How to treat SFA In-Stent Restenosis: Case Examples SCAI CPVI: SFA - PowerPoint PPT Presentation

How to treat SFA In-Stent Restenosis: Case Examples SCAI CPVI: SFA State-of-the-Art Treatment Strategies Andrew J. P. Klein, MD, FACC, FSCAI Interventional Cardiology Vascular and Endovascular Medicine Piedmont Heart Institute Atlanta, GA

Disclosures: ▪ I have nothing to disclose.

Conflict of Interest • Advisory Board for Medtronic Peripheral Vascular Section (March 2018-Oct 2018)

The Data

“We are going to talk about LASERS”

Laser:Mechanism • Photochemical – Breaks carbon – carbon bonds (photochemical) • Photothermal – Increases temp intra-cellular H2O → cell rupture → vapour bubble at the catheter tip • Photomechanical – Expansion and implosion of these bubbles disrupts the obstructive intra- vascular material • Fragments released are <10 μm in diameter

Data J Am Coll Cardiol Intv 2015;8:92 – 101

Take Home from EXCITE ISR

Laser + DCB vs. Laser+ PTA Figure 1. One-year freedom from (A) target lesion revascularization, (B) target lesion occlusion, and (C) target lesion reocclusion among lesions treated for in-stent occlusion (Tosaka III). BA, balloon angioplasty; CI, confidence interval; DCB, drug-coated balloon; HR, hazard ratio; KM, Kaplan-Meier; LA, laser. Kokkinidis, D. G., Hossain, P., Jawaid, O., Alvandi , B., Foley, T. R., Singh, G. D., … Armstrong, E. J. (2018). Journal of Endovascular Therapy, 25(1), 81 – 88. https://doi.org/10.1177/1526602817745668

Laser Choice • 4 diameters (0.9, 1.4, 1.7, 2.0 mm) • Larger diameter lasers (1.7, 2.0 mm) – Straight vessel >3 mm – 7F and 8F guides Interventional Cardiology Review, 2016;11(1):27 – 32

Laser Atherectomy

Lasers • Turbo-Elite Laser – CVX-300 Excimer Laser – Can be used independently or prior to TT when a pilot hole is not evident • Turbo Tandem Laser – Constrained within a guide catheter – Ablate concentric and eccentric lesions in FP vessels>5mm – Requires >2 mm Pilot channel – 7Fr

Laser Case • A 74-year-old severe claudication (Rutherford class III; TASC A; ABI 0.81) in the right leg. • Stent placement by PTA of the right femoral artery extending from the proximal to distal segments was performed less than 1 year prior. Miller et al. VASCULAR DISEASE MANAGEMENT 2016;13(1):E17-E30

Laser Case 2 • 78 yr old female with rest pain of LLE Miller et al. VASCULAR DISEASE MANAGEMENT 2016;13(1):E17-E30

Case 2: Off the reservation • 60 yr old male with a history of PAD s/p SFA stenting presents with recurrent lifestyle limiting claudication • No rest pain, no ulcers ABI Monophasic signals are seen bilaterally. ABI in the right is .49 with a toe pressure 20. ABI in the left is .31 with a toe pressure 20. Impression: moderate to severe arterial insufficiency on the right and severe on the left.

Preprocedural CTA

Angio

Procedure

OFF LABEL USE OF DA

FINAL (before DCB was an option)

FINAL

Rinse Repeat

Usual

Off label DA use

Usual with a Twist

Follow Up ABI Monophasic signals are seen on the right and biphasic on the left. The ABI's are >1.0 bilaterally. toe pressure on the right is 124 and on the left is 116 Impression: No hemodynamically significant arterial insufficiency to either lower extremity at rest.

ISR: Jetstream Atherectomy Korean Circ J. 2018 Mar; 48(3): 191 – 197.

ISR: RELIGN • Covering ISR with Viabahn stent grafts • Cannot get ISR inside these • Edge restenosis • Go down hard! • Might be considered for long lesions Adams G et al. Endovascular Today June 2015

ISR @6months Minor and Cook, Endovascular Today June 2015

ISR Case->RELIGN Minor and Cook, Endovascular Today June 2015

Conclusions • ISR is a challenged • Debulking prior limited to LASER (on label) • Balloon alone not great • Can relign the stents – Caveat emptor • DCB better

Thank you PROUD HOST OF SCAI 2020 SCIENTIFIC SESSIONS