Extreme Intervention in the OIS:

Below the Ankle

Eric J Dippel, MD FACC

Davenport, IA USA

April 6, 2019

Conflict of Interest

Consultant

– Abbott Vascular

– Becton Dickinson/CR Bard

– Medtronic/Covidien

– Philips/Spectranetics

– WL Gore

Physicians Initial Response to

Interventional Therapy (at least to me)

1st- “It doesn’t work and it is always dangerous. Clearly those performing it don’t understand plaque.”

2nd- “It seems PTA of stenotic iliacs may occasionally work (never occluded iliacs) – an iliac stent trial would be “UNETHICAL.”

3rd- “It is malpractice to intervene below the inguinal ligament”.

4th – “There may be an occasional role for PTA of short SFA stenosis but one should never intervene below the knee or long segment disease.”

5th- “Stents in the SFA are malpractice”.

6th- “You can’t stick the popliteal artery.” “Can’t cross a CTO”

7th- “ Atherectomy is just inferior endarterectomy”

8th- “You should never intervene on IP vessels”.

9th- “It would be malpractice to access the IP vessels as you may injure targets”. “But didn’t you just advise a BKA”?

10th- “Intervention just doesn’t last”

11th- “You can’t intervene below the ankle”

12th- “How can I do this?”Craig Walker, NCVH 2017

Vascular Anatomy of the Foot

Angiosomes of the Foot

Incidence of Wound Healing

Neville RF, CRT 2016

Importance of Angiosome directed revascularization

Pedal Arch Classification

Kawarada, O, et al. CCI. 2012(80):861-871

Complete Incomplete Incomplete Absent

Predictors of Wound Healing

Kawarada, O, et al. CCI. 2012(80):861-871

Directional Atherectomy

Hawk One-S

– 12,000 rpm

6 Fr

Vessel diam: 2-4mm

Crossing profile: 2.2mm

Effective length: 145cm

Tip length: 5.9cm

DA

Soft/Fibrotic Plaque ++++

Calcified Plaque ++

Thrombus -

Embolization ++++

Forward cutting -

Cost ++++

Laser Atherectomy

Turbo Elite

4-6 Fr

Catheter size: 0.9, 1.4, 1.7, 2.0mm

Vessel size: 1.3-3.0 mm

Shaft length: 150cm

LA

Soft/Fibrotic Plaque ++++

Calcified Plaque ++

Thrombus ++++

Embolization +

Forward cutting +

Cost ++

Case Report

65 yo male

IDDM, Neuropathy, Retinopathy, HTN,

CAD, ↑Chol

R ankle fracture

– ORIF with external fixation (x 3 months)

– Developed ischemic ulcers on all toes and

distal forefoot

Case Study

• Normal Aorto-iliac segment

• Normal Femoro-popliteal

segment

Case Study

Severe distal tibial disease

• Grand slam wire

• 1.4mm Turbo Elite laser

• PT 2.0x200mm

3.0x300mm

• AT 3.0x100mm

Tibial Critical Limb Ischemia

Case Study

Before After

Phoenix Atherectomy

Atherectomy and extraction

– 10,000-12,000 rpm

5-7 Fr

Tracking

– 1.8 mm x 149cm (5 Fr)

– 2.2 mm x 149 cm (6 Fr)

Deflecting

– 2.4 mm x 127 cm(7 Fr)

PA

Soft/Fibrotic Plaque ++++

Calcified Plaque +++

Thrombus ++++

Embolization +

Forward cutting +

Cost +++

Phoenix

Continue Treatment with 1.8mm Phoenix Catheter into Mid-Foot Post-Dilatation with Lutonix

DCB

Case performed by Prof. Zeller

Distal Posterior Tibial Case Study62 yo male, Non-healing foot ulcer

Final result after nitro and

post-dilatation with DEB.

1.8mm Phoenix catheter

being advanced into foot.

Case performed by Dr. Aljoscha Rastan

Bad Krozingen, Germany

Unsubtracted image showing

guidewire in posiiton

Distal Posterior Tibial Case Study

Orbital Atherectomy

Diamondback 360

– 60k, 90k, 140k rpm

– 30-70micron

4-6 Fr

Crown size: 1.25, 1.5mm

Vessel diam: 1.6-3.9 mm

Shaft length: 145cm

Tip length: 7mm

OA

Soft/Fibrotic Plaque ++

Calcified Plaque ++++

Thrombus -

Embolization ++++

Forward cutting -

Cost ++

58YO MALEDIABETES, CAD

NECROTIZING FOOT INFECTION

Courtesy of Eric Scott, MD

DIAGNOSTIC

ANGIOGRAM

AP FOOT LATERAL FOOT

Courtesy of Eric Scott, MD

DENSE CALCIFICATION AT

PROXIMAL CAP

0.014” PILOT WIRE

UNABLE TO CROSS

0.014” COMMAND

WIRE UNABLE TO CROSS

0.014” APPROACH CTO 25G TIP CROSSED LESION

0.014” BALLOON

UNABLE TO CROSS

LESIONCourtesy of Eric Scott, MD

1.25mm Micro Crown

CSI DiamondBackAtherectomy

Courtesy of Eric Scott, MD

FINAL IMAGES

AP FOOTLATERAL FOOT

Courtesy of Eric Scott, MD

3 MONTHS LATER

Courtesy of Eric Scott, MD

Conclusions

Severe pedal disease is very common in critical limb

ischemia

– Frequently the only resort to limb salvage

Endovascular pedal intervention can be safely performed

with a high degree of technical success (>90%)

– Can recanalize arteries that are non-bypassable

Must use meticulous care to avoid complications

– Careful wire selection

Be familiar with all the tools in the toolbox

ConclusionsDA OA LA PA

Soft/Fibrotic Plaque ++++ ++ ++++ ++++

Calcified Plaque ++ ++++ ++ +++

Thrombus - - ++++ ++++

Embolization ++++ ++++ + +

Forward cutting - - + +

Cost ++++ ++ ++ +++

French 6 4-6 4-6 5-7

Tx Vessel (mm) 2-4 1.6-3.9 1.3-3.0 1.8-4.0

Shaft length (cm) 145 145 150 149, 127

Tip length (cm) 5.9 0.7 - -

DA = Directional Atherectomy

OA = Orbital Atherectomy

LA = Laser Atherectomy

PA – Phoenix Atherectomy

Eric J Dippel, MD FACC

www.VIMidwest.com

Dippel@VIMidwest.com

(C) (563) 650-5635