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

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Feb 02, 2024 100 likes •439 views

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

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Andrew J. P. Klein, MD, FACC, FSCAI Interventional Cardiology Vascular and Endovascular Medicine Piedmont Heart Institute Atlanta, GA

How to treat SFA In-Stent Restenosis: Case Examples

SCAI CPVI: SFA State-of-the-Art Treatment Strategies

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Disclosures:

▪ I have nothing to disclose.

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Advisory Board for Medtronic Peripheral Vascular

Section (March 2018-Oct 2018)

Conflict of Interest

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The Data

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“We are going to talk about LASERS”

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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

Laser:Mechanism

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Data

J Am Coll Cardiol Intv 2015;8:92–101

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Take Home from EXCITE ISR

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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

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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

Laser Choice

Interventional Cardiology Review, 2016;11(1):27–32

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Laser Atherectomy

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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

Lasers

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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.

Laser Case

Miller et al. VASCULAR DISEASE MANAGEMENT 2016;13(1):E17-E30

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78 yr old

female with rest pain of LLE

Laser Case 2

Miller et al. VASCULAR DISEASE MANAGEMENT 2016;13(1):E17-E30

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60 yr old male with a

history of PAD s/p SFA stenting presents with recurrent lifestyle limiting claudication

No rest pain, no ulcers

Case 2: Off the reservation

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.

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Preprocedural CTA

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Angio

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Procedure

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OFF LABEL USE OF DA

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FINAL (before DCB was an option)

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FINAL

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Rinse Repeat

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Usual

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Off label DA use

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Usual with a Twist

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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.

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ISR:Jetstream Atherectomy

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

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Covering ISR with

Viabahn stent grafts

Cannot get ISR

inside these

Edge restenosis
Go down hard!
Might be considered

for long lesions

ISR: RELIGN

Adams G et al. Endovascular Today June 2015

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ISR @6months

Minor and Cook, Endovascular Today June 2015

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ISR Case->RELIGN