Complex Decision Making Salvage Therapy for Peripheral Arterial Disease Craig M. Walker, MD, FACC, FACP Clinical Professor of Medicine Tulane University School of Medicine New Orleans, LA LSU School of Medicine Founder, President, and Medical Director Cardiovascular Institute of the South Houma, LA Clinical Editor Vascular Disease Management Global Vascular Digest
Disclosures Speaker’s Bureau: Abbott Bard Boehringer-ingelheim Bristol-Myers-Squibb/Sanofi Cardiva Cook Medical Cordis DSI/Lilly Gore ACHL/Merck Spectranetics PVD Training: Boston Scientific TriReme Medical Stockholder: CardioProlific Cardiva Spectranetics Vasamed Consultant/Medical/Scientific Boards: Abbott Boston Scientific Cook Medical CR Bard Lake Regional Medical Medtronic
Overview of Decision Making Should any form of revascularization be performed Surgery or intervention If intervention Access Anticoagulation Method of crossing obstruction Use of distal protection Treatment tools (stents, DES,DEB, Atherectomy) Thrombolysis
Should any form of revascularization be performed? Acute limb ischemia with no evidence of arterial or venous flow and loss of neurological function amputation needed. Extensive deep infection with extensive osteomyelitis may render revascularization futile.
“For some reason, it is considered conservative treatment to chop someone’s leg off and aggressive treatment to even do an angiogram” “I would consider intervention on any patient facing major amputation except cases of true acute limb ischemia with total loss of neurological function where reperfusion could result in severe complications including death with no benefit”
Access – Many options possible Contralateral femoral Antegrade femoral Popliteal Pedal/digital Trans-stent Access of occluded vessels using US Transcollateral access
Contralateral Access Pros Cons Easiest Access Can use in obese patients Use when origin of SFA is occluded Don’t have to compress treated artery Cons Poor wire control (torque) Less push Poor reach
Antegrade Femoral Access Pros Excellent wire torque and push Great reach Easier device delivery Cons Harder access (particularly in obese) Greater bleeding risk Sheath kinking Must compress treated side
Popliteal/Distal Femoral Access Pros Very useful when SFA lesions can’t be crossed from above Useful when there has been prior AF or transfemoral bypass or prior EVAR Cons May cross subintimally above the origin of the profunda
Pedal Access Pros May allow crossing of lesions that couldn’t be crossed from above Great wire torque and push Allows treatment of patient’s who can’t lie flat Allows protection of distal patent vessels at branch points Very low bleeding risk Cons Small vessels Small sheaths – limit devices Risk of vessel occlusion Can’t puncture into infected areas
Trans-Collateral Access Pros Allows approach of total occlusions with retrograde wire approach from antegrade puncture Can cross multiple lesions with single access Can avoid puncture in areas of infection No need to puncture or obstruct distal vessels Cons Often collateral vessels are small and tortuous Requires more skill and patience
Vascular Anatomy (PEDAL ARCH RECONSTRUCTION)
Trans-occluded SFA/Popliteal Stents Pros Can insure intravascular position in a stent when attempts from above or below result in wire passage outside stents Difficult stick Cons Need dual access and wire snaring to complete procedure
Trans-occluded vessels Pros May allow retrograde crossing starting from an intraluminal position May access in very distal arterial segments Cons Much more difficult Requires dual access
Anticoagulation Heparin vs Bivalirudin Confirmation of adequacy of anticoagulation Concomitant use of 2B3A agents Before After
Methods of Crossing Lesions Intraluminal or subintimal Use of crossing tools or wires
Use of Thrombolytics Needed in occluded grafts or stent-grafts May be useful in acute occlusions ?Role to enhance crossing success or lessen embolic sequelae
Distal Protection or Not??? Pros Are in IFU’s for several atherectomy devices Embolic sequelae are common with all forms of intervention Cons Cost Small risk of vessel injury
Treatment Tools Great debate about what is best interventional therapy Several points where there seem to be consensus In SFA, DEB,DES, Stents better than PTA In Proximal IP occlusions DES (Balloon - expandable) yield better patency Laser atherectomy, covered stents, DEB used alone or in combination are superior to standard balloon in treating SFA/Popliteal ISR Limb salvage and patency are discordant
Goals of intervention (General agreement) Straight line flow to the ischemic area at least long enough to heal ulcers or wounds but longer patency is desirable. Never take away future treatment options such as distal bypass
Future Thoughts Will BVS scaffolds play a major role? What will be the role of atherectomy plus drug delivery? How will interventionists modulate the negative results of dystrophic vascular calcification? Will we be able to immediately assess adequacy of perfusion? How many IP vessels?
Clear Future Directions “Limb salvage teams comprised of multiple disciplines are going to play an integral part in improving rates of limb salvage. I strongly believe that no major amputation that is non-emergent should be performed without review of the team”