Updated: Mar 10, 2019
There are numerous modalities available to characterize and treat peripheral arterial disease (PAD). Dr. Kumar Madassery and Dr. Sabeen Dhand highlight their preferred techniques - covering imaging, atherectomy, drug coated balloons, and stenting.
The BackTable Brief
Cross-sectional imaging can provide high resolution images yet may not be feasible in patients with renal failure; duplex ultrasound can be a useful alternative to learn anatomy, what might be occluded, where the disease is, and access opportunities.
Despite lingering questions on the efficacy of drug coated stents for below the knee disease, Dr. Dhand and Dr. Madassery have had success with them in some CLI patients, particularly in the tibial arteries.
Orbital and directional atherectomy are useful tools to achieve luminal gain, especially for above the knee disease; IRs using Medtronic's TurboHawk (directional atherectomy) should consistently use distal protection filters to avoid embolization.
The CSI Diamondback orbital atherectomy system can be used to remodel the plaque, potentially leading to less dissection after angioplasty.
Disclaimer: The opinions expressed by the participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Preoperative Identification of Disease
[Sabeen Dhand] I feel like when I go to the conferences people talk about having CTAs and MRAs on all their patients, but practically speaking, most of these patients have pretty bad renal failure. And whenever we get a consult for someone with CLI, I'm thinking a couple of things. One, before I even see the patient, I'm looking at what imaging we have. And typically it tends to be either nothing, or maybe an xray of the foot and maybe a Doppler, a duplex study. I've become a huge fan of the duplex studies to learn the anatomy, what might be occluded, where the disease is, and even just looking at access. Before I see the patient I hope to have a duplex study.
[Kumar Madassery] I agree with pretty much everything you said. I think we're not a very cross-sectional imaging heavy institution when it comes to PAD CLI, unless our physical exam when we see him in clinic or in the hospital suggest that there's going to be an inflow disease at the access area.
Primarily, we'll get a CTA, or maybe an MR, if there's question of weak pulses in the femoral, et cetera. Or there's been extensive aorta bifem, to get a lay of the land. I think cross-sectional comes in handy then, but we primarily rely on our non invasives, to get an idea what we're going to do.
What Technologies Do I Use in My Practice?
[Michael Barraza] Yeah, okay. This may be a good point to ask another question. We've got a lot of relatively new technologies in the field. Just to be up a few examples, what role if any does atherectomy, or drug-coated balloons, or protection devices play in your PAD practice?
[Kumar Madassery] Yeah sure. Technology wise, we're blessed to have tons, or a lot of new technologies and equipment. However, I think the way to know what to use when is very anecdotal, it's very experienced based.
[Sabeen Dhand] I agree.
[Kumar Madassery] It's easy for everyone to say, "Oh, this is what I use," but then that might not be the same success someone else gets with it. And I don't think that's a fault of any, it's just what you're comfortable with. What you've learned the nuances of … So there are a lot of new technologies coming out. What's going to be the best for everything, I think it's going to be operator dependent and based on experience. Drug Coated Balloons and Stenting for PAD Treatment [Kumar Madassery] There's always talk about should you plaque modify before ballooning, because ultimately most of us will decide, based on the lesion and the characteristics, are we going to just balloon this with some DCB, or are we going to stent it, depending on the patient and their ambulatory status, and all that. Below the knee, drug-coated trials have been tough and haven’t done so well. But there's newer ones coming out, and there's newer devices for tacking the dissections in the tibials and all that.
[Sabeen Dhand] Typically I believe in remodeling the plaque. I think it gives you less dissection after you do angioplasty. And I will prefer drug eluting angioplasty if I can get away with it. Stenting tends to be something I use as a last resort. Unless the patient's older and especially if I have these kind of flow limiting dissections. But my goal is to get away, just trying to put kind of drug up there. Of course with the tibial, we don't have that yet. But once we do I will end up probably using those too, if the data supports it.
...In addition, the other thing I believe in for below the knee is I do think drug eluting stents, the coronary stents are really useful. I've seen great results with them. In those instances when you have this nasty disease that's not resolving with angioplasty.
[Kumar Madassery] Yeah, I agree. We rely on the tibial drug eluting stents quite a bit. In a lot of our CLI patients we've had great outcomes with it. I know people are questioning whether or not to use it, but sometimes you get remarkably improved flow. Sometimes we'll kiss the tibial stents too, if you have two vessels that you're preserving. It's something that if you're dealing with a lot CLI, I think it's good to have in your armamentarium. Using Atherectomy to Reduce Plaque Burden [Kumar Madassery] For us, atherectomy wise, primarily we'll use directional or orbital. We have access to get the other types. For directional, the TurboHawk to shave plaque, we'll use that mostly in the above the knee category area. But the caveat is that we typically use the distal protection filter for that, just to be on the safe side. Fortunately, because of all these safety guides, we've had very little evidence of embolization for us, but we don't use it all the time. But we also use orbital CSI Diamondback which is kind of sanding the plaque away, which helps us to get luminal gain. Atherectomy is a great tool. It's not something that we use heavily, but it is something in the arsenal that I think helps you especially for above the knee.
[Sabeen Dhand] Yeah, I think Kumar hit it on the point. Coming from a standpoint of a community hospital, and as you know if you follow me on Twitter, I always want more toys and gadgets, but unfortunately we don't have everything on the shelf. And sometimes it's a blessing in disguise because we don't have to make a decision of which one to use over the other. For atherectomy, I like it, I use the Diamondback and it's really the only atherectomy we have on our shelf. We may get the laser soon. Typically I believe in remodeling the plaque. I think it gives you less dissection after you do angioplasty.
Podcast Participants: Dr. Sabeen Dhand is a practicing interventional radiologist at PIH Health in Whittier, CA. Dr. Kumar Madassery is a practicing interventional radiologist with Rush University in Chicago. Dr. Michael Barraza Jr is a practicing interventional radiologist at Radiology Alliance in Nashville. Cite this podcast: BackTable, LLC (Producer). (2017, August 16). Ep 9 – #StopTheChop [Audio podcast]. Retrieved from https://www.backtable.com/podcasts Medical Disclaimer: The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.