Dr.

Aniruddha Bhuiyan
1
st
yr Postgraduate In Vascular Surgery
MS Ramaiah Medical College and Hospitals
Bangalore
Tibial Angioplasty
Tips and Tricks
INTRODUCTION
Arterial reconstruction for occlusions of below knee
vessels
Valuable treatment diabetic patients : adequate wound
healing and limb salvage rates
Variable quality of reports exclusive tibial interventions
not well studied cannot compare, challenging
Development of low-profile balloon catheters, Small-
caliber stents, Steerable and hydrophilic guide wires
Time-resolved CE MRA and superselective DSA with
proper catheter positioning


WHEN and WHAT
Dos - CLI patients with rest pain, ulcers & gangrene
Dont - No distal runoff, fixed flexion deformity, inability
to remain immobile, acute septicemia (wet gangrene)
More options for vessel revascularisation
BASIL suggested Conducive anatomy ? for plasty,
primary PTA first line even if good bypass candidate
Angiosome targetted revascularisation


PROCEDURE CHECKLIST
Access Options
Inflow / Run-off Assessment / Infra-popliteal status
Lesion assessment:
- Length, stenosis, occlusion, calcium
Hardware, amount of contrast
Bailout options
Short/long-term success
TECHNIQUES
Puncture : Ipsilateral antegrade femoral, pedal
Angiography : Dilute non-ionic, CO2
Crossing lesion : 0.014, 0.018 hydrophilic GW
Balloon angioplasty : Low profile, non compliant, long
length balloons
Stents : controversial : balloon expandable proximal ;
self expanding distal
Reocclusion : stent, prolonged inflation, lysis, aspiration

WHAT TO DO IF DIFFICULT ?
SNARING OF RETROGRADE
GUIDEWIRE
DOUBLE BALLOON / REZENDEVOUS
- Double balloons tracked subintimally
- plasty to break membrane to enter
true lumen
SAFARI
- True lumen cannot be reentered,
distal wire is snared inside subintimal
space via proximal access



OUTCOMES
POBA - (24m limb salvage 70%)
Improve blood flow long enough for ulcer to heal
DEB - offer the antiproliferative effect of local drug
elution (limb salvage 95.6%)
- Long, Complex lesions, restenosis, poor outflow
- Restenosis: 27% vs. 63%
Stents - residual stenosis, flow limiting dissections,
perforations reocclusion 50% < 1 yr
DES under trials
Cryoplasty , Atherectomy (orbital)
Image the anatomy well selective injections
Intra-luminal strategy in general
Assess hemodynamic end-point, not just
arteriographic appearance
Learning curve for crossing occlusions
Not being overaggressive
Tibial arteries more prone for vasospasm
vasodilators.
Option for distal bypass
TRICKS
CONCLUSION
Tibial angioplasty vs Bypass (long term patency poor
but limb salvage rates similar)
Unstable looking lesions, limited outflow - SURGERY
Chance to tide over crisis 2
nd
option of distal bypass
With improved techniques and better hardware
TIBIAL ANGIOPLASTY is being rewarded with better
LIMB SALVAGE

Thank You