A short note re. a laser atherectomy i did with LGM

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pt had a L SFA and pop supera stent which thrombosed

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was lysed overnight with tpa

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continued hard intrastent thrombtic material in the pop segment

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in this case, apparently, for in stent resstenosis which is not resonding to angiojet

can use atherectomy device

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in this cased used laser atherectomy

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basically advanced a sheath to the apex of the lesion in the pop

crossed lesion with 018 steelcore wire and put tip in the trifurcation vessels

then advanced a "laser catheter" on the wire

the tip has a "laser" on it

the laser burns tissue

you have to conintusously drip saline through a tuohy adaptor whilst using the laser

so you basially turn the laser on and then cross the lesion 3 times

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we also used a Drug coated ballon- the lutonix from Bard

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basically a long balloon, inflate it in the lesion for 3 minutes and then take down

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do repeat run

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see how it goes

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one of a very few times doing PAD during fellowship

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PAD:

 

how to do arterial lysis of thrombosed leg graft

 

clincal scenario:  

3 month old L thigh CFA-pop bypass graft occluded 

 

start R

 

up and over

access R CFA 

 

do omniflush run

cross up and over using omniflush and long bentson

can also try stiff glide if bentson doesn't go

getting across can be difficult

once get wire purchase in L CFA or SFA or Profunda

advance 6F sheath curved

there are a few, some are preferred over others

track the sheath over the wire

sometimes its difficult to track

can use the dilator trick- push sheath off dilator and then catch dilator up - JMitch trick

get sheath into L CFA

in this case, did angiography of entire leg (run off the entire leg) thru the sheath

in this case, crossed through occluded graft using angled catheter and wire

can use mult combos, usu angled glide cath and stiff glide or or glide advantage can be successful

once cross thru occluded graft, get into tibial vasculature

be careful to not perforate these vessels

exchange for infusion catheter, unifuse, decide infusion length

hook up infusion catheter to 1cc / hr TPA

hook up sheath sidearm to 300U heparin / hr

send to ICU for monitoring for bleeding

bleeding at site is likely

shut off TPA if fibrinogen < 150 or <100

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How to do an SFA plasty + shtent

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leraned this ish on a simulator, jus like real life tho

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start off with omni flush catheter- this allows to do a flush aortogram + get up and over with the bif

get a bentson up into the Abd Ao

chase with the omni flush

pull the wire out do your pigtail run

now just hang a bit of wire out

gently pull the catheter and wire down to engage the contra lat (L  if R access) common iliac

now advance wire

try to get wire purchase in external and then CFA or SFA, sometimes you'll keep going into internal

can use glide if need help

chase with catheter

can switch up to stiffer wire like amplatz or rosen at this point to track sheath

if sheath doesn't go easily, can do this:  push sheath off dilator, catch dilator up and then rinse repeat

oncce get sheath up to the CFA, do a run

evaluate the SFA lesion and eval the relationship to DFA / profunda.  Don't want to jail off profunda with shtent

using an angled cath and a stiff or reg angled tip glidewire, negogiate the SFA lesion

once get across can either chase with catheter and switch ot heavier wire or stay with that wire (glide)

then get balloon across, can start small like 3-4 mm

then get up to nominal size of vessel maybe like 6 mm

then can track stent delivery device over

careful with positioning relative to DFA

depoloy stent

do post stent plasty with same size balloon as stent

do post run

pull stuff out and then close groin, preferably with Perclose- nice device

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R SFA stent occlusion recan- with RR MD (VS)

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had pt with R SFA occlusive lesion, sp 130 mm 7 mm dia viabahn placement 1 yr prior, had sl runoff (PT)

pw loss of PT pulse

?occluded stent

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came down for angio

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Started L groin micro

5F sheath

contra pigtail to renal level- Abd Aortogram

bring cath down gently to break the bif, then send out wire - RR wire of choice is glidewire advantage aka GWA, aka ZB wire

if having difficulty selecting external iliac, can oblique tube and redo run

likes to get wire into CFA and then bring catheter down and run off leg through pigtail as well- thigh, knee, tibials, and foot in lateral

then pull off catheter and sheath and advance 6F long sheath (ansel i think) to R CFA

likes to work with Quickcross catheter

for 018 system like 018 quickcross and V18 wire i think

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for this particular case, did ballooning of occluded stent

proved SL PT runoff to foot with occlusion at level of foot

ballooned close to DFA- caused thrombosis of DFA requiring ballooning of this vessel

eventually ended case and started heparin gtt after closure

likes starclose for closure

i would prefer perclose

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Basics of PAD:

did a case solo around 2/2019

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L LE rest pain and heel pain

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access R, up and over

use contra flush, do angiogram aorta

break the cath over the bif using bentson or glide to get down into L CFA

advance the flush to the CFA and do a runoff, have an exp tech just do this for you, down to the foot

decice where you going to treat

switch for exch length stiff amplatz, plant this in the SFA, then get an up and over sheath, 6F- 7F (depending on what size baloons and stents)

advance the sheath

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