Endovascular Interventions. A Step-by-Step Approach

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 

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