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Popliteal aneurysm and acute
ischemia :
Treatment options
ENTRETIENS VASCULAIRES 2013
Oren K. Steinmetz MD, FRSC(C)
Intra-arterial thrombolysis for
ALI due to thrombosed popliteal
aneurysm is indicated in
patients with:
1) 2) 3) 4) 5)
20% 20% 20%20%20%
1) Grade I ischemia
2) Grade IIa ischemia
3) Grade IIb ischemia
4) Grade III ischemia
5) none of the above
Compte à rebours
6
In my practice I have used the
following to treat popliteal
aneurysm presenting with ALI:
1. 2. 3. 4.
25% 25%25%25%
1. Bypass
2. intra-arterial thromboloysis
3. tibial angioplasty
4. endovascular stent graft
Compte à rebours
6
What should we do with Carey
Price ?
1. 2. 3.
33% 33%33%
1. Don’t give up hope, he is
very talented
2. Give up hope Choix Trois
3. Trade him to Calgary, he is
more comfortable wearing
cowboy hats anyway
Compte à rebours
6
Popliteal aneurysm and acute
ischemia :
Treatment options
ENTRETIENS VASCULAIRES 2013
Oren K. Steinmetz MD, FRSC(C)
Disclosures
 none
Popliteal Aneurysm
 Most common peripheral aneurysm
 Prevalence less than 1%
 55-65 % symptomatic at presentation
 Swedish national registry*
 15 years
 32% present acute ischemia
*Ravn H, Bergqvist D, Bjorck M: Nationwide study of the outcome of popliteal artery
aneurysms treated surgically. Br J Surg 94:970-977, 2007
Robinson WP, Belkin M.
Semin Vasc Surg 2009.
22:17-24 .
Popliteal aneurysm with ALI
Outcomes
 Popliteal aneurysm ALI
Limb loss 20-60%
VS
 Elective bypass for asymptomatic
popliteal aneurysm
>85% 5 year patency
VS
Popliteal aneurysm with ALI
Pathophysiology
 Thromboembolism
 Occlusion of tibial runoff vessels
 Acute thrombosis
 Combination
Popliteal aneurysm with ALI
Pathophysiology
 90% abnormalities of tibial arteries
 22%-38% single vessel runoff*
 Patients with grade IIa ischemia**
 12/13 no tibial runoff
*Lilly MP, Flinn WR, McCarthy WJ 3rd, et al: The effect of distal arterial anatomy on the
success of popliteal aneurysm repair. J Vasc Surg 7:653-660, 1988
**Marty B, Wicky S, Ris HB, et al: Success of thrombolysis as a predictor
of outcome in acute thrombosis of popliteal aneurysms. J Vasc Surg
35:487-493, 2002
Popliteal aneurysm with ALI
Presentation
 PE
 Duplex
 CTA
 Intra-op angio
2013session2 1
2013session2 1
Popliteal aneurysm with ALI
Management
Establish outflow vessel(s)
Effectively
Safely
Robinson WP, Belkin M.
Semin Vasc Surg 2009.
22:17-24 .
Robinson WP, Belkin M.
Semin Vasc Surg 2009.
22:17-24 .
Popliteal aneurysm with ALI
Presentation
Robinson WP, Belkin M.
Semin Vasc Surg 2009.
22:17-24 .
Popliteal aneurysm with ALI
Management
Grade IIb and III ischemia
Anticoagulation
Attempt Immediate revascularization
Popliteal aneurysm with ALI
Management
Grade IIb and III ischemia
Anticoagulation
Identify outflow vessels-angiogram
 (angio suite or intra-op)
Tibial/popliteal exploration and thrombectomy
Popliteal aneurysm with ALI
Management
Grade IIb and III ischemia
Anticoagulation
Bypass/medial approach
Inflow generally from SFA
Vein conduit
Proximal and distal ligation of aneurysm
Popliteal aneurysm with ALI
Management
Grade IIb and III ischemia
No runoff vessel
anticoagulation
amputation
Robinson WP, Belkin M.
Semin Vasc Surg 2009.
22:17-24 .
Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Anticoagulation
Angiography via contralateral femoral
outflow vessels
VS
no outflow vessels
Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Angio- good runoff
1) bypass
2) endovascular
Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Angio- no visible runoff
1) thrombolysis
2) popliteal/tibial exploration
Popliteal aneurysm with ALI
Management
Thrombolysis Contraindications
 Absolute
1. Established cerebrovascular event (including transient ischemic attacks within last 2 mo)
2. Active bleeding diathesis
3. Recent gastrointestinal bleeding (<10 d)
4. Neurosurgery (intracranial, spinal) within last 3 mo
5. Intracranial trauma within last 3 mo
 Relative major
1. Cardiopulmonary resuscitation within last 10 d
2. Major nonvascular surgery or trauma within last 10 d
3. Uncontrolled hypertension: >180 mm Hg systolic or >110 mm Hg diastolic
4. Puncture of noncompressible vessel
5. Intracranial tumor
6. Recent eye surgery
 Minor
1. Hepatic failure, particularly those with coagulopathy
2. Bacterial endocarditis
3. Pregnancy
4. Diabetic hemorrhagic retinopathy
Popliteal aneurysm with ALI
Management
Thrombolysis Contraindications
Absolute
1. Established cerebrovascular event (including transient
ischemic attacks within last 2 mo)
2. Active bleeding diathesis
3. Recent gastrointestinal bleeding (<10 d)
4. Neurosurgery (intracranial, spinal) within last 3 mo
5. Intracranial trauma within last 3 mo
Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Thrombolysis
-catheter positioned in thrombus
-rTPA 5-10mg bolus
-0.5-1.0 mg/hour
Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Thrombolysis-monitoring
-access site
-neuro status
-heparin aPTT 60 sec
-repeat imaging 6-12 hours
-24 - 48 hours
Popliteal aneurysm with ALI
Management
Thrombolysis Complications
 Intracranial hemorrhage: 0 - 2.5%
 Major bleeding requiring transfusion or
surgery: 1 - 20%
 Compartment syndrome: 1 - 10%
 Distal embolization: 1 - 5%
 Failure - up to 33%
Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Angio- runoff re-established
1) bypass
2) endovascular
Case
2.7 Fr microcatheter in BK
popliteal
r-TPA infusion: 5 mg
bolus, followed by infusion of
0.5 mg/ hour
Patient was admitted to ICU
Continuous anticoagulation
with heparin for a goal of
APTT~ 60 sec
12 hours
24 hours
36 hours
Popliteal aneurysm with ALI
Outcomes-preoperative
thrombolysis
Robinson WP, Belkin M. Semin Vasc Surg 2009, 22:17-24 .
VS
VS
Popliteal aneurysm with ALI
Management
Grade I and IIa ischemia
Thrombolysis – gives no patent runoff vessel
options:
1)tibial exploration and thrombectomy
2) endovascular PTA
3) anticoagulation
A Case
 82 male
2 day cold and painful left foot
 PMH: HTN, Renal transplantation
 Grade IIa limb ischemia
A Case – Diagnostic angiogram
PTA
A Case - Thrombolysis
 2.7 Fr microcatheter in proximal PTA
 r-TPA infusion: 0.5 mg/ hour
 Patient was admitted to ICU
 Continuous anticoagulation with
heparin for a goal of APTT~ 60 sec
12h 24h 36h
A Case
 No significant clinical improvement
 Failure to open a single tibial artery in continuity
with the pedal arch
 Thrombolysis was terminated
 No autologous vein available
Endovascular treatment of a PAA
 0.035-inch Amplatz
super-stiff wire
 2 - 8x150 mm
Viabahn stent
grafts
 Post-dilated with a
8x100 mm balloon
Endovascular treatment of a PAA
 the distal third of PTA
was crossed using a
0.018’’ V-18 Control wire
and Quick Cross support
catheter
Endovascular treatment of a PAA
0.014’’ Miracle 3 wire
to the plantar artery
supported by the
Quick Cross support
catheter
Endovascular treatment of a PAA
 Dilation was repeated with a 3x100 mm Savvy balloon (prolonged, high
pressure dilations)
Endovascular treatment of a PAA
PTA
Plantar
artery
TP
trunk
Another Case
-59 yo male
-Grade II ? III ischemia
-Airlift to Mexico City
-Thrombolysis establishes peroneal runoff
Another Case
Another Case
Popliteal aneurysm with ALI
Outcomes-stent graft
Saratzis et al. Perspectives in Vascular Surgery and Endovascular Therapy 2010.
22(4) 245.
Popliteal aneurysm with ALI
Management
Endovascular stent graft
Limited outcome data
Elderly
Medically unfit for bypass
No autologous conduit
From Tielliu et al.
JVS, 51(6), 2010, 1413-1418.
From Tielliu et al.
JVS, 51(6), 2010, 1413-1418.
From Tielliu et al.
JVS, 51(6), 2010, 1413-1418.
 Overlap zones 93%
 Adductor tubercle
73%
 Younger patients
 Not related to
patency
Popliteal aneurysm with ALI
Management
Treatment choice depends on Grade of
ischemia
Priority to establish outflow
Intra-arterial thrombolysis
Grade I and IIa ischemia
Bypass with autologous graft
Popliteal aneurysm with ALI
Management
Endovascular stent graft
Limited outcome data
Elderly
medically unfit for bypass
No autologous conduit
Robinson WP, Belkin M.
Semin Vasc Surg 2009.
22:17-24 .
What should we do with Carey
Price ?
1) Don’t give up hope,
he is very talented
2) Give up hope
3) Trade him to Calgary,
he is more comfortable wearing
cowboy hats anyways
2013session2 1

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2013session2 1

  • 1. Popliteal aneurysm and acute ischemia : Treatment options ENTRETIENS VASCULAIRES 2013 Oren K. Steinmetz MD, FRSC(C)
  • 2. Intra-arterial thrombolysis for ALI due to thrombosed popliteal aneurysm is indicated in patients with: 1) 2) 3) 4) 5) 20% 20% 20%20%20% 1) Grade I ischemia 2) Grade IIa ischemia 3) Grade IIb ischemia 4) Grade III ischemia 5) none of the above Compte à rebours 6
  • 3. In my practice I have used the following to treat popliteal aneurysm presenting with ALI: 1. 2. 3. 4. 25% 25%25%25% 1. Bypass 2. intra-arterial thromboloysis 3. tibial angioplasty 4. endovascular stent graft Compte à rebours 6
  • 4. What should we do with Carey Price ? 1. 2. 3. 33% 33%33% 1. Don’t give up hope, he is very talented 2. Give up hope Choix Trois 3. Trade him to Calgary, he is more comfortable wearing cowboy hats anyway Compte à rebours 6
  • 5. Popliteal aneurysm and acute ischemia : Treatment options ENTRETIENS VASCULAIRES 2013 Oren K. Steinmetz MD, FRSC(C)
  • 7. Popliteal Aneurysm  Most common peripheral aneurysm  Prevalence less than 1%  55-65 % symptomatic at presentation  Swedish national registry*  15 years  32% present acute ischemia *Ravn H, Bergqvist D, Bjorck M: Nationwide study of the outcome of popliteal artery aneurysms treated surgically. Br J Surg 94:970-977, 2007
  • 8. Robinson WP, Belkin M. Semin Vasc Surg 2009. 22:17-24 .
  • 9. Popliteal aneurysm with ALI Outcomes  Popliteal aneurysm ALI Limb loss 20-60% VS  Elective bypass for asymptomatic popliteal aneurysm >85% 5 year patency
  • 10. VS
  • 11. Popliteal aneurysm with ALI Pathophysiology  Thromboembolism  Occlusion of tibial runoff vessels  Acute thrombosis  Combination
  • 12. Popliteal aneurysm with ALI Pathophysiology  90% abnormalities of tibial arteries  22%-38% single vessel runoff*  Patients with grade IIa ischemia**  12/13 no tibial runoff *Lilly MP, Flinn WR, McCarthy WJ 3rd, et al: The effect of distal arterial anatomy on the success of popliteal aneurysm repair. J Vasc Surg 7:653-660, 1988 **Marty B, Wicky S, Ris HB, et al: Success of thrombolysis as a predictor of outcome in acute thrombosis of popliteal aneurysms. J Vasc Surg 35:487-493, 2002
  • 13. Popliteal aneurysm with ALI Presentation  PE  Duplex  CTA  Intra-op angio
  • 16. Popliteal aneurysm with ALI Management Establish outflow vessel(s) Effectively Safely
  • 17. Robinson WP, Belkin M. Semin Vasc Surg 2009. 22:17-24 .
  • 18. Robinson WP, Belkin M. Semin Vasc Surg 2009. 22:17-24 .
  • 19. Popliteal aneurysm with ALI Presentation
  • 20. Robinson WP, Belkin M. Semin Vasc Surg 2009. 22:17-24 .
  • 21. Popliteal aneurysm with ALI Management Grade IIb and III ischemia Anticoagulation Attempt Immediate revascularization
  • 22. Popliteal aneurysm with ALI Management Grade IIb and III ischemia Anticoagulation Identify outflow vessels-angiogram  (angio suite or intra-op) Tibial/popliteal exploration and thrombectomy
  • 23. Popliteal aneurysm with ALI Management Grade IIb and III ischemia Anticoagulation Bypass/medial approach Inflow generally from SFA Vein conduit Proximal and distal ligation of aneurysm
  • 24. Popliteal aneurysm with ALI Management Grade IIb and III ischemia No runoff vessel anticoagulation amputation
  • 25. Robinson WP, Belkin M. Semin Vasc Surg 2009. 22:17-24 .
  • 26. Popliteal aneurysm with ALI Management Grade I and IIa ischemia Anticoagulation Angiography via contralateral femoral outflow vessels VS no outflow vessels
  • 27. Popliteal aneurysm with ALI Management Grade I and IIa ischemia Angio- good runoff 1) bypass 2) endovascular
  • 28. Popliteal aneurysm with ALI Management Grade I and IIa ischemia Angio- no visible runoff 1) thrombolysis 2) popliteal/tibial exploration
  • 29. Popliteal aneurysm with ALI Management Thrombolysis Contraindications  Absolute 1. Established cerebrovascular event (including transient ischemic attacks within last 2 mo) 2. Active bleeding diathesis 3. Recent gastrointestinal bleeding (<10 d) 4. Neurosurgery (intracranial, spinal) within last 3 mo 5. Intracranial trauma within last 3 mo  Relative major 1. Cardiopulmonary resuscitation within last 10 d 2. Major nonvascular surgery or trauma within last 10 d 3. Uncontrolled hypertension: >180 mm Hg systolic or >110 mm Hg diastolic 4. Puncture of noncompressible vessel 5. Intracranial tumor 6. Recent eye surgery  Minor 1. Hepatic failure, particularly those with coagulopathy 2. Bacterial endocarditis 3. Pregnancy 4. Diabetic hemorrhagic retinopathy
  • 30. Popliteal aneurysm with ALI Management Thrombolysis Contraindications Absolute 1. Established cerebrovascular event (including transient ischemic attacks within last 2 mo) 2. Active bleeding diathesis 3. Recent gastrointestinal bleeding (<10 d) 4. Neurosurgery (intracranial, spinal) within last 3 mo 5. Intracranial trauma within last 3 mo
  • 31. Popliteal aneurysm with ALI Management Grade I and IIa ischemia Thrombolysis -catheter positioned in thrombus -rTPA 5-10mg bolus -0.5-1.0 mg/hour
  • 32. Popliteal aneurysm with ALI Management Grade I and IIa ischemia Thrombolysis-monitoring -access site -neuro status -heparin aPTT 60 sec -repeat imaging 6-12 hours -24 - 48 hours
  • 33. Popliteal aneurysm with ALI Management Thrombolysis Complications  Intracranial hemorrhage: 0 - 2.5%  Major bleeding requiring transfusion or surgery: 1 - 20%  Compartment syndrome: 1 - 10%  Distal embolization: 1 - 5%  Failure - up to 33%
  • 34. Popliteal aneurysm with ALI Management Grade I and IIa ischemia Angio- runoff re-established 1) bypass 2) endovascular
  • 35. Case
  • 36. 2.7 Fr microcatheter in BK popliteal r-TPA infusion: 5 mg bolus, followed by infusion of 0.5 mg/ hour Patient was admitted to ICU Continuous anticoagulation with heparin for a goal of APTT~ 60 sec
  • 40. Popliteal aneurysm with ALI Outcomes-preoperative thrombolysis Robinson WP, Belkin M. Semin Vasc Surg 2009, 22:17-24 .
  • 41. VS
  • 42. VS
  • 43. Popliteal aneurysm with ALI Management Grade I and IIa ischemia Thrombolysis – gives no patent runoff vessel options: 1)tibial exploration and thrombectomy 2) endovascular PTA 3) anticoagulation
  • 44. A Case  82 male 2 day cold and painful left foot  PMH: HTN, Renal transplantation  Grade IIa limb ischemia
  • 45. A Case – Diagnostic angiogram PTA
  • 46. A Case - Thrombolysis  2.7 Fr microcatheter in proximal PTA  r-TPA infusion: 0.5 mg/ hour  Patient was admitted to ICU  Continuous anticoagulation with heparin for a goal of APTT~ 60 sec
  • 48. A Case  No significant clinical improvement  Failure to open a single tibial artery in continuity with the pedal arch  Thrombolysis was terminated  No autologous vein available
  • 49. Endovascular treatment of a PAA  0.035-inch Amplatz super-stiff wire  2 - 8x150 mm Viabahn stent grafts  Post-dilated with a 8x100 mm balloon
  • 50. Endovascular treatment of a PAA  the distal third of PTA was crossed using a 0.018’’ V-18 Control wire and Quick Cross support catheter
  • 51. Endovascular treatment of a PAA 0.014’’ Miracle 3 wire to the plantar artery supported by the Quick Cross support catheter
  • 52. Endovascular treatment of a PAA  Dilation was repeated with a 3x100 mm Savvy balloon (prolonged, high pressure dilations)
  • 53. Endovascular treatment of a PAA PTA Plantar artery TP trunk
  • 54. Another Case -59 yo male -Grade II ? III ischemia -Airlift to Mexico City -Thrombolysis establishes peroneal runoff
  • 57. Popliteal aneurysm with ALI Outcomes-stent graft Saratzis et al. Perspectives in Vascular Surgery and Endovascular Therapy 2010. 22(4) 245.
  • 58. Popliteal aneurysm with ALI Management Endovascular stent graft Limited outcome data Elderly Medically unfit for bypass No autologous conduit
  • 59. From Tielliu et al. JVS, 51(6), 2010, 1413-1418.
  • 60. From Tielliu et al. JVS, 51(6), 2010, 1413-1418.
  • 61. From Tielliu et al. JVS, 51(6), 2010, 1413-1418.  Overlap zones 93%  Adductor tubercle 73%  Younger patients  Not related to patency
  • 62. Popliteal aneurysm with ALI Management Treatment choice depends on Grade of ischemia Priority to establish outflow Intra-arterial thrombolysis Grade I and IIa ischemia Bypass with autologous graft
  • 63. Popliteal aneurysm with ALI Management Endovascular stent graft Limited outcome data Elderly medically unfit for bypass No autologous conduit
  • 64. Robinson WP, Belkin M. Semin Vasc Surg 2009. 22:17-24 .
  • 65. What should we do with Carey Price ? 1) Don’t give up hope, he is very talented 2) Give up hope 3) Trade him to Calgary, he is more comfortable wearing cowboy hats anyways

Notes de l'éditeur

  1. Access siteNeuro
  2. Thromboembolism-progressive occlusion
  3. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  4. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  5. Most IIa or Iib ischemiaHistory of claudication
  6. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  7. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  8. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  9. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  10. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  11. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  12. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  13. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  14. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  15. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  16. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  17. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  18. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  19. Mass or prom pulseAaaDuplexNot amenable to fogarty balloon thrombectomy
  20. It was not possible to advance the catheter distally due to tortuosity and kinking. A prograde micro-catheter was advanced to the mid posterior tibial artery.
  21. There was only minimal progress of recanalization after 12, 24 and 36 hours.
  22. An angiogram revealled disease of the end segment of the PTA
  23. a single tibial artery in continuity with the pedal arch was demonstrated at the end and collaterals around the ankle joint
  24. Access siteNeuro
  25. Access siteNeuro
  26. Access siteNeuro