Artery blocked due to Peripheral Artery Disease.

Artery blocked due to Peripheral Artery Disease.


– Hi, we are in the angio suite, and we have an interesting
case this morning. This lady is in the late 70s, and she presented to us
with a long-standing history of vascular blockages in the legs. This is an example of how the plaque in Atherosclerosis disease can affect the circulation of the leg and make the patient suffering
from difficulty on walking and actually pretty much
go around during the day on doing just basic activities. So we already make a small puncture and the left arm circulation
is the brachial artery, and we having a catheter coming
down into that direction. If we look at the screen, you will see a wire leading the path. The wire is located inside the aorta, and we going down all
the way into what we call the abdominal aorta, which
is the lower portion of it. So right at this level, we
have the end of the catheter. We’re gonna hook this with a syringe containing some dye or
some contrast material. We’re going to inject that,
and that will give us a mapping or the configuration of the aorta. In that way, we can identify
where the blockages are. So what we seeing right now is the silhouette of the
lower portion of the aorta. Those two branches at the
top are the kidney arteries, is the artery that gives the
blood supply to the kidney. You can see actually the shape of the kidney
at the end of the rung. And then at the lower portion, I don’t know if it’s possible
to see in the screen, she has two stents placed at what we all the bifurcation of the aorta. That’s where the aorta divide
in two limbs, or two arteries, and those arteries are
the beginning of the flow to the lower legs. And one branch go to the right leg and the other one supposed
to go to the left, but we don’t see that. What we see instead is an absence of flow between the end of the aorta
and those two branches. And you can see in the background the mesh of the two stents that has been placed on
her almost five years ago by another institution. So what I will try to do here is use this tiny wire that
goes inside the catheter, and I will try to see if I
can pass through the stent. And the options of treatment here is, we have the possibility to cross
at least one of the stents. We can re-open that with
different maneuvers. We can do another stenting, we can do angioplasty. Alright, let’s do something here. Let’s do another picture, and
let’s look at the right groin, to see if we have what
we call reconstitution. So I’m injecting the aorta,
the flow is coming collaterals, and you can see the artery right there. So that’s telling me that I have a chance also to come from below up and try to connect the
two ends of the blockage. Alright, so we shift from
the arm to the right groin. So I’m gonna start doing
a picture from below so I can show you the
extension of the blockage. You can see my wire. If I move the wire up, you see it’s gonna get stuck right there. I cannot make any progress
because that’s where the blockage actually starts at the bottom. So I’m injecting from below so we can have what we call the roadmap. It’s an image we can
use and work over there. And you can see how long is the occlusion, it’s not only at the stent,
it’s a little beyond the stent. I’m gonna try to see if we
can cross this blockage. You can see the wire went through. This is where we stand right now. We have access from the
groin and from the left arm. If you can look at the screen, there’s two catheters there. One is coming from above,
the other one from below. We going to get a picture and shoot them simultaneously
from both ends. Here we go. Now. So that’s a large collateral right there, coming up from the aorta. We didn’t see that from above before, but now we’re seeing it because I’m injecting lower in the area. The next step will be also to introduce a tiny catheter which is very
valuable, it’s called IVUS. IVUS is stand for
Intravascular Ultrasound. It’s a catheter that has the capability to show me the inside of the artery. It’s very taper, very small device. Right in this area that is
almost like a yellow color, there is a transducer. It’s a technology that spin around and that recreates circumferentially the anatomy of the vessel
that you want to interrogate, or the vessel that you wanna see. It give you such detail
that you can identify plaque versus thrombus, and also can give you the
dimensions of the artery. We can measure how big the artery is, how long is the blockage, and it just gives you the characteristic of the problem that you’re looking at. So we’re gonna introduce
that in a tiny wire. In a second, you see the round shape of end of the sheath that we
put from the brachial artery, and now this is the probe. The circle that we see right
there is the probe itself. It has a plus sign in the
center, so that’s the instrument. The circumference of the
artery is the white around. So this is, we are right now
in the external iliac artery. I’m gonna push down some more
so we can find, right there. This is normal flow. This is a normal artery right there. Let’s measure the dimensions
of this vessel right here. So we can use the caliper of
the computer of the instrument and then we can measure the dimensions. So this is a 9.4 millimeter vessel. I mean, it’s a pretty good size for the area that we’re looking at. So we’re gonna do what
we call a pull back. If we can do a pull back, okay, let’s go. And what we do is we create
a two-dimensional view of the entire length of the rung. So now we’re gonna come back and you can see that the flow stop and it’s now, kind of
white color in the center, that’s the plaque. And we’re good, we’re
inside the vessel itself. And pretty soon we’re
gonna approach the stent and you will see the very bright marks of a stent right there. Sometimes look like a sunburst coming off every time that we pass a cell. So we are in good location. Look at the stent here,
it’s completely collapsed. It’s almost like an X shape right there, very tight right here in this area. No wonder the vessel got occluded. And then I’m gonna pull back the sheath so we can see better, until we getting to the lumen
of the aorta right there, that’s the aorta. Alright, let’s stop here the rung. And let’s measure the size
and dimensions of the aorta. Maybe 12 in the face clock
we can do a measurement, from the top, 12 to six. So the aorta is close to 11 millimeter. Alright, let’s do something
more interesting with the IVUS. Let me go back again. Now we going to add
some color to the IVUS. This is an interesting feature because it will let you
know where there’s flow. And you can see that red
color means that there is flow in the most of the lumen of the vessel. Remember, because we had
the blockage at the top, we don’t have a good push of flow through because this just kind of very damp flow. But if I pull back, you will see that the red will eventually disappear as we approach the blockage. Now you see just a little tiny areas of flow around the probe that perhaps were created by itself in the attempt to cross this. As we go up, there’s no flow at all. There’s no red. And this is the entire
length of the stent. Again, we see the collapse
of the stent right there. And as we approach the aorta, we should be able to see
flow again, here we go. So that’s the aorta, and there
is good flow at that level. Alright, so from above, what I will do is
introduce a balloon first to make more opening on the stent, and perhaps we can come from
below to do our stenting. You can tell the two radio
paint marks that we have are gonna move the catheters, so we all can identify
the balloon right there. One is past the stent,
the other one is above, so we gonna inflate this like. So you will see the contrast. We mix contrast with saline, and that way we can see
the balloon in the screen. And you can see it fills up
the two ends of the balloon, but in the middle it’s probably that area that we look at the IVUS, that is very collapsed. And that’s probably the culprit or the cause of the failure of the stent. Go up to 10. The patient sometimes feels this balloon in a little back pain. We are doing this procedure actually, with local anesthetic, anesthesia, local anesthesia and conscious sedation, it’s a sedation, so, it’s kind of sleepy. And you can see we have good expansion of the stent right there. Let’s do it for a minute, please. So we keep the balloon
inflated for one minute. And I think we need to
dilate a little lower also, just to reach the other
end of the blockage. Alright, let’s take it down. Right there. Okay, let’s dilate it here. I’m pulling back the sheath so we can uncover the entire
length of the balloon. Go ahead. Here we go. You can see there is some
further narrowing down there. And we knew that because the
IVUS identified that for us. So our next step here
will be repeat the IVUS, look at this area. I’m assuming we’re going to
see a lot of irregularities, but at least we will see
a circumference of flow that we did not have before. Okay. Yeah. Okay, here we go. This is an angio that we’re doing. This is a first angiogram
after we angioplasted this. Alright. Now we have flow through. You know, when I met this patient, she told me that she barely
can walk more than 50 yards without having pain. So we’re using the IVUS one more time. And the reason that we’re
doing the second IVUS is to make our plan of how long of the artery we have to cover, how long is gonna be our new stent. Alright, pulling back. Oh, definitely a better pattern of flow. You can see how the
red is filling entirely the circumference of the vessel. So we should approach the
stent pretty soon here. You can see the burden of
plaque in the left side between nine and six in a clock face. So even though it’s been improved, you can tell that the nidus of the plaque and the burden of the plaque is still significant right there. So that’s the stent. You see how, how stand up by the shining
circumference of the metal. The stent itself doesn’t
actually look bad this time but again, this is this collapsed area. And that’s the aorta right there. Alright, so let me see where the probe is. Right at the top, no? Very good. So let’s go back to that
two-dimensional view and get some measurements. I need to get the size and diameter of the iliac artery one more time. And that will get me the idea of how big should be the stent. So I know that there is
plaque here and there. Right there is completely clean, so let’s make a mark on the screen because I want to bring the stent all the way down to that point. And then I’m gonna come back here and get a measurement right at this level, which is the middle of
the common iliac artery. Having these two lines, I will measure the distance
from the lower line back into the top of a stent, which is right there. And with this ruler, we going to measure the length of the catheter that I pulled back, and based on this length, the
stent has to be 10 centimeter. So because the stent that
we using is quite big, what I will do is coming
from below with the wire, now that the vessel is open, you see how easy the wire now cross. At the beginning, we
couldn’t come from below but now the wire went through easy because it’s completely open. You can see this is a cover stent. It’s called VIVA from the GORE company. You can see the stent goes from
this point here to this one. It’s 10 centimeter long, and
based on our measurement, should be enough to cover
the length of a stent. Encrypted into the
device it has a mechanism in which that you have to pull a string to uncover a very thin layer of membrane that is maintaining the
stent in that collapsed mode. Once we get into the target,
we going to pull the string, I will show you that, and that will start deploying the stent as
you will see on camera. We have our markers in the screen. You can see the device coming in. The end is right there
in one of the markers. So we pulling back the sheath,
all the way above the stent. Keep going, keep going, right there. So we have two blue lines
right there in the screen. One at the top is telling
us what is the end, the top end of the stent; and the other one at the bottom, which is the end of the common iliac that we know is that there is plaque extending all the way down to that point. So I’m gonna bring it back just a tiny bit because I wanna cover just
a little bit above each end. And you can see how
accurate was the measurement from the IVUS which just
right on target, right there. This is the end of the catheter. It has this knob. I’m gonna do a counter-clockwise rotation, and then I start pulling the string. And you will see how the stent is gonna start deploying on the screen. You have actually to pull
significant amount of it. You can see opening on the top. And it just come down,
opening little by little until we reach the other end. Here we go. So to make sure that
we have a good opening, we going to balloon this a little more. And we will do that from below. Alright, here we go, coming up. Alright, let’s dilate it here. So we going inflate the balloon up to 12 atmospheres of pressure. Here we go. Go, go, go, go. Down. And then we gonna get
the other end right here. Let’s get to 12 atmospheres, too. We already witnessed that the
previous stent was collapsed. Although this one is a different one, it’s still a type of a stent that needs some force to make
it go to the nominal size. The nominal size is the intended size of dimension that it should. So I’m using this balloon to reach that. Down. Alright, so right in the
other you can see the flow. So that’s our new stent. It’s definitely better
flow and better lumen. Actually, looks good. It’s not as collapsed as
it was the first stent. I think we had a pretty good result. The only thing that remains
to do here is the pictures, so let’s do an angiogram. Now. Alright. Yep, I think we had a pretty good result. You can see flow through. The big branch that was on the left side that fit all the length is still intact. I bet the pain on walking that
this patient was experiencing is gonna be gone. This was a complex case, even
for endovascular approach, which is this kind of wire
and catheter techniques. However, the alternative for this patient will be an open bypass, which
is still a big procedure. It has to be done under
general anesthesia. There is some risk involved in that given her age and her
past medical history. So I think this is
probably the simplest way that we can actually improve the lower extremity circulation, and all that she will have at the end, I will use a little closure
device for the puncture side, and from here actually, she is going home. So definitely there is a big difference between the two approaches. But thanks for your attention.

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