedal Intervention 164
Troubleshooting 165
Summary 165
References 169
13 Endovascular Management of Access Site Complications 171

Manaf Assafin, Robert Pyo, Pedro Cox-Alomar, and Miguel Alvarez-Villela

Introduction 171
Complications Related to Common Femoral Artery Access 172
Access Site Bleeding 172
Crossover Technique 175
BalloonTamponade, Endovascular Coiling, and Covered Stent Placement 175
Femoral Pseudoaneurysms 176
Ultrasound-Guided Compression Repair 178
Ultrasound-Guided Thrombin Injection 179
Covered Stent Placement 180
Other Techniques 180
Arteriovenous Fistulas 181
Vascular Closure Device Related Complications 182
Radial Artery Related Complications 183
Radial Artery Spasm 184
Radial Artery Occlusion 185
Bleeding Complications 186
References 187
14 Acute Deep Vein Thrombosis 192

Vishal Kapur and Sagar Goyal

Introduction 192
Treatment Strategy 193
Initial and Long-Term Treatment of VTE 196
Oral Anticoagulants 196
Thrombolysis 196
Vena Cava Filters 197
Compression Stockings 198
Cancer-Associated VTE 198
Isolated Distal DVT 198
Extended Treatment 198
Unprovoked VTE 198
Oral Anticoagulants 199
Conclusion 199
References 200
15 Lower-Extremity Venous Stenting 203

Asma Khaliq, Sandrine Labrune, and Cristina Sanina

Introduction 203
Follow-Up 209
References 210
16 Intervention for Pulmonary Embolism 211

Seth I. Sokol, Wissam A. Jaber, and Yosef Golowa

Introduction 211
Pulmonary Angiography 211
Vascular Access 211
Injection and X-Ray Detector Positioning 212
Catheter-Directed Thrombolysis 212
EKOS Catheter-Directed Thrombolysis 212
Preparation of System 213
Access 214
Mechanical Disruption 216
Catheter Fragmentation of Clot 216
Large Catheter Aspiration 216
FlowTriever 216
Access 217
Penumbra 221
AngioVac 223
Patient Selection and Central Venous Access 223
AngioVac Circuit Setup and Thrombus Aspiration 225
AngioVac for Pulmonary Embolus 227
AngioVac for Clot-in-Transit 228
AngioVac for Right Heart Vegetation 228
Patient Selection and Approach 228
Technique 229
References 230
17 Catheter-Based Therapy for Varicose Veins 232

Juan Terre and Nelson Chavarria

Introduction 232
Thermal Techniques 232
Radiofrequency (RF) Ablation 233
Follow-Up 235
Endovenous Laser Ablation (EVLA) 235
Nonthermal Techniques 236
Mechanico-Chemical Ablation (MOCA) 237
Limitations 238
Summary 239
References 239
Index