Achieving Acute Success and Durable Results with Complete Total Occlusion

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Achieving Acute Success and Durable Results with
Complete Total Occlusion?
Christopher J. Kwolek, MD FACS Harvard Medical
School Division of Vascular and Endovascular
Surgery Massachusetts General Hospital
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Background

• Peripheral arterial occlusive disease (PAOD) is
  associated with substantial morbidity and health
  care expediture
• Operative series have consistently demonstrated 5
  year limb salvage rates of 80 or greater
• Complications may occur in up to 25 patients
  after peripheral arterial bypass surgery
• Morbidity may compromise functional outcomes as
  less than 50 patients report a return to
  normal by 6 months postoperatively

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Background

• Increasing application of endovascular therapy to
  all territories of the arterial tree
• Percutaneous endovascular infrainguinal
  interventions (PVI) have been proposed as first
  line therapy for PAOD
• PVI primary patency rates 12-90, but
  secondary interventions are non-surgical
• Enthusiasm for broadening PVI indications has
  continued to increase!
• Claudication?
• Limb Salvage?

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Peripheral Angioplasty

• 5 year patency
• Claudication 40
• Limb Salvage 28
• Stenosis 43
• Occlusion 32
• Good Runoff 47
• Poor Runoff 28

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THE FUTURE DEFINEDINFRAINGUINAL DISEASE

• SFA occlusions - Traditional wisdom The variety
  of endovascular interventions has produced poor
  results
• PTA vs. PTA/Stent Trial
• 221 patients, lt 7cm SFA lesion
• Angiographic failure at one year 40
• Patency _at_ 4 years ? 50 (Becquemin et
  al. SVS, June 02)

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Background

• Development of small diameter catheter systems
  (0.014/0.018)
• Flexible, self-expanding Nitinol stents

Studies with longer follow-up performed over
10-15 yrs outdated
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Mortality of patients with PVD

• 10 Yr Mortality
• Claudication 48
• Rest Pain 80
• Gangrene 95

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Cannulation of Contralateral Iliac Artery
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Torque Device
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Technique

• Contralateral access
• Placement of a working sheath 6Fr Raabe or Balkan
  in the CFA or SFA
• Use of an .035 angled/straight glidewire with an
  angled or straight 4Fr/5FR catheter
• Try to stay intraluminal but frequently end up
  subintimal using the loop of the distal wire to
  advance
• REENTRY
• Retrograde popliteal/tibial approach

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Frontrunner XP Peripheral CTO

• .039 distal tip size
• 2.3mm jaw opening
• 90 and 120cm lengths
• Responsive torque
• Shapeable distal tip
• Blunt micro-dissection technology

.039 XP compared to .035 guide wire
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Outback and Pioneer Catheter
Enables rapid, safe, and reproducible re-entry of
a guidewire from the subintimal space back into
the true lumen of a peripheral vessel
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Outback?LTD Re-Entry Catheter

• Deploy cannula in either T or L view
• Advance wire
• Retract needle
• Remove device

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Technique

• Once intraluminal access is regained will often
  switch to a low profile balloon .018 saavy or
  .014 coronary balloons
• Sequentially dilate up to 5 or 6 mm
• Self-expanding nitinol stents for significant
  recoil, dissection with flow limiting lesion
• Plavix load and then continue for at least 6
  weeks then switch to ASA alone
• Flexed views of the leg

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MGH Results

• 1) Mid-term results of femoropopliteal PTA
• 2) Contemporary series of patients
• 3) Influence of clinical variables on patency
  and limb salvage rates

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Methods

• Retrospective record review 1/02 7/04
• Native femoropopliteal disease
• Chronic LE ischemia
• Exclusion criteria Acute critical limb ischemia
• Functionally unsalvageable limb
• Threatened bypass graft
• Mechanical thrombectomy/ thrombolysis

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Methods
Demographic/ operative data Clinical presentation
(Rutherford classification) 1-3
Claudication 4 Rest Pain 5-6 Tissue
Loss Lesion Anatomy (TASC classification) A
single stenosis lt 3cm B single
stenosis/occlusion 3-5cm or multiple lt3cm C
single stenosis/occlusion gt5cm or multiple
3-5cm D Complete SFA/POP occlusion
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Demographic and Clinical Factors
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Anatomic/Treatment Features
Angiographic success 230 (97) limbs
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Complications
No deaths related to PTA
6 Significant complications 2 groin hematomas
requiring transfusion 1 thromboembolus
thrombolysis 1 intubation from pulmonary
edema 1 SFA rupture FP bypass 1 device
malfunction FP bypass
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Primary Patency
p0.004
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Predictors of Primary Failure
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Assisted Patency
p0.31
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Limb Preservation
p0.007
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Predictors of Limb Loss
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TASC C/D Lesions
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Survival
plt0.0001
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Summary

• PTA of the femoropopliteal arterial segment can
  be performed with 97 technical success and a low
  peri-procedure morbidity
• Three year primary patency is 54, assisted
  patency is 92 and limb salvage is 89 in CLI

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Summary

• Predictors of primary patency failure include CHF
  and TASC C/D lesions
• Predictors of assisted patency failure include
  age lt 65 yrs, CHF and TASC C/D lesions
• Predictors of limb loss include Diabetes and CHF

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Conclusions

• Although primary patency rates remain low,
  excellent assisted patency and limb salvage can
  be achieved with close follow-up
• PTA should be considered as initial therapy
  regardless of Rutherford classification