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D. Scheinert, MDDepartment of Angiology
Heart Center & Park HospitalLeipzig, Germany
Endovascular Revascularization is the Best Option in CLI: When and How?
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Definition:• Critical reduction of the
arterial perfusion• Arterial pressure
< 50 mmHg (ankle)< 30 mmHg (toe)
Rutherford Category4 Ischaemic rest pain5 Ulcera and gangrene
Critical Limb Ischemia
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Distribution of Lesions in CLI
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The SFA-CTO
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Highly calcified occlusion right SFAHighly calcified occlusion right SFA
Unsuccessful wire-passage 2.5mm Turbo-Laser
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Subintimal Recanalization
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1010--15% failures due to inability 15% failures due to inability to reto re--enter the true lumen .enter the true lumen .
Subintimal Angioplasty
Distal extension of the dissection with involvement of the first popliteal segment or below.
Major potential problem :
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Crossing Success> 95%
Outback CatheterPioneer Catheter
Re-Entry-Devices
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After Crossing ... What`s next?
Just stent it.
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12 months restenosis vs. lesion length
Lesion length (cm)
Bin
ary
rest
enos
is @
12
mon
ths
(%)
PTA + provisional stent
Stent
FAST
FAST
RESILIENT
ASTRON
ABSOLUTE
ABSOLUTE
ASTRON
RESILIENT
Data from randomised trials
Modified from Schillinger et al, EURO-PCR 2008
Summary
FACT
DurabilitySUPER SL SMART
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Risk Factors for Stent-Fractures
• Multivariante Analysis
RR p95% KI
Stent length >160mm 5.559 <0.0013.166 9.763Severe Calcification 3.941 <0.0012.261 6.868
Location of the stent was no predictor !
Scheinert D, Sax J et al. TCT 2007
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Angio AP projection Angio LAO projection
% MLD 42%% MLD 15%
Insufficient Radial Resistive Force Results in Suboptimal Deployments
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SUPERA StentInterwoven Nitinol Design
• Diameter:– 4.0 – 10.0 mm
• Length:– 40 – 150 mm
• Introducer:– 7F
• Working length:– 90 cm– 120 cm
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SFA-Registry (n=107)
Leipzig SUPERA-Registry
Primary Patency
Assisted primary Patency
Secondary Patency
6 month 95.2% (SE 0.21)
97.1%(SE 0.16)
97.1%(SE 0.16)
12 month 85.6%(SE 0.24)
92.3%(SE 0.26)
93.3%(SE 0.25)
18 month 75.7%(SE 0.49)
90.6%(SE 0.31)
93.3%(SE 0.25)
24 month 73.2%(SE 0.53)
88.3%(SE 0.37)
93.3%(SE 0.25)
88 patients had an x-ray screening after 14.1 +/- 4 months:No stent fractures detected!
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Characteristics of Patients with Infrapopliteal Obstructions
·· Diabetes mellitus in up toDiabetes mellitus in up to 80%80%
·· Significantly more concomitant diseasesSignificantly more concomitant diseases(Cardiac, cerebrovascular, renal, pulmonar)(Cardiac, cerebrovascular, renal, pulmonar)
·· Severe symptomsSevere symptoms-- Often critical ischemia Often critical ischemia
·· Older patientsOlder patients
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·· Interventional therapyInterventional therapy· Surgery· Surgery
OP vs. Interventional TherapyOP vs. Interventional Therapy
Decision depending on- Comorbidity- Availability of veins- Morphology of the obstruction
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Surgery
Lancet 2005:366: 1925
Amputation-free Survival
PTA
Bypass vs. Angioplasty in Severe Ischemia of the Leg (BASIL)
Bypass vs. Angioplasty in Severe Ischemia of the Leg (BASIL)
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Recommendations for Treatment of Critical Limb Ischemia
TransAtlantic Inter-Society Consensus 2007
The less invasive Technique should be preferred
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Techniques for Recanalization ofInfrapopliteal Lesions
Techniques for Recanalization ofInfrapopliteal Lesions
• Cutting/ Scoring balloon
• Atherectomy
• Laser-recanalization
• Stent-implantation
• DES / DEB
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Semi-compliant balloon with an external nitinol shape memory helical scoring edge
Angioscuplt Scoring BalloonAngioscuplt Scoring Balloon
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Short Infrapopliteal Lesions
TPT-occlusion
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-
Tissue Storage Tip Cutter
Silverhawk Atherectomy DeviceSilverhawk Atherectomy Device
-Tissue excissedfrom the lesion
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ZilverHawk Experience BTK
• 36 patients, 53% CLI• 49 infrapopliteal lesions
• 98% technical success using the SilverHawk
• 2-years follow-up– No major amputation, no bypass-surgery– Primary patency (duplex) 60 %
Zeller et al., J Endovasc Ther 2007
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CSI Orbital Atherectomy System (OAS)
• Rotational atherectomy system using an excentric diamond crown
• Crown sizes– 1.2 mm– 1.7 mm– 1.9 mm
• Three different speeds:– 80.000 rpm– 140.000 rpm– 200.000 rpm
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OAS Atherectomy SystemOAS Atherectomy System
TPT-occlusionTPT-occlusion OAS 1.7 mmOAS 1.7 mm Stand-alone resultStand-alone result
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TYPE AND DISTRIBUTION OF TYPE AND DISTRIBUTION OF 2,8932,893 LESIONS in LESIONS in 417417 Consecutive Diabetic with Ischaemic Foot Ulcer:Consecutive Diabetic with Ischaemic Foot Ulcer:
(Graziani et al. (Graziani et al. unpublishedunpublished data)data)
TYPE AND DISTRIBUTION OF TYPE AND DISTRIBUTION OF 2,8932,893 LESIONS in LESIONS in 417417 Consecutive Diabetic with Ischaemic Foot Ulcer:Consecutive Diabetic with Ischaemic Foot Ulcer:
(Graziani et al. (Graziani et al. unpublishedunpublished data)data)
0100200300400500600
Iliac Femoral Popliteal Peroneal Post.Tib. Ant.Tib.
Occl. 0-5cmOccl. 5-10cmOccl. >10cm
Occlusions
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Equipment for PTA of Equipment for PTA of Extensive Infrapopliteal LesionsExtensive Infrapopliteal Lesions
Equipment for PTA of Equipment for PTA of Extensive Infrapopliteal LesionsExtensive Infrapopliteal Lesions
• Low-profile balloons – Diameter 2.0 – 3.5 mm
– Length 80 – 210 mm • OTW 0.018“ eg. Pacific Extreme (Invatec)• OTW 0.014“ eg. Amphirion (Invatec)
• Hydrophilic 0.018“ or 0.014“ guidewire – V18 Control-wire (Boston Scientific)
– PT2, PT Choice, PT Graphix (Boston Scientific)
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Diabetes Patient with Foot UlcersDiabetes Patient with Foot Ulcers
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PTA of diffuse infrapopliteal lesionsPTA of diffuse infrapopliteal lesions• Patients 56 • Diabetes mellitus 82 %• Clinical vascular status
- Rutherford Class IV 15 (27 %)
- Rutherford Class V 43 (73 %)
• Patients 56 • Diabetes mellitus 82 %• Clinical vascular status
- Rutherford Class IV 15 (27 %)
- Rutherford Class V 43 (73 %)
Schmidt et al. LINC 2006
• Average lesion length 18.5 cm (5 – 30 mm)
• Occlusion 45 (80 %)
• Average lesion length 18.5 cm (5 – 30 mm)
• Occlusion 45 (80 %)
• Successfully recanalized limbs 50 / 56 (89 %)
• Successfully recanalized arteries 54 / 71 (76 %)
• Successfully recanalized limbs 50 / 56 (89 %)
• Successfully recanalized arteries 54 / 71 (76 %)
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Clinical and angiographical follow-up after PTA of diffuse BTK-lesionsClinical and angiographical follow-up after PTA of diffuse BTK-lesions
Follow-up in (n) 29– Mean follow-up (months) 3.4 ± 1.6
Clinical follow-up:
• Bypass-surgery 0• Minor amputation 5 (17 % )• Major amputation 0
Follow-up in (n) 29– Mean follow-up (months) 3.4 ± 1.6
Clinical follow-up:
• Bypass-surgery 0• Minor amputation 5 (17 % )• Major amputation 0
Schmidt et al. LINC 2006
·Improvement 21 ( 72.4 % )·Unchanged 7 ( 24.1 % )·Worsened 1 ( 3.4 % )
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How can we improve the results of BTK angioplasty?
• Revascularization of multiple vessels ?
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Angioplasty in DiabetesAngioplasty in Diabetes--PatientsPatientsAngioplasty in DiabetesAngioplasty in Diabetes--PatientsPatients
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Angioplasty in DiabetesAngioplasty in Diabetes--PatientsPatientsAngioplasty in DiabetesAngioplasty in Diabetes--PatientsPatients
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Angioplasty in DiabetesAngioplasty in Diabetes--PatientsPatientsAngioplasty in DiabetesAngioplasty in Diabetes--PatientsPatients
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Angioplasty in DiabetesAngioplasty in Diabetes--PatientsPatientsAngioplasty in DiabetesAngioplasty in Diabetes--PatientsPatients
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How can we improve the results of BTK angioplasty?
• Alternative approaches for CTO`s in case of failure to cross:
• Transpedal• Transcollateral
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Transpedal Recanalization Transpedal Recanalization -- Sheathless Iechnique Sheathless Iechnique --
Transpedal Recanalization Transpedal Recanalization -- Sheathless Iechnique Sheathless Iechnique --
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Transpedal RecanalizationTranspedal RecanalizationTranspedal RecanalizationTranspedal Recanalization
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Transpedal RecanalizationTranspedal RecanalizationTranspedal RecanalizationTranspedal Recanalization
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Transpedal RecanalizationTranspedal RecanalizationTranspedal RecanalizationTranspedal Recanalization
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Transpedal RecanalizationTranspedal RecanalizationTranspedal RecanalizationTranspedal Recanalization
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Transpedal RecanalizationTranspedal RecanalizationTranspedal RecanalizationTranspedal Recanalization
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Transpedal Approach for Transpedal Approach for infrapopliteal Angioplastyinfrapopliteal AngioplastyTranspedal Approach for Transpedal Approach for infrapopliteal Angioplastyinfrapopliteal Angioplasty
- 29 patients with infrapopliteal occlusions andfailed antegrade intervention
- Retrograde access in all patients possible
- Interventional success in 21 / 29 (72.4 %)
Baker et al. J Endovasc Ther 2008
- Success-rate in long BTK-oclusions ~ 80%
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How can we improve the results of BTK angioplasty?
• Stents and DES ?
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Stents for Revascularisation of Infrapopliteal Arteries
Stents for Revascularisation of Infrapopliteal Arteries
Re-occlusion PTA2 weeks after PTA
BX-Stent 2.5/33mm
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Stents dedicated for Infrapopliteal Arteries
Stents dedicated for Infrapopliteal Arteries
• Selfexpanding stents• Selfexpanding stents
Astron Pulsar (Biotronik)Xpert-Stent (Abbott)Astron Pulsar (Biotronik)Xpert-Stent (Abbott)
• Balloon-expandable stents• Balloon-expandable stents
Chromis Deep (Invatec)Chromis Deep (Invatec)
Maris Deep (Invatec)Maris Deep (Invatec)
• Max. length• Max. length
80 mm80 mm
• Ø• Ø
2-4 mm2-4 mm
3, 4 mm3, 4 mm
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Angioplasty Stenting Pn=74 n=58
Procedural Success 79% 95% <0.01
Clinical Improvement 74% 90% <0.05
Clinical Patency12 Months 53% 84% <0.01
Angiographic Restenosis Rate 53%
PTA vs. Stenting for infrapopliteal Obstructions
Scheinert D et al. EuroPCR 2003
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DES vs. Bare-metal Stentin Infrapopliteal Arteries
BMS DES
Scheinert 2006 56 % 0 %
Siablis 2006 55 % 4 %
Bosiers 2006 - 0 %
- Non-randomized comparison BMS vs. Cypher- 6-months angiographic binary restenosis
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Primary und Secundary Patency
0 6 12 18 240
20
40
60
80
100primary Patencysecundary Patency
Month
Perc
ent
Log Rank = 0,4551
Cypher – BTK RegistryAngiographic Stent Patency
FU-Time PatencyPrimary Secondary
6 months 98.2% 98.2%12 months 94.1% 95.9%24 months 89.2% 95.9%
Scheinert D et al. TCT 2006
![Page 50: Endovascular Revascularization is the Best Option in …summitmd.com/pdf/pdf/1254_Summit Seoul 2010 CLI Main -1.pdfD. Scheinert, MD Department of Angiology Heart Center & Park Hospital](https://reader035.vdocument.in/reader035/viewer/2022081614/5fc69aad1476d87ab23aaf6f/html5/thumbnails/50.jpg)
Cypher for BTK
![Page 51: Endovascular Revascularization is the Best Option in …summitmd.com/pdf/pdf/1254_Summit Seoul 2010 CLI Main -1.pdfD. Scheinert, MD Department of Angiology Heart Center & Park Hospital](https://reader035.vdocument.in/reader035/viewer/2022081614/5fc69aad1476d87ab23aaf6f/html5/thumbnails/51.jpg)
Cypher for BTK 6-months FU
![Page 52: Endovascular Revascularization is the Best Option in …summitmd.com/pdf/pdf/1254_Summit Seoul 2010 CLI Main -1.pdfD. Scheinert, MD Department of Angiology Heart Center & Park Hospital](https://reader035.vdocument.in/reader035/viewer/2022081614/5fc69aad1476d87ab23aaf6f/html5/thumbnails/52.jpg)
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- 2 -STRICTLY CONFIDENTIAL090110 – In.Pact DEEP Summary
NovelNovel Treatment Treatment ConceptConcept
Paclitaxel-eluting PTA Balloon Catheter
built on the proven, first BTK dedicated,Amphirion DEEP™ balloon platform
Worldwide first case performedLIVE @ LINC 2009
![Page 53: Endovascular Revascularization is the Best Option in …summitmd.com/pdf/pdf/1254_Summit Seoul 2010 CLI Main -1.pdfD. Scheinert, MD Department of Angiology Heart Center & Park Hospital](https://reader035.vdocument.in/reader035/viewer/2022081614/5fc69aad1476d87ab23aaf6f/html5/thumbnails/53.jpg)
Leipzig Experience with DEB BTK
![Page 54: Endovascular Revascularization is the Best Option in …summitmd.com/pdf/pdf/1254_Summit Seoul 2010 CLI Main -1.pdfD. Scheinert, MD Department of Angiology Heart Center & Park Hospital](https://reader035.vdocument.in/reader035/viewer/2022081614/5fc69aad1476d87ab23aaf6f/html5/thumbnails/54.jpg)
After 2.5/120mm In.PACT Deep 3 months – follow-up
Leipzig Experience with DEB BTK
![Page 55: Endovascular Revascularization is the Best Option in …summitmd.com/pdf/pdf/1254_Summit Seoul 2010 CLI Main -1.pdfD. Scheinert, MD Department of Angiology Heart Center & Park Hospital](https://reader035.vdocument.in/reader035/viewer/2022081614/5fc69aad1476d87ab23aaf6f/html5/thumbnails/55.jpg)
Unless you try to do something beyond what you have already mastered, you will never grow
Unless you try to do something beyond what you have already mastered, you will never grow