Treatment of distal arterial runoff disease: a challenging task!

Ref: Charing Cross Vascular Symposium 2015 + EndovascularToday

Atherosclerotic lesions affecting runoffs in diabetic patients are super challenging: crossing the lesion, debulking the calcified atheroma, and avoiding arterial dissection for the, commonly, only runoff artery are some of the many challenges that faces the treatment process.

Few tips and tricks have emerged over the years that can provide a good framework to approach those lesions, and avoid major limb amputation if possible.

Crossing the lesions-

  • This article describes some useful tips for crossing those lesions:
  • Dilate the distal microvasculature with an infusion of 200 to 400 μg of nitroglycerin, administered through the sheath before initial treatment. Additional nitroglycerin boluses of up to 400 μg are suggested after every second treatment.
  • Administer systemic anticoagulation with intravenous heparin (100 IU/kg).
  • Possibly run heparin saline infusion through the supporting catheter to provide a jet stream with the GTN.
  • Can we consider using a vasodilator other than GTN? Currently, Iloprost is not licensed in the UK (even to be given intravenously). It should then be only allowed on an off-license basis under a specialist advice exclusively. Patient should be well informed. This is then accepted to be delivered as an IV (despite some RCTs delivering this from within the bypass graft). The efficiency of Iloprost is to be determined. There is currently no clear evidence that Iloprost will dilate the vasculature bed and help the cannulation process whatsoever. GTN is probably much better to use. Papaverine is also well known for its effect (unlicensed).
  • If doing popliteal/TPT endarterectomy before crossing the distal lesion, then ensure avoiding to reach the small arterial lumen with your dissection. Once reached, it would be so hard to keep the lumen open without a dissection flap, which can fully compromise the lumen access later on. You can complete your endarterectomy once an access to the true lumen is well established, and the perfusion started.
  • Cross the lesion with the 0.014-inch ViperWire Advance® guidewire and position the guidewire tip to make sure there is sufficient distance between the guidewire spring tip and the distal end of the shaft (10-cm minimum at all times). The ViperWire Advance® should be within the true lumen of the vessel; subintimal use of the device may be ineffective.
  • If the ViperWire Advance® cannot be placed as a primary guidewire, use a stepwise approach to cross the lesion with a specialized crossing guidewire. A support catheter, such as Quick-Cross (Spectranetics Corporation, Colorado Springs, CO), may facilitate guidewire placement.

Angioplasty +/- Drug Coated Balloons +/- Drug Eluting Stents –  what is the evidence so far?

  • The following few points explains the current understanding in performing distal endovascular procedures (Charing Cross Vascular Symposium 2015), delivered by Prof Thomas Zeller:
    • Use drug eluting stents (DES) in lesions < 10 cm ?PRIMARILY. Current trials support the superiority of Self-expanding (Nitinol) stents (SES) over PTA or Bare-Metal Stents only, for 12-24months follow up.
    • distal stents
    • stents2
    • For lesions >10cm, use drug coated balloons (DCB) primarily. RCTs (IN.PACT, DEBATE) supports their use over PTA or DES.
    •  Atherectomy – this is indicated in diffuse fibrotic and calcified lesions, and in preparation for DCBs.
    • The following presentation summarises the current understanding/evidence behind this area.

5 principles of Yoga that can be used in a busy clinical life

1- correct breathing .. Breathing is considered in yoga as a bridge between the mind and the body. Correct breathing requires both increasing the depth of breathing, and being in conscious control of the breath.

2- complete relaxation– a state of true relaxation is defined in yoga as existing when the body consumes the minimum amount of energy required to exist. Physical relaxation requires loosening areas of muscle tension (by massage sometimes); mental relaxation involves quieting the mind by using breathing techniques.

3- balanced diet – the rule is to eat in moderation, only when hungry, taking time to chew food properly, and eating at set times every day.

4- positive thinking – yoga uses mediation and relaxation to clear the mind, and employs positive affirmations to boost self-esteem.


Ref. A little course in yoga 2013 isbn 97840936523 5. This material is copyrighted and is used here for educational purposes only!

5- beneficial excercises– yoga excercises can, when practiced regularly and correctly, provide full cardiac workout and ensure all areas are worked on thoroughly.

Massage Therapy for patients with peripheral arterial diseases: is it scientifically useful?

ref: Arch Phys Med Rehabil. 2014 Jun; 95(6): 1127–1134

This study, a randomised controlled one was conducted to determine if lower extremity exercise-induced muscle injury (EMI) reduces vascular endothelial function of the upper extremity and if massage therapy (MT) improves peripheral vascular function after EMI. Thirty-six sedentary young adults were randomly assigned to one of three groups: 1) EMI + MT (n=15; mean age ± standard error (SE): 26.6±0.3), 2) EMI only (n=10; mean age ± SE: 23.6±0.4), and 3) MT only (n=11; mean age ± SE: 25.5 ± 0.4). Brachial artery flow-mediated dilation (FMD) was determined by ultrasound at each time point. Nitroglycerin-induced dilation was also assessed (NTG; 0.4 mg). Brachial FMD increased from baseline in the EMI + MT group and the MT only group (7.38±0.18 to 9.02±0.28%, p<0.05 and 7.77±0.25 to 10.20±0.22%, p < 0.05, respectively) at 90 minutes remaining elevated until 72 hrs. In the EMI only group FMD was reduced from baseline at 24 and 48 hrs (7.78±0.14 to 6.75±0.11%, p<0.05 and 6.53±0.11, p<0.05, respectively) returning to baseline after 72 hrs. Dilations to NTG were similar over time.


Those are very interesting results to the importance of massage therapy in this group of patients, and deserve further in depth look to understand the implication of this in the real life practice.




Home-Based Structured Exercises: are they really effective?

Ref: EJVES Dec 2013

This is a systematic review of the effectiveness of an almost self-directed structured exercise ‘activities’ on the IC patients.

The clear conclusion is that there is “low-level” evidence that Home based exercise programme (HEPs) can improve walking capacity and quality of life in patients with intermittent claudication, albeit probably to a lesser extent than supervised exercise training. The recommendation is that HEPs should be used to promote walking in patients with intermittent claudication when supervised training is unavailable or impractical.


Care for patients with AAA – a thorough approach.

Ref.: Clinical Practice Council of the Society for Vascular Surgery

I found this thorough guidelines from the Clinical Practice Council of the Society for Vascular Surgery pretty useful. It is focused, thorough, and very well thought about. Issues such as operating on patients with 5.0 -5.4cm aneurysms, comparing older trials to new EVAR era, using statins to prevent expansion of AAA, are very well documented in here.

Here is the link:


Travelling in aeroplane with an aortic aneurysm: what to do? 

As far as travelling with airlines in patients with AAA is concerned, the NHS screening programme reports that the Association of British Insurers (ABI) has been advised that AAAs are no more likely to rupture at altitude than on the ground and it is not aware of any airlines operating a standing rule about refusing patients with this condition. The ABI is also unaware of any travel insurance policies that contain a specific exclusion for AAAs as part of their standard wording.

Stopping smoking – a patient’s story

This story is impressive in all aspects .. and Pat has agreed to spread the word for generations to come .. the publisher is Ashford and St Peter’s Hospital NHS Foundation Trust:

Stopping smoking – a patient’s story

Dear Mr Jibawi, I thought I’d drop you this note about my smoking and to say thank you for all your hard work in keeping me alive!

I started smoking when I was 14 years old. In those days a schoolgirl (or boy!) could buy one cigarette, two matches and a bag of crisps for two old pence from the local corner shop. Some 54 years and myriad operations later (I’ve had three operations for cancer and two to try to save my leg in the last 13 months alone) I’ve at last stopped smoking.

Every time over the years, whenever I’ve needed an operation or had a chest infection, I’ve always been told “You have to stop smoking. It’s going to kill you”. And, of course, I always thought “You have to tell me that, maybe it’s required by law or something!” And anyway, I told myself, I didn’t smoke much, and I was still young and had plenty of time. And of course, death is something that happens to other people, by a fatal accident or when you get really, really old.

And then I started with the horrendous claudication pain in my left leg, which led me to you. I knew immediately what it was, having had the same problem ten years previously in my right leg. Having attended your outpatients clinic on 2nd June last year, Dr Anneleise Lawn told me that I simply had to stop smoking. I saw you later that month and in your subsequent letter to my GP (copied to me) you were much more outspoken, telling him that if I didn’t have an operation before Christmas there was a 42% risk that my leg would need to be amputated within six months with the very real associated risk of death. As you can imagine, that really made me sit up and take notice. Whilst I’ve been told verbally many many times, there’s something about having it in black and white in front of you that you can’t escape from.

So, in June last year I stopped smoking tobacco. On the advice of Dr Lawn I bought some e-cigarette batteries and cartridges and can truly say I haven’t missed cigarettes at all. I started on 1.8% nicotine strength cartridges (the equivalent of the low tar cigarettes I was previously smoking) and am now on the 0% nicotine cartridges and will soon stop those as well.

So … thank you for your directness, and for your skill and for putting such a good team together. And five weeks after the second operation and an arterial bypass (I seem to recall a certain surgeon telling me I had “terrible arteries, terrible!”) I’m now walking between three-quarters and one mile every day.

Pat Smith

Music for surgeons ,, for patients ,, or for staff??

well .. the evidence sounds quite conflicting …

The Lancet (Aug 2015) published a systematic review and a meta-analysis of 73 RCTs, showing a significant improvement in patient’s level of anxiety and pain. The evidence is good and the message is clear. Results are linked herein.

Music for surgeons has long ben known to promote a positive mind and to enhance surgery. It has been shown, in the case of plastic surgeons, to improve timing by 10% or more. Music has been shown to improve performance in laparoscopic simulation surgery, and on the cardiovascular reactivity among surgeons.

Nurses, however, were not in quite agreement with this. Music generally caused more distraction and inability to hear surgeon’s instruction than it helped in relaxing the scrub nurses.

The question then remains in who is more important: an euphoric surgeon who can perform better, a more relaxed and less painful surgery to the patient, or a happier scrub nurse? I guess this has to be judged at the very individual setting. I am afraid that in many cases, the nurse becomes the most disadvantaged!

Here is a good article from the Independent: