Vascular PlugsHigh abnormal flow into another blood vessel or leak

closure without scalpel and suture

Plugs

• self-expanding devices made of nitinol wire mesh which can be cylinderlized into a sheath and realise gets back there shape for stoppage of flow

Misnomer

Through vascular is used for plugging abnormal congenital or acquired vascular connections but is also used for sometimes intracardiac plugging (off-label)

Types

1. Amplatzer vascular plugs (AVP) [St. Jude Medical, Inc.; Minnesota, USA] :I to IV for small and medium size vascular communications.

• Cera™[Lifetech Scientific Corp., China]: A single lobe device coated with Titanium Nitride (TiN) to prevent thrombosis and improves endothelialisation. PTFE occludes vessel faster• Cardiac plugs for the closure of left atrial appendage and Paravalvular

leak : The Amplatzer cardiac plug-2 (ACP 2) • Micro plugs(3 mm and 5 mm sizes that enables super-selective

embolization of distal vessels)

First approved AVP

AVP was approved by the US FDA in May 2004 for peripheral vascular embolizations.

AVP I

• Made of finely braided Nitinol wire• A single-layer mesh• A single-lobe • High radial force• Short landing zone• Choosing the appropriate length

and diameter of the device is very critical as there are no rims on either side• Longer time for complete occlusion

AVP II

• Introduced in 2007.• More occlusive • Finer and more densely woven nitinol

braided in two or 3 layers• A central lobe and 2 discs on each side• The multi-layered, multi-segmented

design reduces the time to occlusion and offers full cross-sectional vessel coverage

• Lower migration and recanalization chances

• The multi-layered mesh lobes create six occlusive planes, which enable faster vessel occlusion

AVP III

• High flow • Oblong cross-sectional shape made of

multiple Nitinol mesh layers and has extended rims• Fastest occlusion• Device rims extending beyond device

body enables full wall apposition• Stability• in high-flow vessels• Fits elliptical shaped vascular

structures

AVP IV

• best and smaller profile • Delivered through a 5F diagnostic

catheters(0.038)• No need for catheter exchange• distal vasculature/ tortuous and

angulated structures• Multi-layered,double-lobed

design also enables rapid embolization • Size of up to 8mm.

How to implant

• Groin or jugular approach • Sheath at Groin or Jugular route • Diagnostic catheter • A good quality angiogram• Delivery catheters or sheath • Retrieval and reposition • Confirmation

Diagnostic catheter

Judkin's right coronary, Picard or Conard catheter is used to hook the vessel and cross the site of interest using a J tipped Terumo wire (Terumo Medical Corporation, Somerset, NJ, USA). An exchange length Terumo or ordinary guidewire is advanced and is parked distally

Delivery /guide catheter of sheath

• Judkin's right (JR) guide catheter (Cordis Corporation, Miami, FL, USA) 5-7F for most of the plug delivery• Other catheters : Multipurpose (MP),Amplatzer duct occluder (ADO)

delivery sheath (St Jude Inc,MN, USA), Cook delivery sheaths (Cook, Bloomington, USA),carotid shudder sheath, renal guide, Amplatzer left (AL) and Amplatzer right (AR) guide catheters

Delivering

• Like ASD/VSD/PDA devices • Confirmation of successful deployment by a repeat angiogram after 5-

10minuts • A little larger device is better • Retrieval and preimplantation is possible in these devices

Which lesion and which devices

Advantages

• medium to large vessels with high flow• One plug substitutes for multiple coils • Cost effective • Lower profile ,so easy delivery, less trauma • Radio opacity good for visualisation • Some plugs can be even delivered by using diagnostic angiograghic

catheters

Technical issues

• Technical success:92-100%• Residual flow: higher flow, large vessel size and coagulopathy are

predictors of residual flow• Recanalization:0.4%• Device migration and embolization• Reconfiguration

Conclusion

• Know the vascular properly before choosing the type of plugs

Dedicated to Ex-President And Missile Man Of India on his death on Monday 27-2015APJ Abdul Kalam had said once, “Don’t declare holiday on my death, instead work an extra day, if you love me.”