BackTable / VI / Podcast / Transcript #118

Podcast Transcript: Treating Acute Limb Ischemia

with Dr. Donald Garbett

Interventional Radiologist Dr. Donald Garbett talks with Dr. Michael Barraza about how he approaches acute limb ischemia, including different endovascular techniques for removing acute arterial clot. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Referral Patterns for Peripheral Arterial Disease

(2) Workup for Peripheral Arterial Disease

(3) Thrombolysis Procedure and Frequency

(4) Thrombectomy Procedure and Devices

(5) Revascularizing Arterial Grafts

(6) Dealing with Unexpected Intraprocedural Clots

(7) Dealing with Chronic Occlusions

(8) Follow-Up Care for Acute Occlusions

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[Dr. Michael Barraza]
This is Michael Barraza, your host for today's episode, recording in Baton Rouge, Louisiana. Today, we're talking about dealing with arterial thrombus and thrombotic occlusions in the leg, and I'm honored to welcome Dr. Don Garbett to help walk us through this. Don is an interventional radiologist and presumably all-around great guy in Eugene, Oregon. Don, thanks for sharing your time and expertise with the BackTable Community.

[Dr. Donald Garbett]
Hey, thanks for having me. I’m super excited to talk with you guys.

[Dr. Michael Barraza]
Don, why don't we start by having you tell me about your practice. Just give me the basics.

[Dr. Donald Garbett]
I'm part of a private practice group. We're about 20 radiologists, 5 interventionalists. We operate at two hospitals and then we have our own outpatient clinic. Our practice is pretty varied. We do PAD, venous work, all the standard IR stuff, nephrostomy tubes, and a lot of oncology. Two of my partners do strokes as part of a multidisciplinary team. We mostly do IR. I'll do one or two diagnostic days a month. It’s like a break. My wife says, "Are you in diagnostic today? Can we go to dinner?" But I feel like it's pretty high-level IR for the most part, complex cases.

It's a satisfying practice. We're doing quite a bit of PAD. We get referrals from primary care, but we also get referrals from our vascular surgeons. It's interesting because they do mostly open surgery, honestly. Then they each have a day in the lab and I think they have to choose what they want to do, so they'll just do three diagnostics and then anything else gets sent to us. We get community referral and we get referral from vascular surgery too.

(1) Referral Patterns for Peripheral Arterial Disease

[Dr. Michael Barraza]
That's pretty cool, Don. Is there anybody else doing endovascular PAD work besides your group in the hospital? I mean, aside from the diagnostic ones that the vascular surgeons are doing. Cardiologists or anybody else?

[Dr. Donald Garbett]
There are probably eight cardiologists. One of them does PAD, and he has one PAD day a week. He'll do three cases, and he'll do more complex cases like an atherectomy and some other complex stuff, but he won't do a CTO. And then, we operate at another hospital, our smaller hospital. There's a vascular surgeon over there who's a little younger and does almost all endo.

[Dr. Michael Barraza]
Do you guys have a vein clinic as well?

[Dr. Donald Garbett]
Yeah, we do. That's our outpatient clinic. We do saphenous vein work and all the complex stuff and that feeds into our deep vein practice too.

[Dr. Michael Barraza]
But the PAD stuff, you're doing that at the hospital.

[Dr. Donald Garbett]
Currently, yes. We do have some exciting things. We're opening an outpatient lab, which I'm pretty excited about.

[Dr. Michael Barraza]
Nice. That's great.

[Dr. Donald Garbett]
Yeah. I can't wait.

[Dr. Michael Barraza]
Moving on to what we came here to talk about, thrombotic occlusions of the lower extremity arteries. It's important for obvious clinical reasons, but in my opinion, it can also be vital for any vascular specialist, from a practice-building standpoint. In my experience dealing with acutely cold legs, it can be a gatekeeper of sorts for elective PAD work. I've heard colleagues use it to justify losing PAD to cardiologists and vascular surgeons. They'll say, "We don't have to take the cold leg consults anymore. Don't get called in for that at night." Then on the other end of that, other people are using that as a tool to keep people out saying, "Well, if you're not doing the cold legs, why should we give you the chronic PAD patients?"

In my own experience, I think it's very important. I actually used that as a tool to break into PAD at a hospital where we weren't already doing it. I gave my cell phone to the ER docs, the intensivists, and the hospitalists at one hospital and just said, "Look, call me for these." Or, if I saw an acute occlusion on imaging, I'd just call them myself and was able to use that to get them to send me inpatients. Then, these patients would follow up in clinic and they were able to go to chronic stuff from there. Are you the only ones that are doing it at your hospital?

[Dr. Donald Garbett]
As far as the work, yeah. Were there vascular surgeons where you worked, or were you basically the only one?

[Dr. Michael Barraza]
Yeah. There was everybody. Vascular surgeons, cardiologists and interventional radiologists. But there were only a couple of us in interventional radiology who had done a good bit of PAD and wanted to continue that.

[Dr. Donald Garbett]
It's interesting at our place. We’re the first step on venous. But, anything that comes in through the ER for arteries is going to get a vascular surgery consult. We're not going to get the first call on arteries. Vascular will do their assessment. Do they still have movement? Do they still have sensation? Get the Doppler, feel for pulses. And as soon as the Doppler comes, they just call us and say, "Hey, you got a 72 year old guy with acute pop thrombosis. Can you get them in today?" That's the process. They say, "I'm starting them on heparin." And that's during the day. If it's after hours, if it happens at 8:00 PM, they'll call us at home, "Hey, just started a guy in heparin. Can you get them in for an angio tomorrow? Here's the story."

[Dr. Michael Barraza]
I think that's important though. You bring out a good point. In my turf, that was how I was able to get those phone calls and get those patients. I made an effort to be the person who's available first for an angio. If you can be the first one to get that patient on the table, that's helpful to them. They just want to get those patients out of the ER.

[Dr. Donald Garbett]
Exactly. For IR, we have leverage in our hospital because we have a lab all day. And the vascular surgeons, they have an OR all day.

[Dr. Michael Barraza]
Right.

[Dr. Donald Garbett]
They don't have a lab. They have a lab one day per week and they've already got outpatients booked for that day. They have no interest in taking that hospital patient to angio. They're happy to take them to the OR. It's a bigger ordeal to go to the OR than it is to the angio.

[Dr. Michael Barraza]
It is where I am.

[Dr. Donald Garbett]
Oh yeah, same.

[Dr. Michael Barraza]
So it sounds like your ER is pretty used to fielding these. They know how to do the initial workup. I've seen a lot of variability in different places, depending how much guidance you give them in terms of working these patients up. When they call you, it seems like they've at least already gotten a Doppler. Is that correct?

[Dr. Donald Garbett]
Yeah. Everybody gets Doppler out of the ER and then, and then Heparin is started in the ER. So at least they're not asking, "Hey, what do we do?"

[Dr. Michael Barraza]
It’s not uncommon to get those phone calls. The one I would get a lot is, "Do we need a CTA?" And sometimes the answer is yes. Are you getting that for a while?

[Dr. Donald Garbett]
My answer is always yes. I think one of the variabilities is, I'm on call Monday night and then my buddy is on call Tuesday night and then we're alternating all week. It comes out of the ER that vascular surgeons don't care for CTAs unless there's a triple way. Right?

[Dr. Michael Barraza]
Right.

[Dr. Donald Garbett]
They have no desire. There's just a delay of care for them. Typically, the surgeon calls me and says, "Hey, can you get him in for an angio tomorrow?" And I'll just jump on Epic and throw in an order for a CTA, so that I have something for tomorrow. But I'm going to switch that to MRA soon.

(2) Workup for Peripheral Arterial Disease

[Dr. Michael Barraza]
I don't know if we have the ability to do that here. What else are you getting in the workup before you go in?

[Dr. Donald Garbett]
A lot of patients have prior angios. Basically, I just look up the history: Have they thrombosed before? The basics of the workup have usually been done, so are they acute-on-chronic? Are they totally de novo history with a thrombosis? Was there an event? Do they have stents? What's there? What's the roadmap? And the CTA, I like to get that before we get to the lab.

[Dr. Michael Barraza]
In terms of putting it all together and establishing the severity, do you usually rely on Rutherford classification [for chronic limb ischemia] or just gestalt?

[Dr. Donald Garbett]
I love our Rutherford because it's just nice to put one word on them (Rutherford 4, Rutherford 5). Rutherford is good for the acute-on-chronic patient, which most of them are. I would say that half of the patients we see like this already have an ulcer. Most are going to be Rutherford 5’s, so they're acute, probably chronic, with an ulcer. It's not common to have a 6 with massive, sloughing tissue, but usually it’s a little bit earlier. Although, during early COVID, we saw a whole bunch of just black feet. People were just like, "It was fine. I was fine." It was pretty bad, but now it's sort of tapered off to mostly toe ulcers and profound ischemia. We'll see an arterial thrombosis and no pulses, then we'll get the Doppler and the tech will say, "Hey, there's DVT also."

[Dr. Michael Barraza]
Really?

[Dr. Donald Garbett]
Yeah. When I originally came here, I had very little arterial experience and I was a little bit scared. I needed to learn this. I just started grabbing the Journal of Vascular Surgery and grabbing textbooks from vascular surgery and just reading about how to assess the patient. I know that vascular surgery would see him, but I have to know it too.

[Dr. Michael Barraza]
Oh, absolutely. I started with a lot of experience in chronic PAD, but I didn't have a lot of experience with acute emboli, thromboemboli, or cold legs. That was something I had to learn early on. I agree. I spent a lot of time reading about the clinical assessment. Some of it's straightforward. That was something that I picked up my first couple of years. In most circumstances, it sounds like if you're called at night, you usually have them Heparinized and then set them up for an angio in the morning. Are there any circumstances in which you feel like you need to go in and do it now?

[Dr. Donald Garbett]
I'd say it's pretty rare. There are some. You have a patient who has an EF of 25, which is probably the source of their embolism. They probably had an LV thrombus and those patients will be profoundly ischemic, super painful. And so occasionally, we'll take them at night, but not in the middle of the night. We'll get them at 8:00 PM, maybe do a late angio. But even then, those patients are a little difficult, because you're doing sedation and they maybe have some delirium. I've certainly made some bad choices, taking a delirious patient to the cath lab.

[Dr. Michael Barraza]
It's a challenge because you don't want to give him anesthesia if you could avoid it. I've had a couple cases where we're going to have to use anesthesia, and I don't know how well he's going to tolerate being on his back, under sedation. It can be frustrating to try and do an angiogram with a patient moving his legs. I have traditionally done these with light sedation. What are you usually doing?

[Dr. Donald Garbett]
I say super light. For the elderly folks, I go real light: half a milligram of Versed, 25 micrograms of fentanyl, that's the whole case. I just want it like pretend sedation.

[Dr. Michael Barraza]
Totally. There is a placebo effect.

[Dr. Donald Garbett]
I'll throw a Benadryl. They might have an allergy. Let's give him 50 of Benadryl.

[Dr. Michael Barraza]
I love Benadryl. Benadryl's great.

(3) Thrombolysis Procedure and Frequency

[Dr. Michael Barraza]
So I guess we'll jump into the procedure. But let's start with managing the anti-coagulants. Do you just continue the heparin?

[Dr. Donald Garbett]
I don't stop it. They'll call me and say, "When do you want to stop Heparin?" No, just continue it.

[Dr. Michael Barraza]
Were you bolusing on the case? What do you do during the case, managing that?

[Dr. Donald Garbett]
I'll get started, get access, get some initial angios and depending on what the scenario is, I may be shooting aorta, or I may not be. Then I'll get an ACT right away just to see where we are if we haven't stopped Heparin. It is essentially weight-based, so for my bolus, I’ll do 100 milligrams per kilogram.

[Dr. Michael Barraza]
Okay. Do you have a target?

[Dr. Donald Garbett]
Yeah. Over 300 if they're working on a clot because it's so easy to display stuff.

[Dr. Michael Barraza]
Yeah, absolutely. For selecting access, how do you select your access based on location of the clot, expected treatment plan, and assuming no other chronic occlusions?

[Dr. Donald Garbett]
I would say traditional, mostly femoral, access. But I'll look at the Dopplers because I don't want to be accessing some severely stenotic area. I want to be able to address every issue along my treatment track. If there's a severe left iliac stenosis, but we're treating the right leg, I don't want to do the procedure and then leave something that could be a problem at the end.

[Dr. Michael Barraza]
Yeah. I'm with you. What about sheath size in terms of what device you think you're going to be using?

[Dr. Donald Garbett]
I'll start with a 5 Fr just for my diagnostics. Then, I think in general, I don't have any mental limits on sheath size except for one thing: If I'm going to lyse overnight, I want to keep my sheath size small. I'll generally go up to 9 Fr overnight if I have to, based on tool use. I don't want to be putting a 12 Fr in and then leaving that overnight.

[Dr. Michael Barraza]
I will go to great lengths to not lyse if I can. Overnight lysis is the bane of my existence. I'm glad I don't do it as much anymore. I wasn't asking you what all you need to image, but if you've got a CTA, you know pretty specifically what you need to look at when you're going in, for the most part. I can't think of any other scenarios. Do you usually do both legs if you're treating one leg? I guess if you have a good CT runoff, you probably don't need to.

[Dr. Donald Garbett]
There are still days where I come in and all I have is a Doppler. That's pretty much based on when the patient came in at midnight. If we get an urgent Doppler, we start heparin and I take them to the lab in the morning. Those ones, I'll do a full runoff, I'll put a catheter in the aorta, shoot that, and then shoot both legs runoff. That's probably what I do in half of the cases.

[Dr. Michael Barraza]
You answered a question for me. I was going to ask you, with all the new thrombectomy and thrombolysis systems that we're seeing all the time, if you're still doing lysis and if so, roughly how frequently?

[Dr. Donald Garbett]
I've struggled to answer this to myself. My lysing this one. I hate to say it, but I think: How much work do I have to do today? Are we starting this case at 8 am, and I have two Y90s right after this? The dose is decaying. I think in that scenario, obviously I’ll just see if I can do them later in the day, after all the outpatients are done so that I don't have to lyse. If I'm getting them first thing in the morning and I have a bunch of cases, I'll throw a lysis catheter. I'll have a really strong game plan. We're going to get in, I'm going to get through the obstruction, I'm going to drop a lysis catheter and I'm going to come back at 3 pm when I'm done with my other cases. I think that decreases the number of lyses I do is... It was 100% for some periods of time.

[Dr. Michael Barraza]
Exactly.

[Dr. Donald Garbett]
And it's probably 50% or less now.

[Dr. Michael Barraza]
Even now I'll go into it saying, "I don't think I'm going to lyse." And I still end up lysing. A lot of times I'd plan not to.

Let's say it's Tuesday, and you have a busy day. You got that patient, let's just get him in here, let's cross it, lyse it, and then bring him back. How long are you waiting for those? If you have the opportunity to get that catheter in early, which is not always feasible. You might find out about it at night or in the afternoon. If you get that thing in early, when are you bringing him back?

[Dr. Donald Garbett]
It depends when I got it in. I don't think four hours is adequate. If I get it in, in the morning, I'll bring them back at the end of the day. So maybe four or five.

[Dr. Michael Barraza]
You have at least like eight hours or so, it sounds like-

[Dr. Donald Garbett]
Yeah, based on the science.

[Dr. Michael Barraza]
Yeah. How fast are you running the tPA??

[Dr. Donald Garbett]
We pretty much have standard. We'll start it at one milligram an hour, and then after 12 hours, cut it back to half. If I'm doing more than one limb, I'll just do half each.

[Dr. Michael Barraza]
Are you using fibrinogen levels and having them adjusted it based on that?

[Dr. Donald Garbett]
That's a good question. We're still checking. And I get that 2 am phone call saying the fibrinogen is 110. And I go, "Great. Thanks."

[Dr. Michael Barraza]
At my last job, we had this great order set. It was so specific and we gave very detailed instructions on how to adjust based on the fibrinogen level, but they still call me anyway. And I found myself occasion, saying,"Just forget what all that said, just leave it alone." I don't know the right answer.

[Dr. Donald Garbett]
At the 2 am phone call, I'll actually say, "That's great. Thank you. Is there any bleeding? Yeah. Okay. I don't need to know about any more levels tonight."

[Dr. Michael Barraza]
And I'm sure you haven't had any issues based on that.

[Dr. Donald Garbett]
Just the standard leaky sheath. There's a lot of blood around the sheath and I just tell them it's doing its job. It shows it's working.

(4) Thrombectomy Procedure and Devices

[Dr. Michael Barraza]
Right. Enough about lysis because I hate it. What else are you using in these acute cold legs?

[Dr. Donald Garbett]
So the basic tools now, the Penumbra catheters, CAT6, CAT8, and the RX, which is the 4 Fr one. And then I don't think I use CAT3 much anymore because the RX basically covers the same zone and then I haven't used the CAT12 in an artery yet.

[Dr. Michael Barraza]
But you're using almost entirely the Penumbra system for cold legs?

[Dr. Donald Garbett]
Pretty much. That's basically all I've used for thrombectomy in lower extremity arteries. And I love them. I've put the FlowTriever in the iliacs-

[Dr. Michael Barraza]
Interesting!

[Dr. Donald Garbett]
And that worked immensely well.

[Dr. Michael Barraza]
Did it really? How'd you close it?

[Dr. Donald Garbett]
Just pre-closed it with Perclose. Yeah, it was ridiculous. Just ran it in and the claw was gone.

[Dr. Michael Barraza]
No way. One pass?

[Dr. Donald Garbett]
One pass.

[Dr. Michael Barraza]
That's awesome, man. I may have to see this. It's really cool. So, mainly the Penumbra system. It's a good system and the first time I ever used it was on a case that I thought was mostly chronic, but blew up an angioplasty balloon and then shot the run after and the tibials were trash. I called the Penumbra rep. It's like, "I need you right now." Fortunately he got over there really quickly, and sucked it out with a beautiful result. Okay, I liked this thing. So mainly that system. What do you do when you run your Penumbra catheter and it looks just almost exactly the same after?

[Dr. Donald Garbett]
I think there's some nuance to that. I'll shoot the angio and I keep discovering new things. I feel like every time I do a case, I discover something new. Just because of the sheer volume of it; we're doing a few a week.

[Dr. Michael Barraza]
Oh, wow.

[Dr. Donald Garbett]
Yeah. You get to keep trying new things. Sometimes you shoot the angio and you know from the Doppler that it's clotted. We know usually there's an underlying thing, right? There's a lesion in your chronic folks. There's a stenosis somewhere that was the leading edge of it. Maybe there's a dissection. Maybe the tibials went down and then took the whole thing . Maybe there's a pop aneurysm. You don't always know these things.

And so there's a look, right? And you know, from DVT, when you shoot the venogram, if you've got the central clot going all the way down, so that is somewhere in the mix. That's not acute. Or we think of it as acute, but that's not acute. That came from somewhere to somewhere else and it's formed. And so your wire will sail around. But what I find is that the catheter, the CAT8, might get it out. So you get your wire down, you send your CAT8 down, but not much is going to come out. You're just going to get little bits because it's like a little sausage. That's one type of clot.

And then you see other clots where it's maybe more like pudding, and you see the contrast kind of mixing. You wonder if there are dissections in there. And that thing comes out. You put the CAT8 down. That starts breaking down and coming through, or maybe a little separator, but it's that tube. So the tube was a puzzle to me for a while. Like the little sausage guy. So now what I do with the sausage thing is I can put an EN Snare down, the little triple loop EN Snare, and you twist it like you're doing spaghetti, like a little mixer. It looked like the Trerotola. It's like putting a Trerotola in. You twist it up and then you try and pull the EN Snare into your CAT.

If it just comes in, you know you don't have anything. And so you twist, twist, twist, twist, twist, until you try to pull it and it gets caught. As soon as it's caught, you've got a big string. You just keep suction on and you keep your EN Snare hanging out and you pull it through. Often that's the leading edge. It'll pull the whole thing out. You get an Inari in the pulmonary type of fat, you get a big thing coming out.

[Dr. Michael Barraza]
That's cool. That's a great idea. I've never heard of that.

[Dr. Donald Garbett]
So again, I discovered it by accident after just flailing for an hour.

[Dr. Michael Barraza]
Discovered by accident.

[Dr. Donald Garbett]
Well, what else guys? I'll go to my texts. Any ideas, guys?

[Dr. Michael Barraza]
That's awesome, man. I mean that, that's where these ideas come from, disaster cases. Are you using a filter wire or anything else for embolic protection? I mean, you're dealing with emboli.

[Dr. Donald Garbett]
That's a good question. I personally don't like them because they’re a pain in my butt. I'll use them if the tibials are clean. So the tibials are clean. I'll throw that down. And then the case takes twice as long. And I'm magging up on the filter and I'm telling my tech to be careful. It's this long tenuous process and every time the stupid wire filter moves, I get annoyed. But I guess it takes longer, but it saves you in the end.

[Dr. Michael Barraza]
Yeah. Then you look at the basket, and do I really want to know? So you get it out, and everything looks good. And as we see in many cases, there's an underlying stenosis. Do you treat at the end when the patient is fully anticoagulated, has had clots, or do you bring them back?

[Dr. Donald Garbett]
I will treat the underlying issue at the same session. Initially, when I first started, I was reluctant. I would wait, but I saw too many failures. They come right back, right? So then he came back the next week, thrombosed. Even a minor dissection, like the old non-flow limiting dissection. There was a period of time when we had DCBs or early DCB experience. Everyone says, "Oh, the non-flow limiting dissections, you just leave them. The DCB works." And I found the opposite. The non-flow limiting dissection seems to be the leading point. I don't know if it flips over or what happens. If there's a flap, I stent it.

[Dr. Michael Barraza]
You've got to wonder what it looks like under IVUS, if it's actually worse than it looks angiographically. What are you using with those?

[Dr. Donald Garbett]
I try to use Supera whenever possible if it's SFA or popliteal. It's just personal preference. I like the Innova stent. It's the same platform as Eluvia, just non-drug. It's super flexible. Like Supera, it's super easy to put in, it lands on a dime.

(5) Revascularizing Arterial Grafts

[Dr. Michael Barraza]
Love it. Okay. I'm sure I'm forgetting some big things, but let's move on to talk about grafts, and opening up a graft. What really guides your approach to revascularizing a graft? Thinking about the anatomy, the material, age.

[Dr. Donald Garbett]
You've got your vein grafts, your repeat vein grafts, your cryo vein grafts, your Gore-Tex grafts. What's nice about the synthetic grafts is it's either a 5 or a 6 or a 7 or something. So it's easy to pick your balloon size, at least. And your synthetics can be super. I like it because I can be super rough there. I could just ram and jam with the CAT8, no wire, just bouncing around smooshing, not worried about side branches. They can be clotted for a month and you can still get it open. We had one maybe last month where I thought I had read that the graft had just occluded. I went in, cleaned it out with a CAT8 and my EN Snare thing. And then the vascular surgeon comes to me the next day and he says, "Hey, you know that graft was down for like a year."

[Dr. Michael Barraza]
Oh, my God!

[Dr. Donald Garbett]
I was like, there's no way. There's no way it was down for a year.

[Dr. Michael Barraza]
That's incredible. He was surviving off his perfunder or something. Man, was he around marathons after you were done?

We're usually accessing for a graft. I know it is always going to vary based on where it is. Do you ever just do direct stick of it? You know, like a fem thing?

[Dr. Donald Garbett]
Yes. Yeah. So the fem-fem... I often find that the ends of the grafts, they're just like rocks. I'll try from wherever it is. Let's not say fem-fem for now, let's say fem-pop. I'll try from common, invert the up and over and try to get in, but often that's not feasible. I'll take an 18 gauge needle, ultrasound guide a needle into somewhere in the proximal aspect of the graft, then just send that wire back up, snare it through, and now you've got something-

[Dr. Michael Barraza]
You snare it through your common femoral access.

[Dr. Donald Garbett]
Yeah, to at least get your tools going into it.

[Dr. Michael Barraza]
Yeah. I know you're talking about okay.

[Dr. Donald Garbett]
The danger of that is that you may get a little lipstick effect on the top of some clot popping out and going into your profunda, which can be a pain.

[Dr. Michael Barraza]
You already taught us about how to remove those. So, all is well. What about underlying stenoses, the anastomotic stenoses in the graft, are you treating those?

[Dr. Donald Garbett]
Yeah, I do. I'll usually use a traditional regular balloon, Mustang, or whatever it is. You find that you need a cutting balloon for those things.

[Dr. Michael Barraza]
Yeah. How far across the lesion are you inflating it? I’m thinking about something with an acute angle with its origin artery or insertion and, kind of nervous-

[Dr. Donald Garbett]
It's going like this, a jackknife effect?

[Dr. Michael Barraza]
Yeah.

[Dr. Donald Garbett]
I'll just put a wire way through and so that it's dangling down.

[Dr. Michael Barraza]
No issues with that. All right, cool.

[Dr. Donald Garbett]
That is a concern. As long as there's not a huge size mismatch. You can always undersize. You can go 4 millimeters and hope everything looks good.

[Dr. Michael Barraza]
Does it work pretty well during an angioplasty, even anastomotic stenosis like that, and is it durable?

[Dr. Donald Garbett]
Long-term, hard to know. I haven't done many of those. They work in the short term. I think the fem-pop that goes down is already destined for failure in the next year or two. You're just getting them to their next solution. You're keeping the leg alive until we can do something better.

(6) Dealing with Unexpected Intraprocedural Clots

[Dr. Michael Barraza]
My last question is dealing with unexpected intraprocedural clots in lower extremity arteries. Either you're treating somebody with a chronic lesion, a CTO, and then you see a little bit of clot developing distally, or the one that I've seen a handful of times is somebody that I think is mostly chronic. I'll send the Bentson wire toward the lesion and it just passes, flies right through. It's like, oh no. What's your approach to those?

[Dr. Donald Garbett]
Those are tough. Meaning the clot that just happened during your case?

[Dr. Michael Barraza]
Either. Take one.

[Dr. Donald Garbett]
Either one. Okay. That's where I feel like it doesn't matter, if it's super acute like that, it happened during the case, then it doesn't matter what you use. You can use CAT, you can use AngioJet, you can take the AngioJet down. Don't have to worry about blood loss because nobody knows, right?

[Dr. Michael Barraza]
It's always 30.

[Dr. Donald Garbett]
Exactly. In the hyper-acutes, Angiojet, CAT, whatever. It might be based on what sheath I have in. The problem is if it's in the tibials, I'll just try. My first piece will be, "Let me take the RX, the CAT RX down into the tibial and see if I can get it. And if that doesn't work, I'm starting to swear.

[Dr. Michael Barraza]
I'm starting to sweat a little bit.

[Dr. Donald Garbett]
Yeah, exactly. Trying to get a wire all the way down through it, to salvage, and lysis is still in my mind, "Oh, we might keep this patient overnight, but I'll try to resolve it with either the RX or maybe the AngioJet, or just a balloon." I find it often I just try and balloon it, "Oh, we're just gonna turn it into toothpaste. Smoosh it along the side. It's going to be fine." Never works. I always do it. Occasionally the Jetstream.

[Dr. Michael Barraza]
That was going to be my question for you. That one that you think is chronic, and it may be acute on chronic if you're using that.

[Dr. Donald Garbett]
So it does work. I would use it more, except every time I'm in a case and I say "All right guys, Jetstream," and everyone goes, "Ugh," and they'll just wheel the Penumbra vacuum into the room instead. And they're like, "You said 'Penumbra,' right?"

[Dr. Michael Barraza]
"Yeah. We heard you say Penumbra, we've already opened everything, they're paying for it, so you gotta."

[Dr. Donald Garbett]
I don’t know why the techs hate it so much.

[Dr. Michael Barraza]
I don't know.

[Dr. Donald Garbett]
It will clean out a clot in a tibial.

(7) Dealing with Chronic Occlusions

[Dr. Michael Barraza]
What about that other scenario, when you think that you're dealing with a chronic occlusion and the wire just flies? What's your approach to those lesions, say like distal SFA?

[Dr. Donald Garbett]
Yeah. Were you thinking it's a CTO?

[Dr. Michael Barraza]
I think that most of those are acute on chronic or even subacute on chronic.

[Dr. Donald Garbett]
Right. You know, I'm just trying to think of the last time I did that. The wire goes through. Okay. So I'll re-check ACT. Make sure we're good on that. I will put a little bit of tPA into it right away. We keep IV-tPA in the room. Give me the IV-tPA.

[Dr. Michael Barraza]
That's a great idea.

[Dr. Donald Garbett]
Make sure the ACT is okay. And then I'll put a catheter right into that area and put a little tPA right into there. You're treating it like a fistula. I don't have patience to let it sit, so I'll just go immediately... My first thoughts are, "Can I stent this? Can I just stent and get out? Am I going to displace the clot?” Maybe I've just been lucky, but I will often just stent those and I get away with it. I don't send anything downstream. Maybe it's because of the tPA, maybe it's the heparin. Honestly I saw my partner do that, where I was like, "Here's a huge clot. You need to go aspirate." He just laid the stent. I see these European guys posting how they're dealing with these things, and I see they're using the Aspirex a lot. That's their main thing now. I could see doing that. You've got essentially an AngioJet with an atherectomy device on it. It's a cool tool.

[Dr. Michael Barraza]
I'm sure it's all going to become a lesion too.

[Dr. Donald Garbett]
It does. It's not always an easy decision and sometimes it’s just guesswork.

[Dr. Michael Barraza]
I've even had a couple like that where I thought I was going to be treating a chronic lesion, and I ended up lysing. That's always the hardest thing to explain to a patient. They're going to be going home in a few hours, and then, "No, you're not.” You do what you have to.

[Dr. Donald Garbett]
I've had my own devastating errors as well. I had a lady, this is an odd one, she just had bilateral severe claudication, buttock claudication. We knew she had at least one iliac occlusion and the angiogram found that she now had bilateral iliac occlusion. I did the radial access, went and put a catheter at the bottom, went and recanalized the iliacs, and my left groin access, I didn't know, was high, well above the ligament. It wouldn't have mattered except that the left external iliac still had some stenosis. I couldn't leave the stenosis at the end. So I balloon, balloon, balloon, but what I don't realize is that I'm ballooning right out of the arteriotomy because my axis is high. I shoot the final pictures, and I'm like, "Victory! Everything looks great!" Shoot the pictures, just huge extrav [contrast media extravasation] coming out of the left-

[Dr. Michael Barraza]
So scary.

[Dr. Donald Garbett]
And it's in the retroperitoneum. And I had that moment of "Oh God." First, “What's going on?”, because I still don't realize it's a high stick, and then “How do I fix it?” I immediately said, "Call Vascular Surgery." And I just get a balloon in. She's a lady with an EF of 30. I've lost two or three liters of blood, I finally get it, I can't cross my access site, so I go down into the SFA access, get a line across the axis site. So it's all fixed but there's a lot of blood loss. She's thrombosed both legs. Both of them. We have too much blood loss already. I can't lyse. I can't aspirate. We took something good and messed it up. Vascular surgery said, "All right, it looks like we should just do an open thrombectomy." They took her to the OR, mostly saved everything. It was one of those learning pieces. Not that it came in with a clot, or I caused it. It was something I couldn't fix right away.

[Dr. Michael Barraza]
Those are the ones that stick with you, and those are the lessons you learn best. You won't make that mistake again. Don, what else did I forget to cover that you think is important?

[Dr. Donald Garbett]
Some of the stuff is just the workup. That's done simultaneously. They come in, the Doppler, the CTA. We get an echo, see if it’s thrombotic, the hypercoag workup if the echo is negative. They may have Factor 5, or they may have anticardiolipin antibody, or antiphospholipid where they can throw arterial or whatever. Those things happen immediately, but we don't know the answers to these until days later. It's just the workup piece, because we want to know what to do with them after we've cleaned them out. I think for the most part, they'll be heparinized until everything is good, and then most of us go with Eliquis at this point. It seems mostly good for all comers. I've talked to nephrology folks about renal dysfunction, like "What if their GFR is 15?" They like Eliquis too. That just makes it easier.

(8) Follow-Up Care for Acute Occlusions

[Dr. Michael Barraza]
For the ones who had acute events, acute or cold legs, and they're more on the severe side, who do you have involved with follow-up? Evaluating limb salvage, compartment syndrome, anything like that?

[Dr. Donald Garbett]
Most of them will spend a week in the hospital for workup and recovery. Vascular surgery is involved in all of them. A lot of them need minor amputations; they need a toe or whatever. That usually happens during the hospitalization. They'll be set up with wound care. If there's an ulcer or an amputation, they'll be plugged in. There's debate about it, but we have them follow up with us. We have a lot of PAs. They're like, "Vascular surgery is already seeing them, should we be seeing them too? Isn't that just a waste of the patient's time? I just tell them, "Look, we operate on the patient. I don't care who else is seeing the patient." The vascular surgeons are thinking about one thing, and we're thinking about a totally different thing.

[Dr. Michael Barraza]
These patients develop new stenoses, they have contralateral stenoses, and there's a lot to break down.

[Dr. Donald Garbett]
We want the patient to get the best out of what we can do for them. Let's keep the legs as long as possible, let's keep the feet as long as possible, and I think that everyone has that same outlook. The vascular surgeons definitely approach it in a different way.

[Dr. Michael Barraza]
It's all local. What people are doing will differ no matter where you go. I saw variability between the eight hospitals where I worked that all you can do is what you. I think you have the right approach in that you're seeing these patients regardless of who else is.

[Dr. Donald Garbett]
I think that's the politics, and you have to decide. We have to think of ourselves as surgeons, however you want to do it. Once you touch that patient, now they’re your responsibility. You can't just say, "Oh, they got it."

[Dr. Michael Barraza]
It's easy to do that. It really would be so easy to do it.

All right. I think that's about all I've got, Don. Thank you for doing this. We appreciate your time and expertise. We'll catch you on the next one.

[Dr. Donald Garbett]
All right. Thanks, man.

Podcast Contributors

Dr. Donald Garbett

Dr. Donald Garbett is a practicing Vascular and Interventional Radiologist at Minimally Invasive Specialists in Eugene, Oregon.

Dr. Michael Barraza

Dr. Michael Barraza is a practicing interventional radiologist (and all around great guy) with Radiology Associates in Baton Rouge, LA.

Cite This Podcast

BackTable, LLC (Producer). (2021, March 29). Ep. 118 – Treating Acute Limb Ischemia [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.