As part of this year’s Peripheral Arterial Main Programme, Charing Cross yesterday hosted a series of live cases from Münster, Germany. There were also a number of edited cases presented by Faculty from across Europe.
The session was chaired by Michael Jaff (Boston, USA), and moderated by Giovanni Torsello (Münster, Germany) and Thomas Zeller (Bad Krozingen, Germany).
Live cases were performed by Arne Schwindt and Theodosios Bisdas and transmitted from St Franziskus Hospital in Münster, Germany. Audience participation was strong and the aim of the session was to improve the understanding of why a technique is chosen for a particular clinical situation.
In the first live case, the operators demonstrated the use of the AngioSculpt scoring balloon catheter followed by a Stellarex drug-coated balloon (both Spectranetics) in a 67-year-old male patient with critical limb ischaemia (Rutherford stage 4) of his left leg and rest pain at the right stump after below-knee major amputation. The patient’s main comorbidities consisted of arterial hypertension, heart insufficiency (NYHA III), hyperlipidemia and ongoing tobacco use. In addition to the previous below-knee amputation of the right limb in 2010, the patient underwent an aorto-bifemoral Y-prosthesis in 2006 due to acute aortic occlusion with prolonged wound healing at both groins and a drug-coated balloon angioplasty of both femoral anastomoses one year ago.
The clinical examination revealed no palpable pulses at both groins. The CT-angiography revealed a high-grade restenosis at the level of both common femoral arteries. Due to the involvement of both sides and the previous groin infections they performed a transbrachial approach through the left brachial artery. In order to avoid any dissection at that level and to achieve an appropriate lumen gain, the operators chose to perform an angioplasty of both anastomoses and common femoral arteries.
As for why the Stellarex drug-coated balloon was the balloon of choice for this case, Bisdas explained two main reasons: “the first reason is the good results
[as were presented on Tuesday at CX], and the second reason is that we have a long distance to go from the transbrachial approach up to the common femoral artery, so I needed a balloon where I have no concerns about loss of the drug.”
In the second live case, the team from Münster used the Rotarex device (Straub Medical) in an 83-year-old female patient with critical limb ischaemia (Rutherford stage 4) of her left leg. Main comorbidities of the patient were arterial hypertension, coronary artery disease, hyperlipidemia and obesity. The patient underwent previous stent implantation at the distal superficial femoral artery and proximal popliteal artery on the left side.
In the clinical examination, only the common femoral artery was palpable. The duplex ultrasound revealed a complete occlusion of the stent. The CT-angiography confirmed the results by means of a Tosaka III class in-stent occlusion. The operators demonstrated percutaneous rotational thrombectomy of the stent and the treatment of the in-stent stenosis according to the angiographic results post-thrombectomy.
The third live case was one of a 57-year-old male patient with intermittent claudication (Rutherford stage 3) of his left limb. His main comorbidities were type 2 diabetes mellitus, arterial hypertension, hyperlipidaemia, obesity and ongoing tobacco use. In 2015 the patient underwent drug-coated balloon angioplasty of a TASC B lesion in the distal superficial femoral artery (SFA). In the control angiography a non-flow-limited dissection was observed and this was left untreated. Two months later a control angiography due to the treatment of the contralateral limb revealed an excellent angiographic result with disappearance of the dissection membrane.
There were no palpable pulses at the left popliteal artery. In duplex ultrasound, an occlusion of the middle- and distal SFA was found. The CT angiography revealed a complete occlusion of the previously treated lesion and the suspicion of thombotic material into the lesion. The operators recanalised the left superficial femoral artery under filter protection and performed primary stenting with a drug-eluting stent (Zilver PTX, Cook Medical).
The fourth transmission from Münster demonstrated the use of the Supera stent (Abbott Vascular) for a calcified artery without pre-treatment. The operators presented a case of an 81-year-old female patient with critical limb ischaemia (Rutherford stage 4) of her left limb. Her main comorbidities consisted of arterial hypertension, hyperlipidaemia coronary artery disease and hypothyreosis. No previous vascular interventions had been performed at the index limb.
In the clinical examination, only the left common femoral artery was palpable. The duplex ultrasound revealed an occlusion of the distal superficial femoral artery and the first segment of the popliteal artery. The lesion showed moderate calcifications. The diagnostic angiography confirmed the ultrasound findings. The operators performed recanalisation of the occluded superficial femoral artery and popliteal artery. They prepared the vessel with a balloon catheter and stented with the Supera stent.
Case five was that of a 78-year-old male patient with intermittent claudication (Rutherford stage 3) of his left limb. His main comorbidities consisted of arterial hypertension, hyperlipidaemia and ongoing tobacco use. No previous vascular interventions had been performed.
In the clinical examination, only the left common femoral artery was palpable. The duplex ultrasound revealed a long occlusion (19cm) of the SFA. The CT-angiography confirmed the ultrasound findings. In this case, the operators recanalised the left SFA and performed primary stenting with a drug-eluting stent (Eluvia, Boston Scientific).
The sixth and final live Peripheral Arterial case demonstrated atherectomy with HawkOne (Medtronic) followed by drug-coated balloon (IN.PACT, Medtronic). The patient was a 69-year-old male with intermittent claudication (Rutherford stage 3) of his left limb. His main comorbidities consist of arterial hypertension, hyperlipidaemia, coronary artery disease with previous coronary artery bypass grafting and obesity. One year previously the patient underwent drug-coated balloon angioplasty of the distal superficial femoral artery with an untreated non flow-limiting dissection.
In the clinical examination, only the left common femoral artery was palpable. The duplex ultrasound revealed several stenoses at different levels: proximal SFA, first segment of the popliteal artery as well as a flow-limiting dissection at the level of the distal SFA. The diagnostic angiography confirmed the ultrasound findings. The operators treated the dissection as well as the stenosis with directional atherectomy and drug-coated balloon angioplasty.
For the edited cases, presenters gave an overview of the case details, showed a video of the procedure and explained why each device was selected for the respective case. The devices highlighted were the IN.PACT drug-coated balloon for long lesions; the Jetstream atherectomy system and Ranger drug-coated balloon (both Boston Scientific) in restenosis of a bare metal stent; the use of the Tigris dual component stent (Gore); the use of the Smart Flex stent (Cordis); and finally, the Viabahn stent graft (Gore) for the treatment of popliteal aneurysm.
[email protected] focuses on below-the-knee interventions
Also featured in the Peripheral Arterial Live and Edited Cases was a session hosted by the directors of the Live Interventional Course (LINC). Chaired by Giancarlo Biamino (Mercogliano, Italy) and Dierk Scheinert (Leipzig, Germany), the session placed focused on interventions below-the-knee. The audience heard the latest techniques for retrograde vascular access and crossing challenging below-the-knee chronic total occlusions, and discussed the future of the below-the-knee treatment—whether the device of choice will be drug-eluting stents, drug-coated balloons or bioabsorbable scaffolds. In terms of ongoing trials, Scheinert presented the LIMBO trial which is investigating the Bullfrog Micro-Infusion device (Mercator MedSystems) in the USA and Europe, and reported that there was been no procedural issues so far. There was also an edited case demonstration of the Bullfrog device and an edited case demonstration of popliteal artery recanalisation through a proximal anterior tibial access.