plantar arch and below-the-ankle angioplasty who, …€¦ · plantar arch and below-the-ankle...
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Plantar arch and below-the-ankle angioplasty –who, when and how?
Tatsuya Nakama MD.
Miyazaki Medical Association Hospital, Cardiovascular Center
Miyazaki, Japan
Presentation and case examples
Speaker name: Tatsuya Nakama MD.
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I have the following potential conflicts of interest to report:
Consulting: Boston Scientific Japan, Century Medical Inc.
Employment in industry: None
Stockholder of a healthcare company: None
Owner of a healthcare company: None
Other(s): Honoraria recieved from
Abbot Vascular, Asahi Intecc., Boston Scientific, COOK, Cordis
Cardinal Health, Goodman, KANEKA, Lifeline, Medikit, Medtronic,
Orbus Neichi, Terumo,
Disclosure
Our first case of BTA angioplsty
Trans-collateral approach
Final angiogram
Achievement of wound healing
Nakama T, et al. EJEVS Extra, 2014; 27: e7-e9
Change
Should treat
Below-the-ankle
our mindset
Single center registry
Nakama et al, JEVT 2016; 23: 83-91
Single-center
Retrospective
Trial
PAA(+): 86 days
(IQR: 63 - 155)
PAA(-): 152 days
(IQR: 80 - 365)
P=0.050
Time to wound-healing
Nakama et al, JEVT 2016; 23: 83-91
improve the rate of wound healing
P=0.050
PAA(+) 93%
PAA(-) 60%
Next step…
Multi-center
Trialis necessary!
Japanese Red Cross
Kyoto Daini HP, Kyoto
Kasukabe Chuou
Genera HP, Kasukabe
Nagoya Kyoritsu
HP, Nagoya
Tokeidai Memorial
HP, Sapporo
Nakama T, et al. J Am Coll Cardiol Intv 2017; 10: 79-90
Miyazaki Medical
Association HP, Miyazaki
59.3%
38.1%
P= 0.003
Nakama T, et al. J Am Coll Cardiol Intv 2017; 10: 79-90
HigherRate of wound healing
59% vs 38%
FasterTime to wound healing
211days vs
365days
More distal revascularization
Improve the blood supply
is needed
problems
of BTA intervention
Who?
How?When?
Who?Who received the
Benefitof BTA angioplasty
From the RENDEZVOUS registry
Daily hemodialysisNon-ambulatory Depth of wound
Delayed wound healing score (DH-score) was evaluated
DH-score 1 - 2Moderate-risk population
(n=196)
DH-score 3High-risk population
(n=33)
Nakama T, et al. J Am Coll Cardiol Intv 2017; 10: 79-90
DH-score 0Low-risk population
(n=28)
Low-risk
population
Moderate-risk
population
High-risk
population
Acceptable but
controversial
Good
indication
Too much
treatment
Nakama T, et al. J Am Coll Cardiol Intv 2017; 10: 79-90
Decision making by DH score
When ?Indication of
aggressive treatment
There is NO evidence about
“Objective” & “Quantitative”
findings
Anatomical variation BTA disease
Serial PD(BTK to BTA disease)
Separate PD(BTK and BTA disease)
Isolated PD (Pure BTA disease)
Separate
isolatedSerial
When BTA intervention needed?
Should be treated in primary session
2. Separate disease (BTK & BTA disease)
1. Serial disease (BTK to BTA disease)
Staged treatment is better
3. Isolated disease (Pure BTA disease)
Should be treated in primary sessionCare the Indication of intervention
Separate
isolated
Serial
How?technical problem
How to guidewire crossHow to open (expand) the lesion
How to cross GW
・ Understand the complex BTA anatomyFigure of 8 (eight) shape
・ Set up the Bi-directional approachDistal site puncture (DP)Trans-collateral approach (TCA)
There is No Distal puncture site!!
Distal puncture is impossible!
Trans-collateral approachis important technique for
BTA CTO revascularization
70s male,
CLI (1st toe ulcer)
DM, HD, AmbulatoryPrevious history of
FP bypass
DH-score: 2Moderate risk
Control angiogram
1st EVT: proximal recanalization
Pedal arch was occluded
Pedal arch recanalization
2.0mm balloon pass the pedal
Whole pedal reconstruction
Final angiogram
Who?
How?・ Bi-directional approach is important
・ Patients with moderate risk (DH score 1 or 2)
Summary
When?・ Decided based on Lesion anatomy
Objective & Quantitative finding is needed
Conclusion
Pedal arch & BTA angioplasty is always
challenging and included some risk
Accumulation of
experiences & evidencesis necessary
Systemic review of below-the-ankle, inframalleolar intervention
When and how? Last frontier of lower limb intervention
Tatsuya Nakama MD.
Miyazaki Medical Association Hospital, Cardiovascular Center
Miyazaki, Japan