Is there a place for very distal BTK stenting?

What are the options for acute PTA failure?

Dr. E. Puras Mallagray Hospital Universitario Quirón Madrid SPAIN

Enrique Puras Faculty disclosure I disclose the following financial relationships:

Consultant for Abbott, Medtronic , Cook, Covidien, Biolitec

Employee of CEVIFE

Receive grant/research support from Covidien , Urgo, Astra Zeneca

Advisory board of Abbott, Angiodynamics

• Endovascular first

• Straight line to the foot preferably through dorsalis pedis

artery or plantar artery

• Aggressive angioplasty regardless CTO length

• Several techniques: Subintimal angioplasty, SAFARY,

pedal-distal retrograde punctures

• Bailout stenting. Spot stenting

• Angiosome concept

BTK approach 2014

BTK lesions

Current endovascular strategy

BTK for CLI-patients

Short focal lesion Long diffuse lesion

PTA with long low-pressure balloons

Focal stenting if residual flow-limiting lesion

PTA

Bail-out stenting with balloon-exp stent

Bail-out stenting with self-exp stent

Calcified/Ostial

DEDICATED WOUND CARE

Appropriate technical endpoint for BTK intervention is remained unclear.

What should we do if out initial strategy in BTK PTA fails?

1.Unable to cross the lesion….What options do I have? Other GW? Other devices? Retrograde access?

2.Recoil, Dissection…….Re- angioplasty? Same ballon or change size?, time? DEB?

3.Rupture, AVF, calcified lesion……Stent?, What stent SE or BE?, in what position can we deploy safe?

Unable to cross a lesion: GW Selection Dr M MANZI

UNABLE TO CROSS A LESION……….

Not all crossing tools are created equal, and each has a

place in an algorithmic approach to crossing complex CTOs

Other devices that CAN help us crossing a BTK lesion:

1. Support catheters: CXI, TRAILBLAZER, Total Across

crossing catheters

2. Low profile ballons, hydrophilic, trackability, pushability

3. Mechanical devices……. No personal experience

• The TruePathTM CTO Device (Boston Scientific

Corporation)

• The Phoenix Atherectomy™ System

• Peripheral Rotablator Rotational Atherectomy System

• Diamondback orbital atherectomy system (OAS)

(Cardiovascular Systems Inc. [CSI], St. Paul, MN),

Natick, MA)

Crossing devices can potentially improve procedural

outcomes but also come with difficulties. The added cost

of these devices can be significant, and some require

capital equipment. Thomas P. Davis, MD EVT MAY 2013

1. GUIDEWIRE PERFORATION of the Vessel:

- frequent, but not a problem in small vessels

- when important / proximal: outside compression with blood pressure cuff

- Option nº1 ……try re-enty and PTA

- Option nº 2 ….retrograde access, trans-collateral

Failed POBA , Challenges in BTK:

Acute complications

Indications are limited to CLI patients with:

– Failure of antegrade approach

– No proximal stump at the origin of the target vessel

– Immediate origin of collateral at the re-injection-side (danger with antegrade approach to lose the collateral)

Retrograde Pedal/tibial access to angioplasty : when to do it.

Pedal access to retrograde tibial angioplasty when to do it.

ADVANTAGE DISADVANTAGE

IMMEDIATE Already anaesthesia

Already roadmap

Already on the table

No preparation of distal puncture side PREP

PLANNED Good preparation of distal puncture side with doppler and disinfection

Two times anaesthesia,

two times roadmap/ contrast

Failed POBA, Challenges in BTK:

Acute complications 2. DISSECTION

- moderate frequent in vessels below the knee

- Option nº 1: prolonged PTA +/-3-5 minutes

insufflation time……..DEB?

- Option nº 2: STENT ONLY WHEN FLOW

LIMITATION/ Severe Recoil

- Spot stenting; Avoid crushing Zones

Optimal plain balloon angioplasty

Prolonged inflation (180 sec)

improves the immediate result

of BTK angioplasty compared to

short dilation times (30 sec)

• Significantly fewer major

dissections and a modest

reduction of residual stenoses

are observed

N. Zorger et al. Peripheral Arterial Balloon Angioplasty: Effect of Short versus Long Balloon Inflation Times on the

Morphologic Results. J Vasc Interv Radiol 2002

Current Evidence for DEB in BTK • • Leipzig Registry (Schmidt A, et al.)

Large, singel-center CLI experience

• • DEBATE-BTK (Liistro F, et al.) Small, single-center RCT with 2-year FU

• • InPACT-DEEP (Zeller T, et al.) Large, multi-center, adjudicated (2 core labs)

RCT with 1-year follow-up

• • Biolux PII (Brodmann M, et al.)

Small, multicenter, RCT

good

bad

Potential Advantage of DEB

• Ease of use & repeatable

• Favorable clinical results in fem-pop arteries in reducing restenosis & TLR

• Local delivery of anti-proliferative drug with “nothing leave behind”

- Less neo-intimal hyperplasia than stents

- Stent disadvantaged zones

• Treat long BTK lesion

• Preserve future treatment options

Cassese S, et al. Circ Cardiovasc Interv. 2012;5(4):582-9

Chocolate BAR:

3. AV-FISTULA

- moderate frequent

- Option nº1 : prolonged PTA (3-5 min)

- STENT ONLY WHEN SEVERE

4. SPASM

- Calcium antagonist selective in artery

- Papaverine / Nitro 100-300 μg ia

Failed POBA,Challenges in BTK:

Acute complications

BTK DES STENT TRIALS

BTK STENTS: ACTUAL PROBLEMS

• Long BTK segment disease vs currently available short stents

• Leaving a permanent implant – stent induced inflammation, in-stent stenosis and thrombosis

• Poor runoff into foot – stent patency

• Difficulty in monitoring stent patency

• COSTS!!!!

How distal can we stent a BTK vessel?????? When stenting distally, be sure that:

• Only stent proximal arteries

• the distal stent edge is at least 3 cm above the ankle joint to avoid stent

injury

• Stent prone to crush in distal locations due to

superficial course of tibial arteries as well as

torsional movement

• It is advisable not to stent across major branches, when the vessel caliber

is 2 mm or less, and when the distal runoff below the ankle is poor.

• Always preserve a distal landing zone (maintain an option for a

distal bypass )

3/4 cm

A NEW PARADIGM: VASCULAR REPARATIVE THERAPY

Gradual disappearance of supportive structure

BVS Stent

• • Single centre • 3 Implanters

• • Chronic lower limb ischemia: RC 3-6 • De novo lesions; length ≤4cm, diameters 2.5-

4.0mm • Tibial arteries (distal P3) • Sample size: 15 patients

First experience with BVS in BTK Dr Ramon Varcoe Sydney, Australia

LINC Asia-Pacific 18-MAR-2014

Image courtesy Dr Ramon Varcoe

Image courtesy Dr Ramon Varcoe

RESULTS • • 10 patients • 11 Limbs

• • Age range 73-82yo

• • M:F 60:40

• • 14 Scaffolds

• • Vessels treated ATA ; 2 PTA; 2 PA; 4 TPT; 8 (P3; 0)

• • 100% Technical and Procedural success

• • 1 Acute occlusion (day 1: no DAPT)

First experience with BVS in BTK Dr Ramon Varcoe Sydney, Australia LINC Asia-Pacific 18-MAR-2014

Challenge in BTK:

5. Acute distal embolization

from atherothrombotic debris

-Prevention: Carotid Filters

-THERAPY:

• Aspiration Embolectomy

• Thrombolysis

• Open Surgical Thrombectomy

Take Home message:

development of the therapeutic

strategy in BTK revascularization

• Knowledge/EVIDENCE

• Materials/TOOLS

• Experience/Patient oriented

• Indications/LESION TAILORED

GOOD

RESULTS

BAD

• In cases of Endo-fail (technical, non healing, repeated intervention, mounting cost...)

• Long, calcified, multi-level disease

• Large tissue loss

• Distal target ok

• Going to live >2 years

• Those who have good veins.

When bypass is best??!!

I AM STILL A (endo)SURGEON………………