is there a place for very distal btk stenting? what are the options … · 2020. 12. 21. · btk...
TRANSCRIPT
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………………