Endovascular Techniques for Limb Salvage: How to Succeed ......Intravascular Lithotripsy (IVL)...
Transcript of Endovascular Techniques for Limb Salvage: How to Succeed ......Intravascular Lithotripsy (IVL)...
Curtiss T. Stinis, M.D., F.A.C.C., F.S.C.A.I.Director, Peripheral Interventions
Director, Interventional Cardiology Fellowship Program
Scripps Clinic
La Jolla, CA
Endovascular Techniques for Limb Salvage:Endovascular Techniques for Limb Salvage:How to Succeed With Complex CasesHow to Succeed With Complex Cases
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PAD is Everywhere….
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CLI Affects
PAD and CLI: A Serious Problem!
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CLI AffectsApproximately20 MillionAmericansPer Year!
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Endovascular Therapy has Become theTreatment Strategy of Choice for CLI
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Endovascular Therapy vs. Vascular Surgery:Cost Effectiveness
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• Endovascular procedures for PAD cost the health payer less comparedwith open surgery and primary amputation
• Endovascular devices are more expensive, but the reduction in hospitaldays, ICU days, and hospital resources used results in a significantlylower mean total cost per admission
Journal of Endovascular Therapy, Vol 25, Issue 4, Mar 2018
Challenges for the Operator:Lengthy occlusionsFlush occlusions/Proximal cap ambiguityMulti-level diseaseHeavy calcification
Challenges for EndovascularProcedures for CLI
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Heavy calcificationOld occluded stentsAltered anatomy post-bypass
Challenges for the Healthcare System:Expensive “Toys”Cases can be quite long
Effective Endovascular Therapyfor CLI: Procedural Goals
MUST get inlineflow directly tothe affected area
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Vessel needs tostay open longenough to healthe wound solimb can returnto baseline
CTOs are Very Common in CLI Patients
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Old Habits are Hard to Break
“I tried to cross it with a V18 andit wouldn’t go, so I don’t think anendovascular approach ispossible”
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Critical Tools for Complex and BTK Work:
0.014 Wire Technology
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Command ES Wire (Abbot Vascular)-Works like a “Mini Glidewire”
Confienza Pro: 9g and 12g tips (Asahi)-Tapered tip to 0.009” for CTO crossing
Sion: (Asahi)-Highly torqueable, long transition fromfloppy to supportive body-Designed to navigate collaterals andextreme tortuosity
Critical Tools for Complex and BTK Work:
Microcatheter Technology
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Turnpike and Corsair Microcatheters- 0.014 based systems
•Hydrophilic coating
•Tapered flexible tip, braided supportive body
•Available in 135 and 150 lengths
Critical Tools for Complex and BTK Work:
Support Catheter Technology
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CXI Support Catheter: 0.035 (Cook Medical)-Braided, hydrophilic, tapered tip-Far lower profile than Vert or Kumpe
Stiff angledGlidewire 0.035(Terumo)
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• Leading failure modality is the inability to cross andenter into the true lumen
• Antegrade attempts can fail in up to 40% of cases• Dedicated CTO devices marginally increase
success but add substantial cost
Peripheral CTO Crossing
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success but add substantial cost• Retrograde crossing increases success rates as
compared to antegrade only attempts• Combined antegrade and retrograde approaches
increase crossing success to nearly 100% (Scripps)
Typical Subintimal TechniqueTypical Subintimal Technique
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Challenges of the TraditionalSubintimal Technique
Excessive wireloop or probingleads to largeopening in
Extension ofintramuralhematoma with
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Collateral
Ideal locationfor re-entry
opening insubintimalspace whichbecomespressurized
hematoma withcompromise ofcollateral flow
Re-entry devices arefar less effectiveonce subintimalhematoma ispresent!!
Dedicated Re-entry Devices
NOT SEPARATELY REIMBURSED!
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True LumenTrue Lumen:Dedicated CTO Crossing Devices
LIMITED SUCCESS AND NOTSEPARATELY REIMBURSED!
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Truepath(BostonScientific)
Frontrunner(Cordis/Cardinal)
Crosser(Bard)
Wildcat(Avinger)
VianceCovidien/Medtronic)
Centercross(RoxwoodMedical)
Dedicated or “True Lumen”CTO Technologies
• NOT separately reimbursed
• Many require significant capital equipmentinvestment (costly consoles or upfront purchase ofcertain number of catheters)
• Typically no consignment
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• Typically no consignment
• Only work on relatively straightforward cases thatyou could have crossed with wire and cathetertechniques
• Often end in subintimal passage and require re-entry device adds substantial cost
• Don’t solve the issue of proximal cap ambiguity!
The Solution for Challenging CTO Cases:Access and Manage the Proximal and Distal Caps
• Highly complex cases can be performed with nearly100% procedural success by a combination of:
Well developed wire and catheter skills
Knowledge and understanding of CTO anatomy
Proper angiogram interpretation: correctly identify
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Proper angiogram interpretation: correctly identifyproximal and distal caps and collaterals
Obtaining access to the proximal and distal capsvia alternative access or collateral networks
Appropriate and selective use of advancedtechnologies
The Key To Success: SimultaneousManagement of the Proximal and Distal Cap
Performing wire re-entry within the occludedsegment avoids:
• Extension of dissection planes proximally ordistally to the occlusion
• Compromise of collaterals
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• Having to “chase” a dissection or increasing thearea that requires treatment
•• Preserves distal bypass targets
• Burns no bridges
Simultaneous management of the proximal anddistal cap also eliminates proximal cap ambiguity
Management of Proximal and Distal Cap:
Reverse CART Technique
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Accessing the Proximal Cap:Challenges for Antegrade Wire Passage
• Inability to navigate the wire past the proximal capdue to fibrosis or heavy calcium
• Proximal cap is ambiguous, but not flush occluded
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• Wire wont penetrate the proximal cap because it isalmost flush occluded and keeps going into sidebranch instead
• Flush occlusion- where is the proximal cap?
Problem:Wire unable tocross the proximalcap and enter the
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cap and enter thesubintimal space
Solution: Balloon-Assisted Push Technique
Wire tip pinnedby balloon
Pinned wire tipallows forfulcrum andadvancementof stiffer portionof the wire andanchoring of
Wire wontcross lesion,poor support
Prolapse wire,change supportcatheter forOTW balloon
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anchoring ofsystem
SOLUTION:Balloon-AssistedWire PushTechnique
Hydrophilic wirelooped with tip nextWire Tip Pinned
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to balloon surface
OTW ballooninflated to pin tip ofwire in place
Wire thenadvanced throughdifficult area
Wire Tip Pinned
Problem:Where is the ???
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proximal cap?
Solution:Use IVUS to
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determine locationof proximal cap
SFA
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Collateral
Solution:Wire passed intotrue lumen ofpopliteal artery
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popliteal arteryusing IVUSguidance
Problem:
Cant engageproximal cap
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proximal capbecause the wirekeeps sliding intoprofunda
SOLUTION:
Outback catheterused to “poke” intoproximal cap and
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proximal cap andprovide additionalsupport/penetrationpower so that wirecan be inserted intothe subintimal space
Problem:Proximal Cap is
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Proximal Cap isFlush Occluded
Solution A:Use IVUS to
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Locate theProximal Cap
IVUS left in placefor guidance
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Wire directed intoand throughproximal cap
Problem:
Proximal Cap isFlush Occluded
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Flush Occluded
SOLUTION B:
Use retrograde wirepassage to eliminateproximal cap
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proximal capambiguity
Retrograde wirepassed via profundacollaterals and up toproximal cap
SOLUTION B:
Use retrograde wirepassage to eliminateproximal cap
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proximal capambiguity
Pass second wireantegrade throughproximal cap
Problem:
Covered stent graftextending from
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extending fromCFABypassacross native SFAprevents wirepassage acrossproximal cap intonative SFA
Double Problem:
Covered stent graftextending from
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extending fromBypassPoplitealacross nativepopliteal preventswire passageretrograde too!
SOLUTION:
Direct antegradepuncture into
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puncture intooccluded SFA stents
SOLUTION:
Direct antegradepuncture into
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puncture intooccluded SFA stents
SOLUTION:
Antegrade wirepassage past distal
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passage past distalstent graft
SOLUTION:
Then retrogradewire passage past
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wire passage pastdistal stent graftthrough CXIcatheter
So.. Why UseCART? Can’t I JustGo Retrograde?
Use caution enteringdirectly from the
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directly from thesubintimal spaceeither antegrade orretrograde
RISK of CFAdissection and lossof profunda!
Primary entry fromretrograde subintimalspace
Looks good, right?
OOPS…..
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Good thing I didn’tballoon and stentthat!
Accessing the Distal Cap:Options for Retrograde Wire Passage
•Pedal Access:
Dorsalis pedis or posterior tibial distal tothe lower leg compartments
Avoid directly accessing the peroneal- risk
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Avoid directly accessing the peroneal- riskof compartment syndrome on exit
•Transcollateral Approaches:
Antegrade Transcollateral
Retrograde Transcollateral
Optimal Access via DP and ATAvoid Direct Peroneal Access
Peroneal arterylies deep betweentibia and fibulawithincompartmenttissues
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PT and DP arteriesare superficial inthe foot, easilycompressible, andnot in acompartmentspace
Pedal Access Technique
• Use ultrasound to find vessel
• Use 22 gauge Smart needle (doppler needle)to access vessel to be sure you are fully inthe lumen and not partially in the wall
• Use 300 length 0.14 soft tipped wire for initialwire passage
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wire passage
• After successful wire passage, use Corsaircatheter as support/sheath directly throughthe skin
• DO NOT insert a sheath- can be occlusive
• Use Verapamil generously to reducevasospasm and improve microcirculationflow
Correct Technique Incorrect Technique
Needle bevel notfully insertedthrough vesselwall, but insertedenough to getflash
Pedal Access Technique
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Wire advancedinto subintimalspace leading todissection
Problem:
How to access thedistal cap in theperoneal?
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peroneal?
DP cannot beaccessed due toinfected openwound
Peroneal accessvia transcollateralapproach viaoccluded PT
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Corsair navigatedthrough collateralsinto peronealusing Scion wire inorder to accessdistal cap
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distal cap
Access to distalcap via:
Posterior Tibial
Collaterals
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Collaterals
Peroneal
Problem:
How to get accessto the distal cap inthe peroneal?
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Open wound ontop of foot, PT toosmall to access
SOLUTION:
Antegradetranscollateralapproach
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Corsair and Scionwire
SOLUTION:
Antegradetranscollateralapproach
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Corsair and Scionwire
SOLUTION:
Antegradetranscollateralapproach
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Corsair and Scionwire
SOLUTION:
Antegradetranscollateralapproach
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Second Corsairand wire passedantegrade andreverse CARTcompleted
What About Calcium?A Major Challenge in CLI
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What About Atherectomy?
Additional Reimbursement!
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Atherectomy Devices:What Does the Data Show?
• Overall quality of the data is very poor
• Most devices have only been studied in smallnon-randomized registries
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• Thus far, only 5 randomized control trials ofatherectomy devices in the periphery have beenpublished (Silverhawk, CSI, Laser)
• And none present data past 12 months!
Traditional Atherectomy Devices:A Less Than Ideal Strategy
• Penetrate, denude, and injurethe intima
• Remove a very limited amountof superficial plaque andcalcium at best
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calcium at best
• No effect whatsoever on deepcalcium
• Substantial risk of distalembolization
• Time consuming
Better Treatment for Calcified Vessels:Intravascular Lithotripsy (IVL)
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IVL THERAPY
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Successful Treatment of CLI Patients:It Takes a Village!
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Progressive gangreneof right foot following2 failed lowerextremity bypasssurgeries
Told by his surgeon
47 year old Type I Diabetic
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Told by his surgeon“no other options”
Scheduled for belowthe knee amputation
Presents for secondopinion
1 week post complexendovascularintervention
Pre-procedure
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1 month post complexendovascularintervention
intervention
Pre-procedure
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1 week postcomplexendovascularintervention
4 weeks post
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6 weeks post
8 weeks post
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8 weeks post
Pre-procedure
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2 months post
9 weeks post
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• All wounds healed by 12weeks post-intervention
In Summary…
• PAD patients often present with complex multi-level diseasewhich can pose technical challenges for endovascular therapy
• Advanced lesion crossing techniques utilizing combinedantegrade and retrograde methods can markedly improve theprocedural success of endovascular procedures
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procedural success of endovascular procedures
• Dedicated CTO crossing technologies typically are not usefulin highly complex lesions, often require high capital equipmentcosts, and are not separately reimbursed
• Success in the treatment of CLI patients is best achieved via ateam approach with effective use of multiple resources andspecialists