Fernando Gallardo

MD Angiology and Vascular Surgery
Vascular specialist involved in worldwide training in endovascular procedures with different international societies, specially in planning aortic interventions.
  • Function: Consultant
  • Speciality: Vascular Surgery
  • Country: ES
  • Working place: Hospital Quironsalud Marbella, Marbella, Málaga, Spain. , ES

Activities

Comment on Jan 30, 2019

Fernando Gallardo commented on presentation Calcium: The Achilles Heel of Endovascular Procedures?.

»Thanks for sharing this excellent presentation Dr Stavroulakis. Calcium is a challenge. I agree with your algorithm showed at the lasts slides, for long CTO, in old patients, about the recommendation of the need of stents. In my humble opinion, and even if I am also a believer of the "don't live nothing behind concepts", my personal experience is that in this more 15 length CTO, many times recanalized subintimal I don't achieve a great vessel preparation , and recoil is there after DEB, also many non limítanos flow dissection, so my option is to leave a BMS, or covered stent, or DES there if not used DEB. I also agree that for young patients, claudicants, atherectomy devices + vessel preparation and DEB should be the first strategy and yes, avoid stent in patients with large expectancy of live. Best regards.«
Comment on Aug 13, 2018

Theodosios Bisdas replied to your comment on presentation Paving and cracking technique for severely calcified SFA lesions.

»Dear Fernando, Regarding your questions: 1. Exactly, we performed an endo-bypass with Viabahn and we reinforced the stent-graft at the level of the severe calcification. 2. I have also the same opinion, but this was challenged by other specialists. We have no data regarding this issue in the bypass studies because the quality of the vessel wall was not always analyzed. 3. Totally agree. 4. When you decide to perform an endobypass I do not think that you need such a dedicated device for vessel prep and cause extra costs, because you are going to use a non-compliant balloon for the paving and cracking technique. If you decide to leave nothing or a BMS behind, I would suggest cutting balloon or Shockwave balloon.«
Comment on Aug 02, 2018

Fernando Gallardo commented on presentation Paving and cracking technique for severely calcified SFA lesions.

»Thanks for sharing this complex case Theo. Just two comments, 1. How many stents did you finally use in this case? Once you have crossed the lesion why not perform a endobypass with 25 cm Viabahn? or did you use this ballon expandable stent to reinforce the Viabahn?? 2. Even with such calcifications, I don't agree that PTFE fempop bypass has superior patency to endobypass with Viabahn. 3. I know you are most experienced than me, but I recommend you US guided puncture always, specially in this calcified arteries, all closure devices can fail if you puncture in a calcium plaque and the only way to avoid it is with US guidance. 4. Do you see role of SERRATO/CHOCOLATE/SCORED OR CUTTING BALLON for vessel preparation here?? Best regards, Fernando«
Comment on Aug 01, 2018

Fernando Gallardo replied to your comment on presentation How to deal with a limb occlusion after EVAR?.

»Hi Philipe, Thanks for your comments and questions. Yes, I have realized that is when you are performing high volumen of aortic procedures when problems appear, and the importance of review carefully the planning, not just saying "it was just a limb occlusion due to bad stentgrafts limbs" as I have heard many many times...and it is also our responsibility remain educational and share with other colleagues our experience and failures. 1. Yes, at this case we observed the immediate occlusion of the limb, with a pigtail we delivered a bolus of 300000 UI urokinase inside the aorta and the beginning of the occluded limb, and it worked. No distal embolization was observed, as probably it was a very recent thrombus it was totally disolved. Anyway we assumed this risk. 2. About ACT measurements, I have to be honest with you and our colleagues, I don't use it for standard infrarenal EVAR, usually less 90 mins procedures, I use a 5000 UI doses after proglide deployment (pre-closure), (about 60UI/kg). And sometimes 20 UI Protamine when closing access. For complex EVAR/ FEVAR, we measure ACT with a target pick value <250 sc. 3. Yes It could happen, thrombosis due to heparin-resistance, but in my humble experience there is usually a mechanical cause during the deployment or a failure in the planning or graft selection that could explain the limb occlusion. HIT is quite unfrequent, about 0.3%, in this publication (J Cardiothorac Vasc Anesth. 2017 Oct;31(5):1751-1757. Incidence and Outcomes of Heparin-Induced Thrombocytopenia in Patients Undergoing Vascular Surgery. Chaudhry R1 et all), but at other reports (1-5%). Best regards, Fernando«
Comment on Jul 29, 2018

Konstantinos Stavroulakis commented on presentation Paving and cracking technique for severely calcified SFA lesions.

»Thank you Theo for this interesting case. 2 Questions as always: 1. If you have to deal with such a heavy calcification why not preparing the vessel with endovascular lithotripsy and proceed to either DCB angioplasty or Interwoven stent deployment? 2. Do you think that this patient would benefit from a primary above the knee bypass given 1) the severe calcification and the length of the CTO, which will surely challenge the outcomes of endovascular therapy, and 2) the superior outcomes of primary surgery than secondary grafting after endo failure in CLI patients?«
Comment on Jul 28, 2018

commented on presentation How to deal with a limb occlusion after EVAR?.

»Hi Fernando, thank you very much for this nice presentation. Often people publish success stories, but rather rarely problems they have to manage. This is very much appreciated as it gives direct impact into learning how to get out of trouble in different situations. It also demonstrates how important is the initial planning process and the choice of stentgrafts. In one case you mentioned thrombolysis, intra-aortic, with a PigTail catheter. Did this work? No distal embolisation? Also how do you manage intraoperative ACT measurement? What is your target ACT? Do you think some occlusions may occur in the context of Heparin-resistance or even HIT? (I had 2 in the past 2 1/2 years over a volume of 170) Very Best, P«
Comment on Jun 11, 2018

Efthymios (Makis) Avgerinos replied to your comment on presentation Catheter Interventions for pulmonary embolism.

»Access site can be the IJ or the common femoral vein whatever you're familiar with. If you're targeting bilateral pulmonary arteries you can do two separate sticks or use a dual lumen sheath (10 or 12Fr). Navigate a starter (or a glide) wire into the right atrium then right ventricle then main PA. if you're planning on using a large thrombectomy device you will need to cross with a pigtail so that you don't go through the chordae of the tricuspid. Once in the PA do an arteriogram, transduce pressure and then navigate your catheter (glidecath) right or left depending where your target is. Exchange over a starter (or a rosen) wire to a lysis catheter (5, 6, 10 or 12 cm EKOS or standard multisidehole). Do the same for the other side and initiate tpa drip 1mg/hr per catheter for 6-12 hours. You may stop whenever you see signs of improvement (heart rate going down, less oxygen requirements etc) and pull the catheter on the bedside. Suction thrombectomy devices are more cumbersome to use but you typically navigate them over a stiff wire. Sometimes you can just use your pigtail to fragment clot or a large catheter (Pronto) and manually aspirate)....«
Comment on Jun 07, 2018

Martin Schroeder replied to your comment on presentation 12 M Outcomes of the Veniti Vici Venous Stent System for iliofemoral deep vein thrombosis.

»First of all, thank you for your interesting comments Fernando. We know the closed cell design among others in the area of Carotis stents. Here are some comparisons and studies between open and closed cell stents. One of the benefits of the closed stent structure may be the prevention of re-thromboembolic events. This is one of the advantages associated with pelvic veins, especially MTS. The associated structural structure of the stent and its properties with regard to radial rigidity and flexibility are, in my opinion, further positive characteristics. Surely, however, further studies and head to head comparisons are needed here - as well as the open cell design stents have good results in terms of patency rates and properties. Second: The Cavafilter is not our standard and there are no Algorithms. We also use it only in the cases you specify (Cava / pronounced DVT or with pulmonary embolism). In the case of a lysis therapy, we leave this until the end. In individual cases, you can aspirate existing thrombi before removal of the filter with appropriate devices (eg Penumbra) to avoid re-embolization. Once again thank you for your comments best Martin«
Comment on Jun 06, 2018

Efthymios (Makis) Avgerinos replied to your comment on presentation Catheter Interventions for pulmonary embolism.

»Fernando seems you did the right thing with the resources you have and you saved the patient! We have used Angiojet in the past but now we have adopted the newer dedicated devices. As a general rule Angiojet is avoided in the Pulmonary arteries and FDA has issued a warning due to multiple adverse events (bradycardia, arrest etc). Angiojet will soon introduce a new device for PE. Until then suction catheters and aspiration devices (Penumbra, Flowtriever etc) will lead the non-lytic therapies. Catheter lytics are otherwise a good option for those who have no contraindication and have intermediate or high risk PE. Best regards, Makis«
Comment on Jun 05, 2018

Fernando Gallardo commented on presentation Catheter Interventions for pulmonary embolism.

»Thanks for the review Makis. I performed few days ago the first case at my institution inside the new PERT (Pulmonary Embolism Rescue Team) 64yo man, massive pulmonary embolism with RV failure and pulmonary hypertension in a patient with recent history of gastrointestinal bleeding in critical care unit for 2 weeks. I did not have avalaible thrombectomy suction device as Penumbra at this moment, only angiojet and I was not sure about the use of it in the pulmonary arteries... I gained the pulmonary arteries with a pigtail then I went with a Cook 8 F flexor curved sheath, and I performed first left pulmonary artery mechanical thrombectomy with the pigtail rotation through local arteries, also with a MPA, and the same maneuver at Right pulmonary artery. And one shoot of 150000 UI urokinasa right and 150000 left. Due to risk of bleeding I did not leave 24 fibrinolysis...but I measured immediately lower RV pressures. One week later cardiac US showed no dilated RV and neither pulmonary hypertension. As you mentioned there are inherent risk with this procedures but in selected cases it avoids catastrophic situations. Best regards Fernando«
Comment on Jun 05, 2018

Fernando Gallardo commented on presentation 12 M Outcomes of the Veniti Vici Venous Stent System for iliofemoral deep vein thrombosis.

»Thanks for sharing your experience Pr Schroeder, excellent results. 1.In your opinion which are advantages of closed cells stents as Veniti VS other open cell stents also dedicated for Veins?? I have experience with Venovo, SinousVena and Sinous Oblikus, and Zilvervena for these cases of Thrombosis with MTS, and it seems that they all work well at 12 months, except Zilvervena that shows early re estenosis in MT compression point, but our group experience is only about 30 cases in 2 years. 2. About the use of temporary Cava filter? I saw in your presentation, I only use it when free thrombus in Cava or DVT associated with Pulmonary embolism, do you agree with this approach or you use in all acute cases?? Best regards Fernando«
Comment on Jun 05, 2018

Fernando Gallardo commented on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Thanks for sharing your tricks. For this maniouver I have used as Pr Efstratios comments a Relliant Ballon partially inflated to straight the neck is much us possible, but also using the contralateral limb sistems works, and probably a long big sheat or anything that could make righter the neck could works... Anyway for more 70 angulation we should be careful, my option now for this neck is more Aorfix or even Gore with Aptus, more comfortable grafts. The battle stentgrafts VS hostile anatomy will be always won by the anatomy at mid-long term!! Also consider that Endurant suprarrenal stent is totally straight, difference with COOK suprarrenal stent, and in cases with severe angulations I have seen total apposition of the suprarrenal stent one half side and the half of the suprarrenal stent free in the aorta without wall contact... Best regards Fernando«
Comment on Jun 03, 2018

Theodosios Bisdas replied to your comment on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Exactly Stratos! You could not describe it by a better way. The risk of angulated necks is the poor apposition of the proximal stents on the wall. This is a good solution. Your suggestion is also good and works fine. I have tried it in the past. The only advantage of my tip is that you win some time because you do not need to remove the sheath of the contralateral extension. After implanting the ETLW you do not remove it but you further open the main body. Then, you connect the top cap and you advance the sheath of contralateral extension at the height of the top cap. In any case, both work fine.«
Comment on Jun 03, 2018

Efstratios Georgakarakos commented on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Nice information and demonstration. If i get it right, the philoshophy of the “pushing-up”maneuver of the mainbody after the top-cap release (and before the contralateral limb release) is to shrink the fabric between the 1st and 2nd covered stent, thereby reducing the distance between these covered stents and aproximating them in order to achieve the optimal position of these within the infrarenal neck length; therefore, you should start pushing-up the whole device just after the deployment of the 1st stent-top cap release and before the deployment of the 2nd covered stent, so that the latter could actually be positioned as close as it gets to the 1st one, leaving perhaps extra place for the third stent etc., isn’t it? Regarding the 2nd excellent tip of yours i.e., engagement of cap with suprarenal stent, an alternative maneuver would be to inflate a Relay molding balloon mildly leaving a pathway through which the top cap could withdraw safely without the aforementioned problem.«
Comment on Jun 03, 2018

Theodosios Bisdas commented on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Thank you, Philippe, for your comment. Of course, you need experience with this maneuver. The trick here is to 'cram' the prosthesis into the angulated neck. I have not seen an upward migration yet, but there is sure a risk for this. Thus, you have to do smooth movements and to use some landmarks of the vertebral bodies for your renal arteries. An important issue is also the oversizing in those cases: we recommend at least 30%.«
Comment on Jun 03, 2018

commented on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Hi Theo, very nice case! By what means you judge the pushing-up manoueuvre of the main body once the struts are opened? I'm sure in your hands this reflects experience, but is it not a quite risky step for some less experienced operators? I like a lot the move with the contralateral limb, never thought about this! Very smart indeed!!! Best, P«
Poll 01/08/2018 – 31/08/2018

Asymptomatic carotid artery disease

Patient’s characteristics

 

Gender: Female

Age: 72 years old

Comorbidity: Arterial hypertension, hypercholesterinemia, previous smoker

Symptoms: None

Previous operations: None

Vascular Imaging of the left internal carotid artery: Duplex ultrasound with peak systolic velocity (PSV)> 230 cm/sec

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Poll 13/04/2018 – 30/06/2018

Topic: Asymptomatic juxta- and pararenal aortic aneurysms

Patient’s characteristics

Gender: Female
Age: 75 years old
Comorbidity: Arterial hypertension, hypercholesterinemia, previous aortocoronary bypass grafting, previous myocardial infarction, previous smoker, peripheral arterial disease, atrial fibrillation
Symptoms: None
Previous operations: None

 

Aneurysm characteristics:

Max. aneurysm diameter: 54 mm

Length of proximal infrarenal neck: 0 mm

Distance between SMA and LRA: 20 mm

Diameter of renal arteries: RRA: 5,3 mm, LRA: 6 mm

Suprarenal angulation: 60°

Diameter of distal neck: 30 mm

Minimum diameter of common iliac arteries: R: 11 mm, L:9 mm

Maximum diameter of common iliac arteries: R: 11 mm, L: 14 mm

Minimum diameter of external iliac arteries: R: 7 mm, L: 6,2 mm

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