top of page

BackTable / VI / Article

Tacks vs Stents For Arterial Dissection Treatment

Author Rajat Mohanka covers Tacks vs Stents For Arterial Dissection Treatment on BackTable VI

Rajat Mohanka • Sep 25, 2023 • 130 hits

Bare metal stents, covered stents, and coronary stents are commonplace in the management of lower extremity arterial dissection below the groin. The Tack Endovascular System is a newer device that functions similarly to a stent, but with key differences that may make it more appropriate for treating arterial dissections in the superficial femoral artery (SFA) or the proximal popliteal artery.

Dr. John Phillips, an interventional cardiologist from Ohio Health, discusses his approach to choosing between Tacks or stents for treating arterial dissections after PTA. This article includes excerpts from the BackTable Podcast. The full episode is featured below.

The BackTable Brief

• Stents and Tacks are two tools that can be used to treat clinically significant arterial dissections after percutaneous transluminal angioplasty.

• Tacks are essentially shorter stents that decrease metal burden, however they have less radial strength than stents.

• Tacks can be deployed in regions where stents cannot be used, such as distal lower extremity arteries.

Tacks vs Stents For Arterial Dissection Treatment

Table of Contents

(1) The Structural Properties of Tacks vs Stents

(2) Tacks vs Stents in Distal Lower Extremity Arteries

(3) Follow-Up Surveillance After Deploying Tacks vs Stents

The Structural Properties of Tacks vs Stents

Dr. Phillips notes that one property of Tacks, which differentiates them from stents, is their shorter length, typically around 4-8 millimeters. This shorter system offers the advantage of reducing the metal burden in the body. Within the Tack system, there are typically about 6 Tacks in the catheter available for deployment. Additionally, there are two crowns soldered together. These crowns possess sufficient radial strength to seal residual plaque dissections, but they don't have enough strength for heavily calcified regions. Unlike regular stents, which have radiopaque markers on both the distal and proximal ends, the Tack system has its radiopaque marker situated between its two crowns. Dr. Phillips emphasizes that users should be aware of this distinction: the crowns of the Tacks are positioned on either side of the marker.

[Dr. Aaron Fritts]
Traditionally, we've used bare metal stents, sometimes covered stents, sometimes coronary stents below the groin. What makes Tack so different, just at a high level, for those of us who haven't used it or used it very little, what makes it so different than just a typical stent in the leg?

[Dr. John Phillips]
Well, a couple of things. It is very short so you're getting, let's say you're going to use the bigger ones, the 4-millimeter to 8-millimeter, those are 8-millimeter in length. Basically, the way I describe it, there's two little crowns soldered together basically. It's very short. Very, very little radial strength, but enough to, I think, seal a dissection where there is some residual plaque, but not enough to, say, treat somebody that has coral reef calcification in a fem-pop region because you can get into trouble with them because after you deploy them you have to post-dilate them with a fresh balloon. You don't want anything winged because they can catch and tumble on you.

The ones in the tibialis , the smaller ones, the one five to four fives, those work well also, but again, the tibialis , I think there's a fair amount of calcification in those, whether we see it or not. That medial calcification is always a problem. You have to be careful when you use them down there. I think the sweet spot for them, in my opinion, is some of these no-stent zones as well as the tibialis, below that upper one-third because I've put in a fair share of coronary stents in the tibialis and they come back crushed. I've got one guy that he needed an amp and they put a tourniquet on his leg and he lost the toe and then we lost his stents as well because it was crushed.

[Dr. John Phillips]
…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 fluro 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.

Listen to the Full Podcast

Which Dissections Matter, and How to Treat Them with Dr. John Phillips on the BackTable VI Podcast)
Ep 312 Which Dissections Matter, and How to Treat Them with Dr. John Phillips
00:00 / 01:04

Earn CME

BackTable CMEfy button

Stay Up To Date

Follow:

Subscribe:

Sign Up:

Tacks vs Stents in Distal Lower Extremity Arteries

Though the use of Tacks in very distal lower extremity arteries is rare, Dr. Phillips has treated critical limb ischemia with Tacks in the dorsalis pedis artery when a balloon wouldn't remain open post-treatment. While it's challenging to place a stent in such distal arteries, Tacks can access those areas. The difficulty when using Tacks in these extremely distal arteries arises from the need to magnify and use a ruler on the monitor, all while being on fluoro, to accurately visualize Tack placement.

[Dr. Krishna Mannava]
How far distally have you ever deployed a Tack?

[Dr. John Phillips]
A couple of weeks ago, I put three—well I wanted three, but I ended up putting four in the foot, and it was just one of these situations. The way I approach somebody who has critical limb ischemia-- I don't go into people's tibialis unless they have CLI or rest pain or whatever. For me, it's like, "All right, you got one or two shots at this. Let's do whatever we can," and I just could not get this vessel to stay open. It just kept recoiling. It was the dorsalis pedis. I thought, "Well let's just see where-- let's see, number 1, can I get the Tack down there?" Because I sure as heck am not going to put a coronary stent, but can I get the Tacks down there, and was able to do it.

You have to mag up pretty good, and you can't see, really, because the Tack is obscuring blood flow, and so you're blind a little bit, but you mark it on the screen. That's another thing, too, I think, when people ask about pearls of deploying these, making sure you're marking on the screen, or you've got a ruler and you're off the bone and mag’ed up and all that good stuff.

To answer your question, it's pretty rare, that's only the second time I did it. The first time I did it, I made the mistake. I thought I could prop open this plantar vessel that had a lot of calcium, and I couldn't even get the device to it. It's a pretty forgiving device, but I couldn't get it to where I wanted it to be. So hopefully, they stayed open for the past couple of weeks. I don't know how long it’s going to stay open, but we'll see.

Follow-Up Surveillance After Deploying Tacks vs Stents

Dr. Phillips explains that restenosis or occlusion is more commonly observed between the Tacks when they are deployed in the tibial arteries. However, for the most part, he does not notice any differences in ultrasound surveillance between Tacks and stents.

[Dr. Krishna Mannava]
Some of my ultrasound techs are now asking me, "Did you deploy a Tack or a stent or what do I need to look for?" Is there any differences you've seen or heard of on surveillance duplex imaging with these?

[Dr. John Phillips]
No. I mean it was interesting that you hear, across the country, that docs were reporting lack of use because there was acute or subacute closures and a lot of restenosis or occlusion where I've seen them restenose, and it's in the tibialis. It's between the two Tacks. I think the closures are probably related to just, in my opinion, failing to see or treat another dissection or some plaque disease that the thing was going to fail either way.

I think if you size a vessel appropriately, prep the vessel and treat it appropriately ahead of time, and if you do have a dissection, putting them in specific spots along the way without having to, again, stack a bunch of them, it leads to pretty good results.

When we scan the folks at the one-month, six-month, year, whatever, no difference. I have not, in my knock-on wood, seen any issues with it or at least any reports from our ultrasound staff.

Podcast Contributors

Dr. John Phillips discusses Which Dissections Matter, and How to Treat Them on the BackTable 312 Podcast

Dr. John Phillips

Dr. John Phillips is an interventional cardiologist with OhioHealth in Columbus, Ohio.

Dr. Krishna Mannava discusses Which Dissections Matter, and How to Treat Them on the BackTable 312 Podcast

Dr. Krishna Mannava

Dr. Krishna Mannava is a vascular surgeon and medical director at Vive Vascular in Columbus, Ohio.

Dr. Aaron Fritts discusses Which Dissections Matter, and How to Treat Them on the BackTable 312 Podcast

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

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.

backtable-earn-free-cme.jpg
backtable-plus-vi-cta.jpg

Podcasts

Which Dissections Matter, and How to Treat Them with Dr. John Phillips on the BackTable VI Podcast)

Articles

Arterial Dissection Treatment with Tacks

Arterial Dissection Treatment with Tacks

Topics

Learn about Interventional Cardiology on BackTable VI
Peripheral Artery Disease Condition Overview
Learn about Vascular Surgery on BackTable VI

Get in touch!

We want to hear from you. Let us know if you’re interested in partnering with BackTable as a Podcast guest, a sponsor, or as a member of the BackTable Team.

Select which show(s) you would like to subscribe to:

Thanks! Message sent.

bottom of page