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QUANTIFYING ANGIOPLASTY RESULTSBEYOND ANGIOGRAPHY
Stavros Spiliopoulos
Asst. Professor in Interventional Radiology
University of Athens
2nd Radiology Department, Interventional Radiology Unit
“ΑΤΤΙΚΟΝ” University General HospitalUnit Director: Prof Elias Brountzos
Director: Prof Nikolaos Kelekis
Disclosures
❑I do not have any potential conflict of interest
EVALUATION OF PERIPHERAL ENDOVASCULAR TREATMENT OUTCOMES
Outcome evaluation
• Final result: DSA
• Physical exam
• ABI/TBI
• Imaging: DUS, MRA, CTA
EVALUATION OF ENDOVASCULAR TREATMENT OUTCOMES
• Primary goal of revascularization Tissue perfusion
• Using ABI/TBI and standard MRI, CTA, DUS we cannot
obtain measurements of foot tissue perfusion
NON INVASIVE TISSUE PERFUSION METHODS TOQUANTIFY MICROVASCULAR PERFUSION
• Transcutaneous partial oxygen pressure
(TCPO2): transcutaneous oximetry 1-2 mm
below skin surface. Measures the local O2
released from the skin through the capillaries.
• Skin perfusion pressure (SSP) reflects the local
pressure in the microcirculation
• SPP >40mmHg and TCPO2 >30mmHg have been
correlated with improved wound healing.
QUANTIFICATION OF TISSUE PERFUSIONIS IT NECESSARY?
• Objective measurement of endovascular treatment outcome
• Final angiogram: “looks good”, “I don’t like it” “I think…”
Quantification of outcomes
• During the procedure:
✓More vessels?
✓More luminal gain?
• Follow up:
✓Prognosis of limb salvage/wound healing
✓Decision to proceed to reintervention
Limb perfusion quantification and monitoring modalities
PET
MRI
CTA
Indocyanine green fluorescence angiography
Laser Doppler flowmetry/imaging
Transcutaneous partial oxygen pressure (TCPO2)
Skin perfusion pressure (SSP)
Implantable micro-O2 sensors (MOXYs)
Microwave Radiometry
2D perfusion DSA
Laser Doppler oximetry of venous reserve (INVOS)
INTRA-PROCEDURAL TISSUE PERFUSION QUANTIFICATION
2D Perfusion DSABefore
(Io)
After (I) % Rise 100*(I-Io)/Io
Mean Transit
Time (MTT)1) 17,2526 5,7686
-66,5639
2) 15,7569 7,2700-53,8615
3) 16,0059 10,8468-32,2325
4) 19,0000 11,7872-38
rPBF1) 0,0153 0,0772
404,5752
2) 0,0129 0,0414220,9302
3) 0,0241 0,0804233.61
4) 0,0039 0,06061453,8462
PBV1) 0,2218 0,3893
75,5185
2) 0,1696 0,237139,7995
3) 0,3588 0,409314,0747
4) 0,0747 0,4702529,4511
1
23 4
2D Perfusion DSAReal-time quantification of revascularization
INTRA-PROCEDURAL TISSUE PERFUSION EVALUATION
BASELINE + PERONEAL + PERONEAL + PTA
BASELINE Blood flow: +63% Blood flow: +81%
Mean transit time (slope)
Color-coded perfusion maps
Quantification of tissue perfusion
• Papaverin-induced peripheral-virtual FFR values
• Post-processing of the contrast curves of 2D Perfusion DSA
REAL-TIME QUANTIFICATION OF REVASCULARIZATION
Work in progress
MODALITIES FOR THE QUANTIFICATION OF TISSUE METABOLIC ACTIVITY
INVOS SYSTEM REAL-TIME TISSUE PERFUSION MONITORING
• INVOS (Medtronic) non invasive real time local
assessment of the % of tissue oxyhemoglobin
(depth:1-3 cm)
• Transcutaneous laser micro-sensors (near-infrared
light at 730 and 810 nm wavelengths that are
absorbed by hemoglobin).
• Real-time tissue perfusion monitoring
INVOS SYSTEM TISSUE PERFUSION MONITORING
• Normal values: 40-50%
• Acute ischemia: <20%
CLI CASE
CLI 1
0
10
20
30
40
50
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80
90
1
39
77
11
5
15
3
19
1
22
9
26
7
30
5
34
3
38
1
41
9
45
7
49
5
53
3
57
1
60
9
64
7
68
5
72
3
76
1
79
9
83
7
87
5
91
3
95
1
98
9
10
27
10
65
11
03
11
41
11
79
12
17
12
55
12
93
13
31
13
69
14
07
14
45
14
83
15
21
15
59
15
97
16
35
16
73
17
11
17
49
17
87
18
25
18
63
19
01
19
39
19
77
20
15
20
53
20
91
21
29
21
67
22
05
22
43
22
81
23
19
23
57
23
95
24
33
24
71
25
09
25
47
25
85
26
23
26
61
26
99
27
37
27
75
28
13
28
51
28
89
29
27
29
65
30
03
30
41
30
79
31
17
31
55
Arm
Target limb
3 h
Revascularization
•Fem-fem bypass 7 days ago
•DUS low flow
•No clinical improvement
2.5mm
3 mm
Near infrared spectrometry (NIRS)
Continuous, non-invasive monitoring of tissue oxygen balance
COMMERCIALLY AVAILABLE TISSUE PERFUSION MONITORING SYSTEMS
•HyperView (HyperMed Imaging; Memphis, USA)•Hyperspectral imaging for superficial tissue oximetry• Measurement of oxyhemoglobin, deoxyhemoglobin and oxyhemoglobin saturation in superficial limb tissue•CE-Mark
CONCLUSIONS
of tissue perfusion and metabolic
activity during and following endovascular procedures is feasible
• HOT TOPIC currently under investigation
• Initial results are encouraging
• Quantification of outcomes and improvement of surveillance is
essential for the optimization of endovascular treatment
THANK YOU FOR YOUR ATTENTION