Endovascular Skills

Guidewire and Catheter Skills for Endovascular Surgery, Fourth Edition

Peter Schneider

• Publisher: CRC Press
• Year: 2019
• ISBN:
  9781498717090
• Edition: 4
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Since the first edition of this text was published, endovascular technique has become a mainstay of vascular care, treating disease that would have previously required open surgery. This book provides a step-by-step approach to endovascular intervention and aims to assist clinicians in the development and refinement of skills that are now essential

PART I

Catheter and guidewire skills

1 Case preparation

2 Safe and strategic vascular access

3 Sheath access

4 Guidewire skills

5 Small platform guidewires and monorail systems

6 Handling catheters

7 Guidewire and catheter passage

8 Imaging: The key to success

9 Selective catheterization

10 Principles of arteriography

11 Arteriography of the vascular beds

1

Case preparation

ENDOVASCULAR SKILLS IN PRACTICE

Endovascular skills are an integral part of vascular patient care and will continue to be for the foreseeable future. As the scope of catheter-based treatment broadens, the ability to manage more complex lesions with these techniques will continue to increase and, hopefully, drive better overall results of care. The development of guidewire–catheter skills is not an easily definable goal, but is a dynamic process. As the array of possibilities in the endovascular field has blossomed, the necessary skills included under the heading of guidewire–catheter skills have likewise increased substantially. On the basic level, guidewires and catheters are the universal instruments of success in endovascular work. A more advanced approach includes an amazing and expanding myriad of devices passed over the guidewire to help manage vascular disease.

Knowledge and facility must be achieved in several areas that are not necessarily intuitive, including coordinating fluoroscopy–eye–hand motion, predicting guidewire–lesion interactions, understanding the behavior of various guidewire and catheter combinations, and learning the limits of each technique. These are the basic endovascular skills. Part I of this book provides an overview of basic endovascular skills. Part II presents techniques in endovascular therapy that build on the basic skills, such as guiding sheath access, balloon angioplasty, stenting, and how to use these techniques in various vascular beds. Part III covers advanced endovascular techniques and devices in an effort to assist the reader in becoming familiar with rapidly evolving technology.

REINVENTION OF VASCULAR CARE

Endovascular concepts are reshaping treatment. The potential for simple, low-morbidity solutions to complex clinical problems is a common goal among vascular specialists. Near-term progress in reconstructive capability is likely to result from advances in endoluminal technique. Guidewires and catheters form the technical and conceptual basis of endovascular intervention and technology, while device and skill development are taking the field to the next level. Endovascular procedures have dramatically changed the spectrum of vascular practice. Iliac angioplasty and stenting have almost completely replaced aortofemoral bypass. Stent–graft repair of abdominal aortic aneurysms has dramatically altered the management paradigm for aneurysmal disease. Although some endovascular procedures are not currently durable enough to offer long-term solutions, such as many of the infrainguinal treatment options, they may still be adequate for patients with multiple comorbidities or limited life expectancy. These techniques also hold hope for becoming more clinically useful as they are refined and patency improves. Our focus is on making vascular treatment safer and more durable, whether it involves medical, endovascular, or open surgical procedures, or a combination of these.

SETTING YOURSELF UP FOR SUCCESS

The success of a case depends in part on addressing a few concerns that arise before the procedure commences. Evaluation of the patient and a preprocedure analysis make a difference. Decisions about access and strategy, how compelling the indications are for treatment, and the expectations of the patient and family all play important roles. Throughout this book, there is advice about these issues. Chapter 2 details access choices and how to use them. The chapters included in Part III offer a number of ideas about treatment strategy. Chapter 13 discusses where we work and related issues. This chapter deals with some of the logistical issues that everyone faces in performing endovascular surgery.

SIZING UP THE CASE

Issues to address with regard to medical management of the patient may be numerous. The ones that occur most frequently are management of diabetes, renal insufficiency (contrast tolerance), and anticoagulation or antiplatelet agents. Each of these must be appropriately balanced based on an estimation of what needs to be done, how long it will take, how extensive it will be, and whether or not it will solve the patient’s problem. In the midst of all this, the patient must be prepared by the physician and staff for the shortest possible hospital stay, maybe only a few hours. Logistical issues around transportation, mobility, and accompany home by a family member must be addressed. In preparing for the technical part of the case, check old angiograms and procedure notes. Examine the patient and perform a complete vascular examination. Palpate the arteries and assess puncture sites. Obtain and analyze some type of preprocedure noninvasive study to assist with planning.

PRIOR TO THE PUNCTURE

Informed consent is best obtained in the office when the patient is afforded time to consider issues and to consult with family. Patients on warfarin or other anticoagulants should be considered on a case-by-case basis. It is usually safe to perform either arteriography or endovascular intervention in patients on antiplatelet therapy as long as there are no other factors that are likely to promote hemorrhage, such as dialysis dependency. It is usually not necessary to stop antiplatelet agents prior to endovascular intervention. If for some reason the antiplatelet agent must be stopped, it should be 10 days prior to the procedure. If endovascular intervention is required, warfarin should be stopped approximately 5 days prior to the procedure. Patients who require anticoagulation to be continued, except for a “window” when it is stopped, may often be treated with outpatient enoxaparin sodium to shorten the hospital stay. At the operator’s discretion is whether a prothrombin time should be obtained on the day of the procedure. Patients with renal insufficiency are managed with preoperative hydration with a bicarbonate infusion and mucomyst. Methods of preprocedural evaluation are available that help to limit the contrast required for the study. These are discussed in Chapter 11. A contrast agent that is less toxic to the kidneys (e.g., CO₂) should also be considered. Patients with a history of contrast allergy should be treated before the procedure with prednisone and diphenhydramine. This protocol is detailed in Chapter 13.

WORKING ENVIRONMENT

Experts understand that top performance is something that does not happen randomly. It develops with preparation. Judgment and technical skills take time, effort, and enthusiasm to develop. The staff that assist you, the equipment available, and the facility where you use those skills can either promote or detract from your ability to guide sick patients through difficult situations. These preparations help to limit the variables and optimize results. Endovascular work is no different. There is a substantial learning curve associated with each procedure. Creating a working environment where high-quality endovascular practice can be carried out is essential.

It is imperative to ensure the presence of the proper interventional equipment when performing endovascular interventions. The necessary catheters, guidewires, guiding catheters and sheaths, balloons, and stents must be available. The room must be equipped to adequately monitor the patient. Medications must be available, including anticoagulants, antiplatelet agents, hemodynamic medications as needed, and sedation as required. The staff must be knowledgeable in the inventory of the supplies, devices, and equipment used during interventional procedures. The surgeon must be comfortable with the ability of the staff to assist in performing these procedures. Educating the staff beforehand on the nature of the procedure to be performed, the important points of the case, and the specific assistance that will be necessary are critical to ensuring smooth progression through the case. Adequate monitoring of the patient allows rapid assessment of the patient’s status, thereby allowing intervention for hemodynamic problems early and limiting their impact on the outcome. It is important that the person performing the intervention is confident that the people assisting can quickly deal with hemodynamic or other problems. Fixed imaging equipment is not mandatory but is best and facilitates performance of endovascular procedures. A room stocked with adequate disposable inventory is desirable. It is helpful to develop a method of arranging the room for different procedures, depending on the proposed access site and the area of intended imaging and target site for treatment.

EQUIPMENT

The patient must be moni...