Polling Station

Poll 01/07/2019 – 31/07/2019

The femoropopliteal In-Stent-Restenosis

Patient’s characteristics:

Gender: Female

Age: 79 years old

Comorbidity: Arterial hypertension, Dyslipidemia,

Implantation of a bare metal stent right SFA 4 years ago, Debulking and DCB angioplasty for ISR 2 years ago

Symptoms:  Calf claudication after 50 meters

DUS: SFA stent Occlusion

Question #1

Does the Tosaka Class of the ISR influence your treatment strategy?
  • Yes

  • No

  • I am not familiar with the Tosaka Classification

The expert: Lorenzo Patrone MD
The Tosaka classification (TOSAKA reference) [1] is useful to understand the difference of ISR different types in terms of future recurrence of the event. In my opinion, in cases of ISR III, the possible endovascular rescue of an occluded stent could definitely benefit from the use of an atherectomy device or from the relining of the original stent(s) with drug eluting / Supera / Viabahn stents. In these ISR III cases we should also keep in mind that, if the endovascular recanalisation of the occluded native vessel has been originally chosen despite the feasibility of the vein bypass option, the latter should at least be carefully considered as possible durable bailout.
Question #2

Which would be your primary revascularization method for focal SFA ISR?
  • Bare Metal Stent

  • Stent Graft

  • Drug eluting stent

  • Plain Angioplasty

  • Drug coated balloon angioplasty

  • Vessel prep and drug coated balloon angioplasty

The expert: Lorenzo Patrone MD
In stent restenosis, particularly in CLI patients, represents one of the cases where the use of paclitaxel coated balloons could be justifiable despite the hypothetical increased risks of death because beneficial in terms of long term patency, demonstrated by randomized control trials [2-9]
Question #3

Which would be your primary revascularization method for long SFA stent occlusion
  • Surgery

  • Endovascular

The expert: Lorenzo Patrone MD
I think that a primary endovascular approach is preferable in case of de novo in stent occlusion, particularly if the patient is not particularly fit for an open procedure/doesn't have vein suitable to be used for bypass. The use of an atherectomy device +/- relining with DES/Supera/Viabahn could decrease the risk of a new ISR event, despite the lack of level Ia evidence supporting their use. In case of recurrent long SFA stent occlusion, an open approach needs to be strongly considered as first option treatment.
Question #4

Which would be your primary endovascular treatment option for a popliteal ISR?
  • Bare Metal Stent

  • Stent Graft

  • Drug eluting stent

  • Plain Angioplasty

  • Drug coated balloon angioplasty

  • Vessel prep and drug coated balloon angioplasty

The expert: Lorenzo Patrone MD
The stented popliteal segment is a challenging territory because the possible surgical option would be often limited to fem - below-knee bypasses. Vessel preparation combined with DCB angioplasty is in my opinion the best treatment which we can offer to such patients [10-11], but still needs to be further evaluated and supported by good quality data [12].
Question #5

Which would be your antithrombotic treatment after endovascular treatment of an occluded bare metal stent in the femoropopliteal segment?
  • Acetylsalicylic acid

  • Clopidogrel

  • Dual antiplatelet therapy

  • Vitamin K antagonist

  • New oral anticoagulant

  • Antiplatelet + Anticoagulant

  • Antiplatelet + Vitamin K antagonist

The expert: Lorenzo Patrone MD
Dual antiplatelet therapy for a period between three and six months is my common approach, to be then switched back to single antiplatelet for life. Statins, if not already present in the therapy scheme, need also to be prescribed, due to their demonstrated benefic effect in PAD and, in particular, when talking about in stent stenosis. [13-14]
Question #6

Would you treat an asymptomatic focal ISR in order to prevent an occlusion?
  • Yes

  • No

The expert: Lorenzo Patrone MD
If the stenosis is >75% in a CLI patient I think that we could compare the treatment of this asymptomatic focal in stent restenosis to the graft salvage procedure. The correlation between severity of the ISR and worse long term patency rate is demonstrated [1] and stent occlusion prevention (especially if a long segment has been stented) should be strongly considered.
Question #7

How often do you perform follow up visits after endovascular treatment of an ISR?
  • 3 months intervals

  • 6 mon intervals

  • At 3, 6 and 12 months after the procedure

  • Only in case of symptoms worsening

The expert: Lorenzo Patrone MD
In my institution we usually perform a standard 6-week follow up only, warning the patient to come back to A&E / vascular clinic in case of symptoms worsening. However CLI patients with tissue loss are followed weekly in our podiatry/wound clinic and this allows us to keep these particularly fragile patients under our radar. In addition to that, for particularly challenging patients we provide an "endovascular graft surveillance" program with duplex scans every 6-12 months.