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Deploying the BioMimics Stent in Femoral Popliteal Disease: Who, When, How?

Author Cullins Nwaogu covers Deploying the BioMimics Stent in Femoral Popliteal Disease: Who, When, How? on BackTable VI

Cullins Nwaogu • Oct 2, 2022 • 40 hits

The femoral popliteal region has been widely regarded as a challenging area to treat peripheral arterial disease, often requiring unique techniques and specialized devices to achieve durable outcomes. According to interventional radiologist Dr. John Rundback, the Veryan BioMimics Stent is able to adapt to the physiologically arduous femoral popliteal region, making it a favorable tool for certain situations. Dr. Rundback discusses the design of the BioMimics Stent on the BackTable Podcast, explains when to use the device, and shares the techniques he uses to maximize its efficacy. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable Brief

• According to Dr. Rundback, the BioMimics Stent excels in situations where there are moderate to severely dense calcifications and nearby collateral arteries.

• The BioMimics Stent has a helical design that is able to foreshorten, rotate, and curve in order to adapt to the patient’s femoral popliteal region. According to Dr. Rundback, the mechanical design of the BioMimics Stent provides antiproliferative and healing effects within the vessel.

• Vessel prep is an important aspect of femoral popliteal treatment with the BioMimics Stent. Dr. Rundback recommends dilating the vessel such that it is 1 mm larger than the stent. To maximize efficacy after placing the stent, he also recommends utilizing drug coated balloons as needed following an initial surveillance period.

BioMImics Stent

Table of Contents

(1) When to use the BioMimics Stent in Femoral Popliteal Disease

(2) Advantages of the BioMimics Stent in the Femoral Popliteal Region

(3) Vessel Preparation and Other Strategies to Maximize BioMimics Stent Efficacy

When to use the BioMimics Stent in Femoral Popliteal Disease

Dr. Rundback believes that the BioMimics Stent can be used in patients that have PAD with moderately dense calcifications within the artery in conjunction with vessel preparation. The BioMimics stent is also Dr. Rundback’s choice over other stents when collateral vessels are nearby and precision is necessary. In the conversation below, Dr. Rundback describes his ‘pave and crack’ strategy, which can be used in situations where dense calcifications are present and adequate vessel prep cannot be achieved.

[Dr. Sabeen Dhand]:
We talked about the delivery of Supera being a little hard. What's the delivery system for the BioMimics. What do you do, Exactly?

[Dr. John Rundback]:
Yeah, I mean, you still want to get good vessel prep. And I said I'm 50-50 because in our population we still get patients who have dense calcification - those dense, circumferential calcifications. You're still leaning more towards the Supera. But again, if you look at the BioMimics data, I think 40 or 50% of those patients had moderate calcification. So, you can use it in calcified arteries, you know, quite well with the vessel prep.



[Dr. Sabeen Dhand]:
One of my questions is going to be, what lesions do you use Supera for and what lesions do you use BioMimics for? You touched on it. You said, you know, potentially heavy calcified vessels that are elastic, you would maybe do Supera to get that radial strength. Are there any other lesions that you would lean towards either stent or trying to go more towards one stent or the other?

[Dr. John Rundback]:
Yeah, although we pre-treat every time, we get lesions that are proximal SFA and ostium or lesions where I need a very precise landing before a big collateral, you know, which I may not want to compromise. I'm going to go ahead and almost always use the BioMimics. The precision of placing that - there's very little foreshortening and it's reliable. There are also interesting - and this is not often talked about - interesting cases where I just can not get, you know, adequate vessel prep. I just can't treat the dense calcium. I've done everything and, you know, it happens. In those cases once you elongate Supera you definitely lose patency and that’s it, your hands are tied. So in those cases, we will go ahead and,even though it's dense calcium, lean towards using BioMimics instead, even if we could then go ahead and sort of rewind or, crack and pave, or I guess it’s a pave and crack strategy in that case.

Listen to the Full Podcast

New Tools to Treat Severe Distal Femoropopliteal Disease with Dr. John Rundback on the BackTable VI Podcast)
Ep 212 New Tools to Treat Severe Distal Femoropopliteal Disease with Dr. John Rundback
00:00 / 01:04

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Advantages of the BioMimics Stent in the Femoral Popliteal Region

The BioMimics peripheral stent is designed as a helical stent with a central line that is able to foreshorten, rotate, and curve. Because of this ability, the stent is able to adapt physiologically to the patient’s femoral popliteal region to maintain a swirling, laminar flow in the vessels, which leads to antiproliferative effects to aid healing and prevents intimal hyperplasia, according to Dr. Rundback.

[Dr. John Rundback]:
So the BioMimics stent has this unique configuration, and there are great videos of this. As the biomechanics change in the popliteal region, it's made to accommodate. It kind of rotates and curves and foreshortens to really match what's happening physiologically in the individual. And as a result, you kind of maintain, swirling flow, but I kind of think of laminar or parabolic flow. And we all know that that's key. If you get turbulent flow that's when you get PMN rolling and all these other things, which lead to that phenotypic change in the smooth muscle cells and intimal hyperplasia. But if you can maintain this swirling laminar flow or parabolic flow pattern that in and of itself is antiproliferative, leading to the formation of healthy endothelium. So the structure itself promotes good healing and prevents intimal hyperplasia.

[Dr. Sabeen Dhand]:
So you mentioned a central line or a helical design. If you put the stent, ex-vivo deployed on a table, it almost looks like a sine wave, right? That's what it looks like and it doesn't lay flat. There’s twists in it. Other than the laminar flow, is that supposed to mimic the same sort crests and troughs of the popliteal artery when it compresses or that's not really the idea? The idea is that it can just shape to what it's needed?

[Dr. John Rundback]:
Yeah, that's a good question. I'm not sure if that was necessarily the idea in creating it. The idea was to create a helical flow pattern, but that being said, when you look at models of cadaver models, SFA, pop segments inflection. They assume the exact same configuration as this helical local structure. So, maybe it was chance or maybe that it's good engineering, but what happens is when these stents are in and you compare them to native arteries in the flex position, they assume the exact same anatomic configuration. So they're very well-suited for them.

Vessel Preparation and Other Strategies to Maximize BioMimics Stent Efficacy

Femoral popliteal treatment with the BioMimics Stent often requires significant vessel prep. Dr. Rundback suggests dilating the artery 1 millimeter larger than the stent. Atherectomy and shockwave lithotripsy can be useful tools in this context. After the stent is placed, Dr. Rundback suggests active surveillance afterwards and then adjunct treatment with drug coated balloons as needed to increase or maintain patency. Studies have shown that bare metal stenting coupled with Drug Coated Balloons leads to safe vital statistics and increases in the patency of the BioMimic stent.

[Dr. Sabeen Dhand]:
What about it's sizing, you know, Supera you want to size one-to-one. Is the BioMimics stent more like you can oversize by one millimeter or do you still go one-to-one?

[Dr. John Rundback]:
No, the recommendation is you go one millimeter over. I mean, obviously, I'm not putting a seven millimeter stent in a vessel. I'm not dilated to six. That's probably some over dilating. The vessel is a five. I'm doing a lot of vessel prep for that and putting a six millimeter stent in.



[Dr. Sabeen Dhand]:
Got it. Back in the day, and I don't do it as much now, but when drug coated balloons were pretty popular, sometimes we would do a stent and we would actually combine like a bare stent and we would maybe put some drugs on the distal ends with plasty kind of like a combo approach. Have you done that at all or do you believe in that?

[Dr. John Rundback]:
Yeah, well, you know, that's the DEBATE SFA approach. There’s that paper, and the intended take home point was that a bare metal stent plus DCB is the same as STS. You know, and they should have pretty good patency, although they're about 75% at two years, I think it was very close to that. So that's a reasonably good strategy, you know, we've not been using that. And it's interesting. I mean, obviously like everybody else, you know, after the JAHA article, we kind of pulled a little bit away from DCB, but I think the vast majority of data shows that DCBs are safe in terms of vital statistics. So we've now kind of incorporated them again. Now very comfortably, even in the outpatient lab for relatively short, you know, intermediate length lesions, we can get away with sort of one DCB. We have a perfect result after vessel prep and POBA, without dissection of flow limitation. However, we're also very comfortable because of the excellent results. You know, just sort of wait and see, do surveillance and if need be come back and use DCB as a secondary technology.

Podcast Contributors

Dr. John Rundback discusses New Tools to Treat Severe Distal Femoropopliteal Disease on the BackTable 212 Podcast

Dr. John Rundback

Dr. John Rundback is a practicing Vascular Interventional Radiologist at AIVS LLP in the New York City area.

Dr. Sabeen Dhand discusses New Tools to Treat Severe Distal Femoropopliteal Disease on the BackTable 212 Podcast

Dr. Sabeen Dhand

Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.

Cite This Podcast

BackTable, LLC (Producer). (2022, May 30). Ep. 212 – New Tools to Treat Severe Distal Femoropopliteal Disease [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com 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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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Arterial Stenting Procedure Prep
Atherectomy Procedure Prep
Critical Limb Ischemia (CLI) Condition Overview
Peripheral Artery Disease Condition Overview

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