Endovascular Skills-4판

Part I CATHETER AND GUIDEWIRE SKILLS 1

1 Case preparation 3
Endovascular skills in practice 3
Reinvention of vascular care 3
Setting yourself up for success 3
Sizing up the case 4
Prior to the puncture 4
Working environment 4
Equipment 5
Facilities and room setup 5
How pretreatment history and physical examination help to plan therapy 6
Pretreatment imaging 6

2 Safe and strategic vascular access 7
Overview of percutaneous access 7
Choosing your approach 8
Femoral anatomy for arterial access 9
Puncture guidance with ultrasound 10
Micropuncture technique 12
Percutaneous retrograde puncture of the femoral artery 13
Percutaneous antegrade puncture of the femoral artery 17
Percutaneous puncture of a pulseless femoral artery 19
Proximal access 21
Percutaneous puncture of the brachial artery 21
Alternative access to the lower extremity: Superficial femoral, popliteal, tibial,
and pedal arteries 23
Percutaneous puncture of bypass grafts 23
Puncture site complications 24
Summary of puncture site options and closure strategy 24

3 Sheath access 27
Introduction 27
Basic access site step-by-step 27
Initial maneuvers to secure the access 28
How do you place a sheath? 28
When is a dilator needed? 30
Basic sizing issues 32
When to use fluoroscopy 32
About access sheaths 33
How do you decide when to place a larger access sheath? 33
When to abandon an access 33
Access in a hostile groin 34

4 Guidewire skills 35
Introduction 35
Mastering guidewires 35
What makes guidewires different from each other 36
Guidewire types in practice 38
When to abandon the chosen guidewire 43
Useful guidewire techniques to start tackling chronic total occlusion 44
Organizing your guidewires 46

5 Small platform guidewires and monorail systems 47
Development of small platform guidewires and monorail systems 47
How do monorail systems differ from coaxial systems? 47
What are the advantages and disadvantages of monorail systems? 49
Principles for the use of rapid exchange systems 49
Which platform is best for each task? 50
Which platform should you start the case with, and when should you switch from one
platform to another? 50
Maneuvers you can undertake with 0.14-inch and 0.18-inch guidewires 51

6 Handling catheters 53
Introduction to catheters: Exchange, flush, and selective catheters 53
Which angiographic catheter should you use? 53
Catheter head shape determines function 54
Describing catheter behavior 58
Handling catheters 58

7 Guidewire and catheter passage 63
The goal of the procedure determines the course of the guidewire–catheter apparatus 63
Guidewire and catheter combinations 65
Where does the guidewire naturally want to go? 65
Passing through diseased arteries 66
Negotiating tortuous arteries 67
Remote puncture site 69
How to change the plan if the catheter will not pass and you have tried everything 70
How do you decide if disease encountered on the pathway to treat the target lesion
also needs to be treated? 71

8 Imaging: The key to success 77
Imaging and best therapy are intricately linked 77
Image quality 77
Generating an X-ray image 78
Digital subtraction arteriography 79
Imaging technique for best resolution 80
Road mapping: How it works and when to use it 81
Automated power injector 82
Power injection versus contrast administration by hand 83
Contrast agents 84
How do you know where you are? 85
Radiation safety and occupational health issues 86
Radiographic equipment 86
Radiographic terms 86
Radiation exposure 87

9 Selective catheterization 89
Many catheter choices but few basic shapes 89
Selective catheterization of the brachiocephalic arteries 91
Selective catheterization of the visceral and renal arteries 98
Selective catheterization of the aortoiliac arteries 100
Selective catheterization of the infrainguinal arteries 105
Selective catheterization of prosthetic bypass grafts 109
Aberrant anatomy to consider 111

10 Principles of arteriography 113
Arteriography is strategic, not diagnostic 113
The future of arteriography 113
Supplies for arteriography 114
Planning for strategic arteriography 114
Questions to consider before arteriography 115
Evaluation before angiography 115
Deciding where to puncture 116
Catheter placement 118
Contrast administration and image acquisition 119
Arteriography sequences 120

11 Arteriography of the vascular beds 123
Arteriography of the brachiocephalic arteries 123
Thoracic aortography 126
Arteriography of the visceral and renal arteries 126
Arteriography of the infrarenal arteries 128
Lesion interrogation: Special views 134
Carbon dioxide arteriography 134
Pressure measurement 136
Arteriography of aneurysms 136
Intravascular ultrasound 137


Part II ENDOVASCULAR THERAPY 139

12 Endovascular workshop 141
Where we work determines what we can do 141
Operating room versus special procedures suite versus catheterization laboratory 141
Stationary versus portable imaging systems 142
The ideal vascular workshop 143

13 Medications for endovascular therapy 145
Sedation and analgesia 145
Local anesthetic 145
Prophylaxis with antibiotics 145
Anticoagulation 145
Heparin alternatives: Direct thrombin inhibitors 146
Antiplatelet agents 146
Thrombolysis 147
Vasodilators 147
Contrast allergies 147
Practical advice for intraoperative problems 147

14 Access for endovascular therapy 149
Make access as simple as possible 149
Create a platform from which to work 150
Sizing considerations 150
What fits into what? 153
General principles of sheath placement during therapy 153
When to avoid using your initial access site for therapy 155
When do you use a guiding sheath versus a guiding catheter? 155
How do you know if the sheath is following the exchange wire? 158
Uses for upper extremity access 159
Sheath placement in remote branch arteries 159

15 Setting up the therapeutic maneuver: Crossing lesions 163
Introduction 163
Three types of lesions 163
Need for support and directionality 164
Crossing stenoses 164

16 Crossing challenging lesions 171
Arteriography of occluded arteries 171
Crossing occlusions 171
Tools for crossing occlusions 174
Subintimal angioplasty 176
Crossing occlusions in various vascular beds 178
When to approach from the other direction: Retrograde access 184
Crossing calcified lesions 186
Crossing really long lesions 186
What to do after the wire is across 187
Anatomic manipulations can assist in guidewire or device passage 188

17 Balloon angioplasty: Minimally invasive autologous revascularization 191
Balloon dilation causes dissection 191
About balloon catheters 192
The angioplasty procedure 193
Balloon selection 193
When to use a monorail system 195
Supplies for percutaneous balloon angioplasty 195
Sheath selection and placement 196
Balloon preparation and placement 197
Heparin administration during intervention 197
Balloon inflation 198
Balloon removal and completion arteriography 201

18 More about balloon angioplasty: Keeping out of trouble 205
Keeping out of trouble is simpler than getting out of trouble 205
What is the strategy for managing multiple lesions? 205
Which lesions should be predilated? 207
Which lesions are most likely to embolize? 208
What about postangioplasty dissection? 208
When to use kissing balloons 210
Pain during balloon angioplasty 210
What about spasm? 211
Preventing puncture site thrombosis 212
Balloon angioplasty troubleshooting 213
Technique: Solving angioplasty problems 215
Management of arterial rupture 217
Management of embolization 218
Management of acute occlusion 219
Technical aspects of balloon angioplasty in different vascular beds 219
Assessing the acute results of balloon angioplasty 221

19 Stents, covered stents, stent–grafts 223
Impact of stents 223
Stent choices 223
Covered stents 225
Indications for stents: Primary or selective stent placement 226
Which lesions should be stented? 227
Residual stenosis after angioplasty 229
Placement technique for balloon-expandable stents 230
Placement technique for self-expanding stents 235
Placement technique for covered stents 237
Which stent for which lesion? 238
How to select the best stent for the job 241
Tricks of the trade 242
Acute complications of stent placement 252
Chronic complications of stent placement 253

20 Other devices and how to use them 255
Microcatheters 255
Re-entry catheters 256
Chronic total occlusion catheters and crossing catheters 257
Atherectomy 258
Laser 260
Drug-coated balloons and drug-eluting stents 261
Cutting, scoring, and cryoplasty balloons 262
Peripheral stent–grafts 265
Thrombectomy and thrombolysis 266
Distal embolic filters 269


Part III THERAPY IN SPECIFIC VASCULAR BEDS 273

21 Brachiocephalic interventions 275
Introduction 275
Arch assessment 275
Innominate and common carotid artery 275
Assessment of arch branch lesions 276
Principal techniques 277
Transfemoral approach to the common carotid artery 279
Carotid bifurcation stent placement 281
Open cell, closed cell, and mesh covered carotid stents 286
Distal and proximal protection devices for transfemoral carotid stenting 287
Transcervical approach to carotid stenting 288
Retrograde approach to the common carotid artery 292
The subclavian and axillary arteries 292

22 Visceral and renal artery interventions 297
Approach to the visceral arteries 297
Celiac and superior mesenteric artery angioplasty and stenting 297
Renal angioplasty and stenting 302

23 The infrarenal aorta, aortic bifurcation, and iliac arteries: Advice about balloon angioplasty and stent placement 311
Introduction 311
Aorta 311
Aortic bifurcation 318
Iliac artery 321
Ipsilateral retrograde approach to the iliac artery 321
Contralateral approach to the iliac artery 323
Self-expanding versus balloon-expandable stents for the aortoiliac segment 326
Use of covered stents 326
Access related issues 327

24 The infrainguinal arteries: Advice about balloon angioplasty and stent placement 329
Introduction 329
Superficial femoral and popliteal arteries 329
Ipsilateral antegrade approach to the superficial femoral and popliteal arteries 330
Up-and-over approach to the superficial femoral and popliteal arteries 334
Access related issues: Difficult up-and-over approach to the superficial femoral and
popliteal arteries 337
Tibial artery occlusive disease: Angioplasty and stenting 341

25 Complex lower extremity revascularization 345
Aortoiliac occlusive disease 345
Femoral–popliteal occlusive disease 353
Tibial artery occlusive disease 365
Angiosomes of the lower leg and foot 367

26 Salvage of previous reconstructions 373
Introduction 373
Previous endovascular reconstruction 373
Managing occluded stents 374
Infrainguinal bypass graft 375
Extra-anatomic bypasses: Axillofemoral and femoral–femoral 378
Reconstructions for aortoiliac disease: Aortofemoral, iliofemoral, and aortoiliac bypasses 378

27 Hybrid procedures 381
Principles of hybrid procedures 381
Technical points for performing hybrid procedures 381
Iliac stent and femoral endarterectomy 387
Femoral endarterectomy plus distal intervention 389

28 Technical aspects of treating aortic aneurysms 391
Introduction 391
Imaging 391
Open access or percutaneous access of femoral arteries 392
Percutaneous large bore access using the pre-close technique 392
Closure of large bore access 394
Managing bad iliac arteries 394
Conduits 398
Endograft placement 401
Cannulation of the contralateral gate 403
Balloon angioplasty after endograft placement 405
Postplacement stenting of iliac arteries 406
Management of a difficult aortic neck 407
Endovascular graft treatment of a ruptured abdominal aortic aneurysm 411
Hybrid procedures associated with aortic disease: Arch debranching 413
Management of endoleaks after endovascular abdominal aortic aneurysm repair 414

29 Coiling of peripheral aneurysms 419
Coils 419
Vessel occluders 423
Endovascular management of a popliteal aneurysm 424
30 Puncture site management 427
Obtaining hemostasis 427
Holding pressure 427
Timing the sheath removal 429
Closure devices 429
Managing puncture site complications 432
Selected reading 433
Appendix: Trade/registered/generic names plus current manufacturers 437

Index 441



The goal of Endovascular Skills: Guidewire and Catheter Skills for Endovascular Surgery has always been to provide a
“step-by-step” approach to techniques and procedures that comprise one of the most exciting and rapidly developing
specialties in medicine today: minimally invasive management of vascular disease. Endovascular technique has gone from
being a novelty to a mainstay of vascular care and this edition of Endovascular Skills has been revised and expanded to
reflect these changes. This book serves as a “how-to” guide for endovascular intervention and aims to assist clinicians
in the development and refinement of skills that are now essential to vascular practice.

The book introduces readers to strategy, vascular access, guidewire–catheter handling, and arteriography in a multitude
of vascular beds. The knowledge base builds as the text progresses in much the same manner that the skill of the
professional builds as experience is gained by performing more complex cases and managing complicated patterns of
disease. The chapters progress to all aspects of endovascular therapy, including sheath access, balloon angioplasty,
stents, and other treatment modalities.