Endovascular Skills : Guidewire and Catheter Skills for Endovascular Surgery.

Foreword iii Preface to the Third Edition v Part I: BASIC ENDOVASCULAR SKILLS 1. Endovascular Concepts 3 Endovascular Skills in Practice 4 Reinvention of Vascular Care 4 Qualifications 5 Selected Readings 6 2. Case Preparation and Room Setup 9 Set Yourself Up for Success 10 Sizing Up the Case 10 Prior to the Puncture 10 Percutaneous or Open? 11 Working Environment 11 Equipment 12 Facilities and Room Setup 13 Selected Readings 14 3. Getting In: Percutaneous Vascular Access 15 Get on the Vascular Superhighway 16 Angio Consult: What Are the Principles of Percutaneous Access? 16 Choosing Your Approach 17 Femoral Anatomy for Arterial Access 18 vii viii Contents Percutaneous Retrograde Puncture of Femoral Artery 20 Plan of Attack: Guidewire Will Not Pass Through the Needle 25 Micropuncture Technique 26 Percutaneous Antegrade Puncture of Femoral Artery 27 Plan of Attack: How do You Enter the Proximal Femoral Artery During Antegrade Femoral Puncture? 31 Percutaneous Puncture of Pulseless Femoral Artery 31 Angio Consult: How to Perform Fluoroscopically Guided Femoral Access? 32 Proximal Access 33 Percutaneous Puncture of Brachial Artery 35 Percutaneous Puncture of Bypass Grafts 35 Puncture Guidance with Ultrasound 37 Puncture Site Complications 40 Summary of Puncture Site Options 40 Selected Readings 40 4. Basic Sheath Access 43 Basic Access Site Step-by-Step 44 Intial Maneuvers to Secure the Access 45 How Do You Place a Sheath? 45 When is a Dilator Needed? 50 Basic Sizing Issues 50 When to Use Fluoroscopy 51 About Access Sheaths 52 Technique: Handling Access Sheaths 52 5. Guidewire–Catheter Skills 55 Guidewire–Catheter Skills are the Basis of Endovascular Surgery 56 Mastering Guidewires 56 Guidewire Choices 56 Guidewire-Handling Techniques 57 Guidewire–Lesion Interactions 57 What Makes Guidewires Different from Each Other? 57 Length 58 Diameter 59 Stiffness 59 Coating 59 Tip Shape 59 Special Features 61 Guidewire Types in Practice 61 Technique: Guidewire Handling 65 Contents ix Introduction to Catheters: Exchange, Flush, and Selective Catheters 70 Which Angiographic Catheter Should I Use? 70 Construction 70 Diameter 71 Length 71 Head Shape 71 Special Features 71 Catheter Head Shape Determines Function 71 Lingo: Catheter Talk 77 Handling Catheters 78 Technique: Catheter Handling 80 Selected Readings 82 6. Small Platform Guidewires and Monorail Systems 83 The Development of Small Platform Guidewires and Monorail Systems 84 How Do Monorail Systems Differ from Coaxial Systems? 84 What are the Advantages and Disadvantages of Monorail Systems? 86 Principles for Use of Rapid Exchange Systems 87 Which Platform Is Best for Each Task? 87 7. Guidewire and Catheter Passage 89 The Goal of the Procedure Determines the Course of the Guidewire–Catheter Apparatus 90 Initial Catheter Placement 90 Fluoroscopy For Catheter Placement 90 Guidewire and Catheter Combinations 93 Passing Through Diseased Arteries 94 Plan of Attack: Catheter Won’t Follow Guidewire 94 Negotiating Tortuous Arteries 95 Going the Distance: The Very Remote Puncture Site 96 Plan of Attack: Guidewire–Catheter Buckling 96 Passing Through Aneurysms 98 Selected Readings 100 8. Imaging: The Key to Future Success 101 Imaging and Best Therapy Are Intricately Linked 102 Image Quality 102 Generating an X-ray Image 103 x Contents Digital Subtraction Arteriography 105 Imaging Technique for Best Resolution 107 Angio Consult: How Can I Get Better Images? 108 Road Mapping: How It Works and When to Use It 108 Automated Power Injector 110 Power Injection vs. Contrast Administration by Hand 110 Contrast Agents 112 Angio Consult: Is There any Way to Limit Contrast Load? 114 How Do You Know Where You Are? 115 Radiation Safety and Occupational Health Issues 115 Radiographic Equipment 116 Cathode/Anode/X-Ray Tube 116 Generator 116 Image Intensifier 117 C-arm 117 Power Injector 117 Digital Console 117 Radiographic Terms 117 Kv 117 Mas 117 Frame Rate 117 Matrix 118 Focal Spot 118 Mask 118 Radiation Exposure 118 Allowable Limits 118 Dose Calculation 118 X-ray Tube Position 118 Organ Susceptibility 118 Protective Gear 118 Limiting Exposure 119 Selected Readings 119 9. Selective Catheterization 121 Too Many Catheter Choices 122 Angio Consult: What Is Your Strategy For Selective Catheterization? 123 Plan of Attack: Should I Lead With the Guidewire or With the Catheter? 124 Selective Catheterization of the Brachiocephalic Arteries 125 Selective Cerebral Catheters 126 Aortic Arch Branches 127 Selective Catheterization of the Visceral and Renal Arteries 134 Celiac and Superior Mesenteric Arteries 134 Contents xi Renal Artery 136 Selective Catheterization of the Aortoiliac Arteries 138 Passage Over the Aortic Bifurcation 138 Plan of Attack: Crossing the Aortic Bifurcation 142 Selective Catheterization of the Infrainguinal Arteries 143 Superficial Femoral and Popliteal Arteries: up-and-Over Approach 143 Superficial Femoral and Popliteal Arteries: Antegrade Approach 144 Tibial Arteries 145 Infrainguinal Vein Bypass Grafts 147 Technique: Entering an Infrainguinal Vein Graft 148 Selective Catheterization of Prosthetic Bypass Grafts 149 Selected Readings 152 10. Arteriography 153 Arteriography is Strategic, Not Diagnostic 154 The Future of Arteriography 154 Supplies for Arteriography 155 Planning for Strategic Arteriography 156 Location of Symptoms 156 Severity of Symptoms 156 Etiology 156 Comorbid Medical Conditions 156 Questions to Consider Before Arteriography 157 Evaluation Before Angiography 157 Deciding Where to Puncture 158 Angio Consult: How Can Duplex Scanning Help in Choosing a Puncture Site? 160 Catheter Placement 162 Contrast Administration and Image Acquisition 163 Arteriography Sequences 164 Arteriography of the Brachiocephalic Arteries 167 Arch Aortography 167 Carotid Arteriography 168 Subclavian Arteriography 170 Thoracic Aortography 171 Arteriography of the Visceral and Renal Arteries 171 Arteriography of the Celiac and Superior Mesenteric Arteries 172 Arteriography of the Renal Artery 173 Arteriography of the Infrarenal Arteries 174 Arteriography of the Abdominal Aorta and Iliac Arteries 174 Infrarenal Aortography with Lower-Extremity Runoff 174 Femoral Arteriography 175 xii Contents Pedal Arteriography 177 Evaluation of a Diabetic With an Ischemic Foot Lesion 178 Angio Consult: What Can I do to Identify Arteriographic Fakeouts? 179 Lesion Interrogation: Special Views 181 Carbon Dioxide Arteriography 181 Pressure Measurement 183 Arteriography of Aneurysms 184 Angio Consult: How Can I Use Duplex Scanning to Limit the Amount of Arteriography Required? 184 Selected Readings 185 11. Setting Up the Therapeutic Maneuver: Crossing Lesions 187 Three Types of Lesions 188 Crossing Stenoses 189 Plan of Attack: Crossing a Stenosis 194 Angio Consult: Avoiding Subintimal Guidewire Dissection, Unless of Course You Intend a Subintimal Course 196 Crossing Occlusions 197 Plan of Attack: Crossing an Occlusion 201 Angio Consult: When is Road Mapping Useful to Cross Lesions? 203 Selected Readings 203 Part II: ENDOVASCULAR THERAPY 12. Strategy for Endovascular Therapy 207 Endovascular Skills 208 Impact of Endovascular Therapy 208 Steps to Endovascular Therapy 208 A Loaded System 210 The Future of Endovascular Surgery 210 Choosing Treatment: The Endovascular Therapy Curve 210 Endovascular Decision Tree 211 Converting a Strategic Arteriogram to Endovascular Treatment 213 13. Endovascular Workshop 215 Where We Work Determines What We Can do 216 Operating Room vs. Special Procedures Suite 216 Stationary vs. Portable Imaging Systems 217 The Ideal Vascular Workshop 219 Facility Requirements 219 Contents xiii Equipment Requirements 220 Personnel Requirements 220 Inventory Requirements 220 Converting an “OR” to a Vascular Workshop 220 Inventory 221 Selected Readings 222 14. Access for Endovascular Therapy 223 Make Access as Simple as Possible 224 Sizing Considerations 225 Guidewires 225 Dilators, Flush, and Selective Catheters 225 Access Sheaths and Guiding Sheaths 226 Guiding Catheters 226 Balloon Catheters 227 Stents 228 What Fits into What? 228 General Principles of Sheath Placement During Therapy 228 When Do You Use a Guiding Sheath or a Guiding Catheter? 229 Technique: How to Place an Up-and-Over Sheath 233 Plan of Attack: Managing a Brachial Access Site 235 Sheath Placement in Remote Branch Arteries 235 Selected Readings 237 15. Medications for Endovascular Therapy 239 Sedation and Analgesia 240 Local Anesthetic 240 Prophylaxis with Antibiotics 240 Anticoagulants 240 Vasodilators 241 Treatment of Contrast Reactions 241 16. Balloon Angioplasty: Minimally Invasive Autologous Revascularization 243 Balloon Dilatation Causes Dissection 244 About Balloon Catheters 244 The Angioplasty Procedure 245 Balloon Selection 246 Angio Consult: How do I Choose the Right Balloon for the Job? 248 When to Use a Monorail System 249 Supplies For Percutaneous Balloon Angioplasty 249 Sheath Selection and Placement 250 xiv Contents Balloon Preparation and Placement 251 Balloon Inflation 252 Balloon Removal and Completion Arteriography 256 Selected Readings 259 17. More About Balloon Angioplasty: Keeping Out of Trouble 261 Keeping Out of Trouble Is Simpler Than Getting Out of Trouble 262 What’s the Strategy for Managing Multiple Lesions? 262 Technique: Keeping Track of the Tip of the Sheath 264 Which Lesions Should be Predilated? 265 Which Lesions are Most Likely to Embolize? 266 Which Lesions are Most Likely to Dissect? 266 Pain During Balloon Angioplasty 268 What About Spasm? 268 Plan of Attack: Options for Treating Residual Stenosis After Balloon Angioplasty 269 Preventing Puncture Site Thrombosis 269 Balloon Angioplasty Troubleshooting 271 Technique: Solving Angioplasty Problems 274 Management of Arterial Rupture 276 Management of Embolization 278 Management of Acute Occlusion 280 18. Stents: Minimally Invasive Relining 281 Impact of Stents 282 Stent Choices 282 Indications for Stents: Primary or Selective Stent Placement 284 Which Lesions Should Be Stented? 285 Postangioplasty Dissection 285 Residual Stenosis After Angioplasty 286 Pressure Gradient 286 Recurrent Stenosis After Angioplasty 286 Occlusion 287 Embolizing Lesion 287 Placement Technique for Balloon-Expandable Stent 288 Placement Technique for Self-Expanding Stent 293 Question: What to Consider When Selecting a Stent 296 Which Stent for Which Lesion? 297 How Do You Select the Best Stent for the Job? 299 Tricks of the Trade 301 Raising the Flow Divider With Kissing Stents 301 Tapering a Stent 301 Contents xv Moving a Self-Expanding Stent 301 Crossing a Stent 302 Going Naked: Placement of a Balloon-Expandable Stent Without a Sheath 303 Technique: Bailout Maneuvers for Balloon-Expandable Stents 304 Technique: Bailout Maneuvers for Self-Expanding Stents 310 Acute Complications of Stent Placement 314 Arterial Dissection 314 Arterial Occlusion 314 Arterial Rupture 314 Migration or Embolization of the Stent 314 Embolization of Atherosclerotic Material 314 Chronic Complications of Stent Placement 315 Intimal Hyperplasia 315 Recurrent Stenosis 315 Infection 315 Stent Damage 315 Selected Readings 315 19. The Infrarenal Aorta, Aortic Bifurcation, and Iliac Arteries: Advice About Balloon Angioplasty and Stent Placement 317 Aorta 318 Aortic Bifurcation 327 Iliac Artery 331 Ipsilateral Retrograde Approach to the Iliac Artery 333 Contralateral Approach to the Iliac Artery 337 Selected Readings 339 20. The Infrainguinal Arteries: Advice About Balloon Angioplasty and Stent Placement 341 Superficial Femoral and Popliteal Arteries 342 Ipsilateral Antegrade Approach to the Superficial Femoral and Popliteal Arteries 343 Up-and-Over Approach to the Superficial Femoral and Popliteal Arteries 347 Selected Readings 350 21. Advice About Endovascular Salvage of Previous Reconstructions 351 Previous Endovascular Reconstruction: Balloon Angioplasty, Stents 352 Infrainguinal Bypass Graft 353 xvi Contents Extra-Anatomic Bypasses: Axillofemoral and Femoral–Femoral Bypasses 356 Reconstructions for Aortoiliac Disease: Aortofemoral, Iliofemoral, and Aortoiliac Bypasses 356 Selected Readings 358 Part III: ADVANCED ENDOVASCULAR THERAPY 22. New Tools and Devices and How to Use Them 361 Microcatheters 362 Subintimal Angioplasty 363 Atherectomy 366 Cryoplasty 368 Laser 369 Drug Eluting Stents 371 Cutting Balloons 371 Peripheral Stent–Grafts 373 Thrombolysis 375 Distal Protection Devices 377 23. Brachiocephalic Interventions 381 Carotid Bifurcation 382 Innominate and Common Carotid Artery 388 Assessment of Arch Branch Lesions 389 Principal Techniques 390 Transfemoral Approach to the Common Carotid Artery 393 Retrograde Approach to the Common Carotid Artery 396 The Subclavian and Axillary Arteries 396 Transfemoral Approach to the Subclavian and Axillary Arteries 397 Retrograde Approach to the Subclavian and Axillary Arteries 399 Selected Readings 401 24. Visceral and Renal Arteries: Advice About Balloon Angioplasty and Stent Placement 403 The Celiac and Superior Mesenteric Arteries 404 Renal Angioplasty and Stenting 408 Selected Readings 416 Contents xvii 25. Complex Lower-Extremity Revascularization 417 Recanalizing Iliac Artery Occlusions 418 Femoral–Popliteal Occlusive Disease: When to Use Each Method of Revascularization? 427 Femoral–Popliteal Occlusive Disease: Subintimal Angioplasty 429 Atherectomy, Stent–Grafts, Cryoplasty, and Cutting Balloons to Treat Infrainguinal Disease 434 Tibial Artery Occlusive Disease: Angioplasty and Stenting 438 Selected Readings 443 26. Coiling of Peripheral Aneurysms 445 Coils 446 Coiling Technique 448 Coiling the Internal Iliac Artery 450 Selected Readings 452 27. Making a Clean Getaway: Puncture Site Management 453 Obtaining Hemostasis 454 Holding Pressure 454 Timing the Sheath Removal 457 Closure Devices 457 Managing Puncture Site Complications 457 28. Endovascular Complications Can Be Avoided 459 Selecting the Appropriate Patient 460 Selecting the Appropriate Technique 460 Selecting the Appropriate Approach 460 Knowing When to Quit 461 Index 463