Presentation
Vascupedia Views Episode 1 BTK: tips & tricks to suceed in your revascularization
Vascupedia Views Episode 1 BTK: tips & tricks to suceed in your revascularization
Dr. Lorenzo Patrone (London, UK)
Moderator: Dr. Theodosios Bisdas (Athens, GR)
Including the most interesting questions which were not answered
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The most interesting questions which were not answered live:
Are you using cardiology stents for the smaller vessels in the foot? Any preference on DES vs bare metal stents in this setting and what does the data support? What about DCB treatment here? (Adam Toulouse)
Dear Adam,
thank you for your question.
The DES (everolimus and not paclitaxel) commonly used are derived from the cardiological experience.
These have demonstrated to be very effective for short to medium lesions (I mentioned in my talk the paper of Spiliopoulos).
No stent should be deployed around the ankle level or lower because the risk of stent fracture is extremely high due to the movements of the foot.
DCB in below the knee still didn’t demonstrate superiority to normal PTA. The combination between vessel preparation and DCB looks promising but still there is no proper scientific evidence to support their use.
In case of desert foot, do you have bone landmarkers to guide you during the intervention? Lorenzo Casadei
Dear Lorenzo,
thank you for your question.
In case of desert foot, I usually try to do superselective injections in the anterior tibial artery or posterior tibial artery to try to show any possible distal landing zone for my angioplasty.
Bone landmarks can be useful to understand vessel anatomy but they are not able to guide a blind revascularisation, at least in my experience.
Have you ever experienced stent fracture in BTK vessels? Giacomo Isernia
Dear Giacomo,
Thank you for your question.
I never noticed stent fracture in the patients which I treated but it is also true that luckily not many of them come back for treatment and my knowledge about the actual rate of stent fracture could be biased.
The important thing is not to stent at/below the ankle level.
In particular the PT has a very impressive range of movements during the dorsiflexion of the foot.
In a patient referred to us from an other centre I have once seen a stent completely smashed in the dorsalis pedis. This preclude any other option of endovascular treatment.
How often do you use DCB in the BTK interventions? Do the results justify the extra cost?
Dear Said,
I never use DEB in BTK. You can check INPACT deep randomised control trial. One-year and five-year results show how the results are comparable with amputation rate and freedom from TLR worse in the Paclitaxel group. The recent discussed methanalysis of Katsanos dedicated to Paclitaxel at the BTK level confirms higher rate for all cause death and major amputation in the drug elution group.
The main mechanism could be due to distal microembolisation.
New products are coming on the market which show a different coating and which could lead to better result but still no randomised control trial confirm better clinical results in the group treated with DEB. As mentioned before the combination between vessel prep and DCB looks promising but still there is no evidence supporting this expensive treatment in terms of wound healing and amputation free survival.
Congratulations Lorenzo and Theo.
Any tips and tricks specific for Buerger disease patients?
Dear Silveira,
Thank you for your question.
There is an interesting paper published in 2017 about these patients sci-hub.tw/10.1177/1538574417744085.
In my practice I have seen that the thickness of the vessels under US is a good predictor of success. When the AT or PT is occluded and with thick walls, the chances of success are very poor because the vessel will react badly to angioplasty.
In all the Buerger’s disease patients which I treated I used CTO wires (being extremely gentle and drilling without pushing) especially to engage the stump. Be gentle and fight hard for these patients. They deserve it!
Should we stent all short lesion or only the calcified ones?
Dear Marc,
This is actually a great question.
I personally evaluate the immediate, short term and “long term” (20 minutes after the inflation of the balloon) reaction of the vessel to angioplasty and then I take a decision. In same cases as TP trunk occlusion in Rutherford 5 or 6 patients I often don’t trust the angioplasty result and I stent primarily. I am also very keen of stenting the origin of completely occluded vessels because I often consider the need to obtain the best flow in a vessel which inevitably presents multiple dissection flaps.
Ballon catheter or support catheter for BTK recanalization? Lorenzo Casadei
What is your preferred wire to recanalize? And what is your preferred wire if you are subintimal to go back in to the true lumen? Michel Bosiers
Which is your workhorse wire for BTK and below the ankle interventions? Lorenzo Casadei
Which wire do you use for CTO ? Martin Schroeder
Dear Lorenzo, Martin and Michel,
Thank you for your questions which I decided to group here.
My workhorse wires are the Command 0.014 (Abbott) and Helberd 0.014/0.018 (Asahi). I use the Helberd in case of CTO and I make sure to drill and not to push to avoid the risk of perforation.
I sometimes use the PT Grafix (Boston Scientific) when I want to get into a very tiny vessel through a tight stenoses and I want to be atraumatic. Remember that this wire gives you very poor support and the tip is very easy to get the tip damaged so it’s not indicated in case of CTO.
Generally speaking I tend anyway to use 0.014 wires instead of 0.018 ones and this is particularly important when going below the ankle.
I also need to mention the Half stiff Terumo when I go subintimal. Because of its diameter when compared to the ones already mentioned and its stiffness it’s ideal to avoid the risk of perforation.
To answer to your second question I try to use low profile balloons to support my wire for two main reasons: I avoid the cost of a microcatheter (which instead I always use for my retrograde approaches made by V18 and CXI) and I am sometimes able to create my way through the occlusions by perform angioplasties in most stenotic/calcific tracts. I tend to use short low profile balloons like Armada XT or Across CTO BTK.
In that picture of the wound not healing and healing then you revascularised the lateral planter artery you definitely improved the flow. But a surgeon these often heal without any further intervention. Without a clinical trial you can’t say that such such aggressive intervention is required. Tahir Hussain
Dear Tahir,
Thank you for your question.
In that particular patient after one week from the amputation there was no granulation tissue and the margins started becoming necrotic.
For this reason, clinically, something needed to be done not to loose the forefoot or, even worse, the leg. After the revascularisation procedure the patient started doing better and he completely healed after few months.
There are trials which are showing the benefit of the BTA treatment and I have also cited one of them during my lecture.
My personal mantra is that if you have tissue loss you need to do everything you can to establish proper in line flow to the ulcer because this makes a difference in terms of wound healing.
Needle drilling technique through distal puncture? Elbasty Ahmed
Dear Ahmed,
Thank you for your question. The drilling technique (which I have used only four times in my life) needs to be done at the point where it is needed (the most calcified point usually) and, generally speaking where the balloon can’t pass. My first case has been a proximal peroneal artery where despite having the wire through and through between antegrade and retrograde access, I was unable to pass any 0.014 or 0.018 balloon.