when is below the ankle angioplasty indicated and how to · bta angioplasty conclusion •less...
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Peter A. Schneider, MD
Kaiser Foundation Hospital
Honolulu, Hawaii
When is below the ankle angioplasty indicated and how to introduce it into your practice?
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Disclosure
Peter A. Schneider
Potential conflicts of interest to report:
Enter patients in studies sponsored by: Gore, Cordis, Medtronic,
Silk Road, Bard, NIH, Limflow
Modest royalty: Cook
Scientific Advisory Board (non-compensated): Abbott, Medtronic,
Boston Scientific
Chief Medical Officer: Intact Vascular, Cagent
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When and how to do below-the-ankle angioplasty?
BTA AngioplastyOne area where endo has a potential advantage over bypass.
Need solutions in diabetics with
compartmentalized pedal perfusion.
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BTA Angioplasty
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58 year old
diabetic on dialysis
Short occlusion of common plantar
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Kawarada et al. Catheter Cardiovasc Interv 2012;80:861
Pedal Artery Classification
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BTA Angioplasty Technique
• Antegrade ipsilateral approach
• 014 wire
• Wire choice: Fielder, Command
• CTO/support catheter-CXI angled tip
• Transluminal vs subintimal
• Value of plantar flexion (AT)and dorsiflexion (PT)
Courtesy: L Graziani
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Pre-treatment Imaging
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Katsanos et al. Cardiovasc Intervent Radiol 2013;36:926
BTA Angioplasty and Stenting
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Katsanos et al. Cardiovasc Intervent Radiol 2013;36:926
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Tacks placed in lateral plantar artery
4F Tack deployeddistal plantar artery
Future: Focal dissection repair
Conflict: Co-Founder and Chief Medical Officer for Intact Vascular
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Kawarada et al. J Endovasc Ther 2011;18:32
BTA Angioplasty
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Kawarada et al. J Endovasc Ther 2011;18:32
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Nakama et al. JACC: Cardiovasc Interv 2017;10:79
BTA Angioplasty
Rendezvous Registry
Faster wound healing
No difference:
Limb salvage
Amputation free survival
Reintervention
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Teyman et al. J Intervent Cariol 2017;1:7
45 patients with both
BTK and BTA disease
When BTA angioplasty also
performed; trend toward
better patency and fewer
amputations.
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BTA Angioplasty
Challenges
Marginal hemodynamic results, difficult to assess, no viable bailout
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Long segment tibial disease that extends into the foot
seems to be worse than focal pedal vessel lesions.
Challenges
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BTA AngioplastyConclusion
• Less hesitation but field not fully formed.
• Technically possible in many/most cases.
• May provide faster wound healing.
• Patency unclear.
• Consider BTA angioplasty when:
– Only outflow to foot is severely diseased
– Pedal artery supplies wound related artery
– Lesion beyond the reach of bypass
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Peter A. Schneider, MD
Kaiser Foundation Hospital
Honolulu, Hawaii
When is below the ankle angioplasty indicated and how to introduce it into your practice?