72ys AF on apixaban, DM, Mesenteric ischemia
Unable to access antegrade
What could be other access and intervention options
44ys CLTI on-top of radiated groin + smoker (melanoma/groin dissection/radiotherapy)
Angioplasty long SFA occlusion. failed following days. Re-opened with further distal stenting.
Same night acute ischemia.
CT patent CFA and thrombosed stents with distal trash
Endo or open
What could be access options and surgical options with heavily scarred groin
1 retrograde access can be achieved through trans peritoneal SMA exposure by opening the abdomen and reflecting the transverse colon cephalad then dissecting through the root of the mesentery to SMA – branches shall be controlled by vessel loopes and avoid ligation which might result in bowel ischemia
2 access to EIA can be achieved by retroperitoneal incision with a line cranial to the inguinal ligament with careful dissection to stay in retro peritoneal plane and perfusion f the limb can be achieved by extranatomical ilio-fem bypass
open repair with ilio-pop bypass via transobturator approach
Q1 retrograde access through laparotomy +- endarterectomy
Q2 ilio popliteal bypass
or if the PFA is patent we can go for PFA popliteal/ tibial bypass
A1 through tranperitoneal laparotomy and do retrograde cannulation of sma
or sma embelectomy
or sma endartectomy and patch closure
A2 endo approach
through contralateral angio
or retrograde angio
or transbrachial angio
open
ilio-fem bypass
ilio female bypass through transobturator tunneling
or lateral thigh tunneling
fem fem cross over bypass
Q1 :
Control AF
Good hydration
Mid line laporatomy then. ::
SMA exposure and embolectomy
+/_ end arterectomy +/- ballon dilitation (DCb) +/- stenting
Q2
Good hydration
Contralateral access with pharmacological thrombolysis by Rtpase + mechanical thrombectomy bt ( angiojet / Rorarex)
If failed
Hyprid technique used :
Open ilio pop by pass + fogarty embolectomy through supragenicular pop opening +/- DCB
Reasonable answer, thanks
Q1 : other intervention options includes surgical exploration and embolictomy and Bypass.
Q2: Endo : Contralateral Angioplasty and using Drug coated balloon.
Other options: retrograde Access, transbrachial access ,Surgical : Extra anatomical Bypass
What are extra-anatomical bypass tunnelling options please
Transobturator bypass
Q1. Laparotomy exposure of SMA and retrograde cannulation (hypbrid
…
Q2
Endo by contralateral approach by using coated balloon
Or retrograde approach
Open
As groin is fibrosed Dt radiation
So I can go for long bypass
From ext iliac to pop
By retropretomeal trans obturator to avoid pelvis
And do thtombectomy for distal run off to secure them
Very good thinking, any other options of extra-anatomical tunnelling please?
1-retrograde or open ( embloctomy +_ bypass)
2-extra antomical bypass (axillofemoral or obturator )
I believe you mean trans-obturator tunnelling
Any other extra-anatomical tunnelling options please
1- retrograde access through open SMA exposure with careful dissection and hemostasis “andenexate antidote for apixaban might be needed (did not see it yet)” if urgent revascularization is needed or prepare the patient for open exposure after 2-4 days of last apixaban dose
Failure of antegrade access indicates severe osteal disease, so after control of SMA in healthy segment, needle puncture and access is used to pass a wire from SMA into aorta and do angioplasty and stenting, if acute thrombus is found a transverse arteriotomy and thrombectomy done then continue angioplasty
If failed endovascular repair a c shaped ileomesenteric synthetic bypass is performed
2- previous surgery and radiation with expected fibrosis and radiation arteritis made the surgeon to choose endo first approach yet early failure of angioplasty means recoil of the artery or dissections and breakdown of intima that was stented, and early in stent thrombosis may be due to proximal coiling and compromised inflow of the stent, or due to stent outflow stasis due to distal trashes.
So if the limb is threatened an open1- CFA “through a suprab inguinal transverse incision” 2- or ext iliac “through retroperitoneal approach” to popliteal artery bypass is the option to avoid hostile groin, diseased SFA, thrombosed stent and to clear the distal trashes.
Or a trans contralateral fem pharmacomechanical thrombolysis and distal trashes retrival then a metal jacket of SFA is an option
3-Heavily scarred groin with healthy arteries access options : contralat fem, retrograde, transbrachial
Surgical lateral approach over sarturios muscle, identifying fem nerve then dissection of the vessls
Trensverse inguinal incision above inguinal crease upward retraction of ing ligament and exposure of CFA
Very good,
any other surgical options or extra-anatomical tunnelling options please?
Extraanatomical tunneling through transobturator or lateral bypass in front of iliac crest and lateral exposure of the popliteal artery
A1: open laparotomy with exposure to the SMA and retrograde cannulation and stenting if the problem still present retrograde ilio SMA bypass should be considered
A2: The treatment plan should be tailored according to the Rutherford Category if limb status category 1,2a thrombectomy using rotarex or angioget combined by thrombolytic therapy
if category 2b I think more proximal and distal exposure away from the hostile and stents areas and followed by distal thrombectomy and bypass through the trans-obturator route
Good answer, methodical thinking
Any other extra-anatomical tunnelling options available please?
Q1 : other intervention options includes surgical exploration and embolictomy and Bypass.
Q2: Endo : Contralateral Angioplasty and using Drug coated balloon.
Other options: retrograde Access, transbrachial access.
Or ,Surgical : Extra anatomical Bypass.
Q1: The fact that acute on top of chronic schema makes mere embolectomy option unlikely successful, other end-vascular options include hybrid option with retrograde access
Q2: What could be the exra-anatomical tunnelling options please?
Q:1 -Retrograde approach using the hybrid technique combining midline laparotomy to exposue the SMA , embolectomy of the embolus by fogarty catheter then cannulation of SMA retrograde, balloon dilatation of stenotic segment with or without stenting and selective angiogram could be done.
-Open surgery using ilio-superior mesenteric artery bypass.
Q:2 Endovascular by using CDT by contralateral retrograde approach by needle puncture of the contralateral CFA .
The other option by open surgery femoropopliteal B.K bypass with thrombectomy of distal vessels.
Very good
Regarding Q2: where do you think should be the inflow and outflow, which tunnelling approach you may consider please?
Q1: using retrograde access through a healthy segment of the distal SMA after laparotomy
then emboloectomy if it acute on top of chronic ischemia and ballooning and stenting
Q2: through contralateral retrograde femoral access and using CDT in the occluded stent and trashed limb
Q1: what are the other options if Endovascular is not convincing or not successful
Q2: what other options if Endovascular option is not successful please?
1 Retrograde access through laparotomy and then access through the SMA or IMA
2 open surgery by tans obturator bypass from external illiac a to popliteal a
Regarding Q1 , what other options than retrograde access please
Q2: what other options for tunnelling please?
Retrograde acsess through mid line laparotomy
Open Surgery
Ilio pop bk bypass+pop emboolectomy
Iliac exposures retroperitoneal
very good answer
What do you think the tunnelling options could be , please?
Trans opturator tunling
A1:
Retrograde transfemoral acces
Hybrid through open surgical exposure of the mesenteric aa then puncture and endovascular thrombectomy with or without stenting in case of chronic lesions or acute on top of chronic ischemia. In acute embolic ischemia regarding the history of AF so transmesentric embolectomy is a good option
A2:
Endovascular CDT would be preferable because of the radiated groin and the trashed run off distally this could be through contralat femoral access cross over sheath passing the wire through the stent and place the fountain cath as far as it can reach to deliver the thrombolytic drug over 24 hours
Surgery could be a last resort if the endo is not working or feasible we can go through btk pop exposure to secure the distal run off which was trashed and then the inflow by thrombectomy of the sfa
I believe for the first case there should be an option of bypass (as it has chronic element)
Regarding 2nd case again bypass option should be considered , the question is about tunnelling , what do you think could be options of tunnelling with giving background please?
For first scenario if I cannot access ante-grade . Another option is open retrograde approach .. other intervention options are retrograde bypass from CIA
For Second scenario intervention depends on the state of the limb
in which rutherford grade is the patient ?. If the condition is only ischemic pain with preserved motor and sensory power . I think endo is a better option in the form of thrombolysis to re open the stent and lyse distal clots . If there is motor and sensory affection and there is no time to waist by thrombolysis . Open is a better option by distal thrombectomy or even and distal bypass
Reasonable approach, good answer