Yesterday, for the first time, the Charing Cross International Symposium broadcast peripheral live cases that were directly linked to data presented the previous day on the theme of peripheral arterial controversies. The aim of the course was to provide delegates with opportunities to learn techniques to achieve the best results with the approaches discussed in the data.
Speaking from Bad Krozingen via satellite video, Thomas Zeller (Bad Krozingen, Germany), the director of the peripheral live cases course, said: “The live case transmissions are little bit different from what people are used to seeing at conferences. Our goal is not to educate or teach you about complex interventions; our goal is to provide you with context to data from recently published trials or even ongoing trials.” He explained that he would be the chief operator in the cases and would be assisted by Alijoscha Rastan, Elias Noory, and Ulrich Beschomer (all from Bad Krozingen, Germany).
The first case of the course was related to the 24-month ILLUMENATE data that were presented on Tuesday at CX by Stephan Duda (Berlin, Germany). It involved a patient who was enrolled in the ILLUMENATE Global Registry, which is evaluating Spectranetic’s Stellarex drug-coated balloon. Zeller explained that the patient appeared to have very mild disease of the distal superficial femoral artery. He added that they had purposely chosen a patient with a “relatively simple lesion” to remind the audience that “almost all of the data you can see so far regarding drug-eluting balloons are TASC A or B lesions”.
Zeller reported that he would be using an 8cm drug-coated balloon (with a 4cm balloon to predilate the vessel) because the rule for using drug-coated balloons should be the same as that for using stents in the coronary arteries: treat from a healthy segment into a healthy segment. He explained that the patient in this case had diffuse disease in proximal areas.
According to Zeller, another rule for using drug-coated balloons was not to put the balloon into the vessel until “everything was prepared”. He said: “Preparation means slashing off the guidewire; it is evacuating cracked air from inside the vessel so that you can see the exact actions of the balloon when it is inflated. If you wait until the balloon is inside the vessel to do the preparation, the balloon is already exposed to the bloodstream; the longer the balloon is exposed to the bloodstream, the more drug you will lose from the surface.”
The second case, in which the Silverhawk atherectomy device (Covidien-Medtronic) and a drug-coated balloon were used to treat a popliteal artery stenosis, was also related to data presented during the peripheral arterial controversies. Zeller commented that the rationale for using atherectomy in this patient was based on the results of the DEFINITIVE AR study, which indicated that directional atherectomy and anti-restenotic therapy (DAART) could be used to improve patency in long and severely calcified lesions: the Zeller himself presented the study’s 24-month results at CX on the peripheral day. However, he commented that the patient in the case was not the typical “DEFINITIVE AR” patient because her femoral artery was “free from disease”. “The popliteal artery, in particular the distal segment, is severely exposed to extra compression forces. Therefore, we usually try to avoid placing a stent in this artery. Thus, we used atherectomy before a drug-coated balloon in this particular patient to try to avoid the need for a stent,” Zeller explained.
Rotational atherectomy, with the Jetstream device (Boston Scientific), and a drug-coated balloon (Ranger, also Boston Scientific) were used, in the third case, to treat a calcified superficial femoral artery lesion. According to Noory, who gave the overview of the case, the first-in-man data for the Ranger device were not yet available but data from the preclinical studies were “promising”. The case sparked a discussion about when to use atherectomy and when to use rotational atherectomy, with Zeller commenting: “Rotational atherectomy is a pretty good tool for occlusions. Also small vessels, 4mm for example, also respond very well to the Jetstream system. If you have larger diameters, 5–6mm vessels, or bifurcations then I prefer to use atherectomy.”
The final case of the morning was supposed to involve the use of the TurboHawk (Covidien-Medtronic) and a drug-coated balloon for the treatment of a lesion in the common femoral artery. This related to the ongoing PESTO-CFA study, which is comparing percutaneous intervention with surgery for the management of common femoral artery lesions. However, Zeller had difficulties putting in the guidewire in the lesion and, after discussing the case with the audience, decided to proceed to putting in the drug-coated balloon without using atherectomy.
In the afternoon, cases were focused on situations in which “stents were unavoidable or beneficial” and “where stents are unavoidable or beneficial and in-stent restenosis treatment”. The devices used in these cases were the Zilver PTX (Cook Medical) with a new release system, the Supera (Abbott Vascular), the Supera with a provisional re-entry device, the Innova stent (Boston Scientific), the SmartFlex (Cordis), a sirolimus-eluting balloon and the BioMimics stent (Biosensors), heparin-bonded contoured-edge Viabahn (Gore Medical), and Rotarex (Straub Medical) and IN.PACT Pacific (Medtronic). During Tuesday’s peripheral programme, there were talks reviewing the current controversies in peripheral stenting.
Giovanni Torsello (Münster, Germany), who chaired the morning session of the live cases course, said the live cases were a valuable educational tool because delegates not only wanted to hear about study data but also see “how they can make their strategies, their techniques better than before. This is why people attend live case courses.”
LINC (Leipzig Interventional Course) once again held a live case session at CX, which this year focused on below-the-knee interventions. The cases included recanalisation of an infrapopliteal obstruction with a drug-coated balloon, retrograde transpedal recanalisation with 3F access system, and lesion-specific use of a drug-eluting stent and a drug-coated balloon for an infrapopliteal obstruction. Giancarlo Biamino (Mercogliano, Italy) told CX Daily News that live cases that “do not go according to plan” were just as educational as the ones that did because it gave delegates opportunities to see how operator can manage and rectify unexpected situations.