1. Complex Decision Making Salvage Therapy for Peripheral Arterial Disease
Craig M. Walker, MD, FACC, FACP
Clinical Professor of Medicine
Tulane University School of Medicine
New Orleans, LA
LSU School of Medicine
Founder, President, and Medical Director
Cardiovascular Institute of the South
Houma, LA
Clinical Editor
Vascular Disease Management
Global Vascular Digest

2. Disclosures Speaker’s Bureau: Abbott Bard Boehringer-ingelheim
Bristol-Myers-Squibb/Sanofi
Cardiva
Cook Medical
Cordis
DSI/Lilly
Gore
ACHL/Merck
Spectranetics
PVD Training:
Boston Scientific
TriReme Medical
Stockholder:
CardioProlific
Cardiva
Spectranetics
Vasamed
Consultant/Medical/Scientific Boards:
Abbott
Boston Scientific
Cook Medical
CR Bard
Lake Regional Medical
Medtronic

3. Overview of Decision Making
Should any form of revascularization be performed
Surgery or intervention
If intervention
Access
Anticoagulation
Method of crossing obstruction
Use of distal protection
Treatment tools (stents, DES,DEB, Atherectomy)
Thrombolysis

4. Should any form of revascularization be performed?
Acute limb ischemia with no evidence of arterial or venous flow and loss of neurological function amputation needed.
Extensive deep infection with extensive osteomyelitis may render revascularization futile.

5. “For some reason, it is considered conservative treatment to chop someone’s leg off and aggressive treatment to even do an angiogram”
“I would consider intervention on any patient facing major amputation except cases of true acute limb ischemia with total loss of neurological function where reperfusion could result in severe complications including death with no benefit”

6. Access – Many options possible
Contralateral femoral
Antegrade femoral
Popliteal
Pedal/digital
Trans-stent
Access of occluded vessels using US
Transcollateral access

7. Contralateral Access Pros Cons Easiest Access
Can use in obese patients
Use when origin of SFA is occluded
Don’t have to compress treated artery
Cons
Poor wire control (torque)
Less push
Poor reach

8. Antegrade Femoral Access
Pros
Excellent wire torque and push
Great reach
Easier device delivery
Cons
Harder access (particularly in obese)
Greater bleeding risk
Sheath kinking
Must compress treated side

9. Popliteal/Distal Femoral Access
Pros
Very useful when SFA lesions can’t be crossed from above
Useful when there has been prior AF or transfemoral bypass or prior EVAR
Cons
May cross subintimally above the origin of the profunda

10. Pedal Access
Pros
May allow crossing of lesions that couldn’t be crossed from above
Great wire torque and push
Allows treatment of patient’s who can’t lie flat
Allows protection of distal patent vessels at branch points
Very low bleeding risk
Cons
Small vessels
Small sheaths – limit devices
Risk of vessel occlusion
Can’t puncture into infected areas

11. Trans-Collateral Access
Pros
Allows approach of total occlusions with retrograde wire approach from antegrade puncture
Can cross multiple lesions with single access
Can avoid puncture in areas of infection
No need to puncture or obstruct distal vessels
Cons
Often collateral vessels are small and tortuous
Requires more skill and patience

18. Vascular Anatomy (PEDAL ARCH RECONSTRUCTION)

22. Trans-occluded SFA/Popliteal Stents
Pros
Can insure intravascular position in a stent when attempts from above or below result in wire passage outside stents
Difficult stick
Cons
Need dual access and wire snaring to complete procedure

23. Trans-occluded vessels
Pros
May allow retrograde crossing starting from an intraluminal position
May access in very distal arterial segments
Cons
Much more difficult
Requires dual access

24. Anticoagulation Heparin vs Bivalirudin
Confirmation of adequacy of anticoagulation
Concomitant use of 2B3A agents
Before
After

25. Methods of Crossing Lesions
Intraluminal or subintimal
Use of crossing tools or wires

26. Use of Thrombolytics Needed in occluded grafts or stent-grafts
May be useful in acute occlusions
?Role to enhance crossing success or lessen embolic sequelae

27. Distal Protection or Not???
Pros
Are in IFU’s for several atherectomy devices
Embolic sequelae are common with all forms of intervention
Cons
Cost
Small risk of vessel injury

28. Treatment Tools Great debate about what is best interventional therapy
Several points where there seem to be consensus
In SFA, DEB,DES, Stents better than PTA
In Proximal IP occlusions DES (Balloon - expandable) yield better patency
Laser atherectomy, covered stents, DEB used alone or in combination are superior to standard balloon in treating SFA/Popliteal ISR
Limb salvage and patency are discordant

29. Goals of intervention (General agreement)
Straight line flow to the ischemic area at least long enough to heal ulcers or wounds but longer patency is desirable.
Never take away future treatment options such as distal bypass

30. Future Thoughts Will BVS scaffolds play a major role?
What will be the role of atherectomy plus drug delivery?
How will interventionists modulate the negative results of dystrophic vascular calcification?
Will we be able to immediately assess adequacy of perfusion? How many IP vessels?

31. Clear Future Directions
“Limb salvage teams comprised of multiple disciplines are going to play an integral part in improving rates of limb salvage. I strongly believe that no major amputation that is non-emergent should be performed without review of the team”