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Arterial Dissection Treatment with Tacks
Rajat Mohanka • Sep 27, 2023 • 89 hits
Arterial dissections can occur after lower extremity arterial angioplasty procedures. When they are both technically and clinically significant, they require treatment. Common methods of arterial dissection treatment include stents or Tacks, with stents being the more prevalent option. However, the Tack Endovascular System is a newer device that has received FDA approval for treating superficial femoral artery dissection (SFA) or proximal popliteal artery dissection complications following percutaneous transluminal angioplasty (PTA).
Dr. John Phillips, an interventional cardiologist from Ohio Health, introduces the components of the Tack catheter, pearls to remember when deploying Tacks, and how to choose the correct Tack size to deploy. This article includes excerpts from the BackTable Podcast. The full episode is featured below.
The BackTable Brief
• Tacks are used for arterial dissection treatment when it is caused by balloon angioplasty in the femoral and popliteal regions.
• No more than six Tacks should be deployed because of the high cost of using an additional Tack catheter. A stent may be more practical and economically favorable in these situations.
• Tacks should not be overlapped.
• Dr. Phillips recommends using the 1.5-4.5 mm diameter Tacks in smaller lower extremity arteries and the 4-8 mm diameter Tacks in larger lower extremity arteries.
Table of Contents
(1) The Role of Tacks in Arterial Dissection Treatment
(2) Tack Placement Technique
(3) Tack Sizing by Vessel
The Role of Tacks in Arterial Dissection Treatment
Dr. Phillips states that Tacks come in three sizes. There are the 1.5-4.5 mm Tacks for below-the-knee interventions, and there are two Tacks for above-the-knee interventions that are 3.5-6 mm and 4.0-8.0 mm. Each Tack catheter contains four to six Tacks. Tacks can be used for femoral artery dissection treatment and dissections of popliteal regions. They are usually deployed at the proximal and distal edges of the dissection, and if necessary, they can be deployed in between the two ends. Dr. Phillips recommends not deploying Tacks in heavily calcified regions unless the vessels have been prepped, because Tacks do not have strong radial force.
[Dr. John Phillips]
It is. I think the couple of things that you have to understand with the tack system, it's not a stent. There's different sizes. They have an adaptive sizing platform, so to speak, so the larger ones are 4-millimeter, 8 millimeters, and they're eight millimeters in length. Those are great for fem-pop regions…
…depending on the length of the dissection and where it is, I consider, assuming it's flow-limiting-- So example, if we're talking fem-pop region, I've been using a fair amount of tacks across the knee joint if there's a dissection, and basically you want to tack up the proximal and distal edges of the dissection and then, in between, I usually put a couple of tacks.
You get six in the device for the four to eights and then the three fives to six or something like that. We really don't use that one. Then the smaller ones, the tibial ones, are one five to four five millimeters, and you get four in those. I think you have to be smart with using them because they are a lot more expensive than stents and I try to avoid using them in heavily calcified areas unless if I've really modified the plaque and prepped that vessel aggressively.
In general, there's such little radial force in those, they're really meant to just quote, I mean literally tack up the dissection. A lot of people ask me, "Do you use them in plaque?" I think, in their IFU, it's like if there's 30% residual stenosis or plaque, you're not really supposed to use them but I use them in plaque all the time. I avoid it in heavily calcified areas.
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Tack Placement Technique
Before deploying Tacks, the operator must understand the unique radiopaque markers on the Tacks. Operators are going to be more familiar with stents by default, which only have two markers - one on the distal and proximal ends of the stents. Tacks, on the other hand, are shorter devices that consist of two crowns, and the marker is in between these crowns. Tacks are deployed using the standard pin-and-pull system, but Dr. Phillips cautions that there are subtle technical nuances to deploying Tacks that may require operators to adjust their technique after observing where the Tacks land. If the operator estimates that they will use more than six Tacks, Dr. Phillips recommends using a stent instead. Overlapping Tacks is not recommended.
[Dr. Aaron Fritts]
Is the deployment mechanism for tack-- You kind of mentioned this, but is it complicated or is it pretty simple? I mean can you walk us through it, for listeners?
[Dr. John Phillips]
Yes, sure. Basically, you get-- Let's use the big boy. So the 4 to 8-millimeter sizing lumens, you get six tacks on the catheter, and it's a pin-and-pull system. And so basically, you have the device and what you need to do is, under fluoro or having talked to the rep ahead of time, you have to understand there's a lot of markers and the catheter itself is kind of busy. The tacks themselves, the radiopaque portion of the tack is actually in the middle of the two crowns. That, in and of itself, is a little bit of a hurdle because when we're putting stents in, our eyes look for the radiopaque marker.
But in most stents or all stents, the radiopaque marker is distal and proximal. This is a little bit different. There are little radiopaque bands between each tack. So ultimately, what you have to do is loosen the tuohy and then you-- I describe it like popping a bottle of champagne and trying to pull that cork out. You don't just necessarily crank the—You kind of have to massage it sometimes. You are pinning and pulling, but sometimes you're pushing as well on the deployment device, and so, there's nuances. You shimmy it out.
And the tacks too, they can pop out on you a little bit, and that irks physicians. When I am asked to speak to reps about how to train and coach physicians through this, it's not uncommon to deploy a tack and have it go in the wrong spot. When we were involved in their clinical trials, I had some, they popped out. It takes about five or six, I think, deployments to kind of really get an understanding of the mechanism and what you're looking at. I find that, after a while, you can be quite accurate with them and place them very specific spots and feel comfortable doing so.
[Dr. Krishna Mannava]
When you have multilevel disease for CLI and let's say you've got dissections above the knee, below the knee, do you open two devices? Do you try and finagle one?
[Dr. John Phillips]
Yeah, I think I try not to open more than two devices in any case, because again, the cost is an issue. I had one doctor tell me that he felt like he needed to deploy all of them-- all the tacks that were in the catheter. I don't subscribe to that notion, but I do recognize that you have to be smart. If you're going to put 12 tacks in, you might as well put a stent in right.
I think they are considering. Having six, I think, is a good number. Four is a little bit limiting. On average, for me, in the tibialis, I'm probably opening two of the small ones and then anything above that SFA pop, I'm only opening one.
Because if I feel I need more than six, then I'm going to put a stent in or I'm going to use a stent someplace and maybe put the tacks in a no-stent zone or something like that.
[Dr. Krishna Mannava]
When we deploy stents in the leg, we're often taught don't leave little gaps or gap areas between some of the stents. What about with tacks? Do you tend to overlap them? Do you ever leave gaps? Is there any amount of overlap that's the right amount?
[Dr. John Phillips]
I think the company will tell you that you shouldn't overlap them because, again, very little radial strength. You have to be careful and you want to deploy, Captain Obvious here, but you want to deploy distal to proximal because you don't necessarily want to be running the catheter through fresh tacks. We do it all the time if you have to, but for me, if I've got, let's say, an 8-centimeter dissection, I'm tacking inflow outflow the top of it, and then I'm probably putting a couple in between. Over the years, I'm putting less in between. That's where I do use IVUS to take a look and see, "All right, what are those tacks doing? Is there something I might be missing?"
It's not meant to-- because I don't kiss them, really, and so I try to separate them. You can kiss them if you need to because when you start using them, you're going to miss, and physicians don't like missing. We don't like geographical miss, but you're going to have it. You just have to understand that. I was telling the salesforce, too, I'm like, "You guys need to tell docs that, 'Hey, these aren't as accurate as you might think early on, so you're going to get some misses.'"
So if you have a miss, yes, you can kiss them or overlap. But I usually try to leave 3, 4 millimeters of gap between. Because, again, if you're going to pile them on top of each other, you might as well just put a stent in because it's a heck of a lot quicker.
Tack Sizing by Vessel
Determining the appropriate Tack size to use depends on vessel type and diameter. Dr. Phillips uses the 1.5-4.5 mm diameter Tacks for the tibialis and the tibioperoneal arteries. However, for popliteal and superior femoral arteries, Dr. Phillips uses the 4-8 mm diameter Tacks.
[Dr. Krishna Mannava]
Sabine had a really good question about sizing. For me, sizing has always been a little confusing, and I think there's three different sizes. I personally keep two on the shelf, mainly, to limit my own confusion in device selection, but do you have any guidance on some of these sizes that overlap in numbers and trying to pick the right size for the right vessel?
[Dr. John Phillips]
Yes. To your point, you really only need two SKUs. The original device was, I think three, five to six, five or something like this. That has been eclipsed with the 4-millimeter to 8-millimeter adaptive sizing. And then the little guy, the one, five to three, five-- I'm sorry, one, five to four, five. For me, most tibialis are getting the one, five to four, five, and then probably maybe the TP trunk. But any popliteal, SFA, whatever, is four to eight. We've got probably five or six patients that we deployed these in the common femoral artery for an iatrogenic perclose dissection, which I thought was a curious way to do it.
The nice thing about it, too, is because of that adaptive sizing, you're able to land that first crown, the more distal one, like in the SFA, and then you can take that second one across into the common femoral and not necessarily jail the profunda. So this was an acute event, but we knew, going into it, that what the size of the vessel was. It was clean. There was a dissection there, so we were able to do it. But again, I think if you have the two sizes on your shelf and anything below the distal pop or TP trunk, you use the small ones and anything above, you use the big ones. You should be okay.
Dr. John Phillips
Dr. John Phillips is an interventional cardiologist with OhioHealth in Columbus, Ohio.
Dr. Krishna Mannava
Dr. Krishna Mannava is a vascular surgeon and medical director at Vive Vascular in Columbus, Ohio.
Dr. Aaron Fritts
Dr. Aaron Fritts is a Co-Founder of BackTable and a practicing interventional radiologist in Dallas, Texas.
Cite This Podcast
BackTable, LLC (Producer). (2023, April 17). Ep. 312 – Which Dissections Matter, and How to Treat Them [Audio podcast]. Retrieved from https://www.backtable.com
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