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BackTable / VI / Podcast / Transcript #212

Podcast Transcript: New Tools to Treat Severe Distal Femoropopliteal Disease

with Dr. John Rundback

In this episode, host Dr. Sabeen Dhand interviews Dr. John Rundback, interventional radiologist, about distal femoropopliteal disease, including the unique pathophysiology of this area, which stents work best at the adductor canal and the trifurcation, and tips for early operators. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Difficulty of the Femoral Popliteal Region

(2) Forces in the Femoral Popliteal Segment

(3) Adjunctive Techniques in Treating PAD

(4) Stent Grafts

(5) Supera Design and Use

(6) Biomimic Stents

(7) Biomimics Stent Utility

(8) Future Advancements in Stents

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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
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[Dr. Sabeen Dhand]
Hello, everyone. And welcome to back table your source for all things endovascular and more, you. can find all previous episodes of our podcast on any platform like Spotify or even our website back table.com.You can also follow us on Twitter, Instagram, or LinkedIn, and keep up with the latest updates and give us feedback through. This episode is sponsored by Varian medical and the biomimicry 3d vascular stent system. The biomimicry 3d stent is attended for the treatment of peripheral arterial disease in the femoral popliteal artery. The biomimicry 3d stent has a unique 3d helical geometry, which enables a stent to shorten with the vessel, improving its biomechanical compatibility and reducing the risk of stent fracture and trauma to the.Varian has amassed a significant body of clinical evidence that supports the hypothesis that Biomimics 3D helical design impacts outcomes and demonstrate superior long lasting clinical results in this challenging segment, learn more at varyanmedical.com.

[Dr. Sabeen Dhand]
I'm Sabeen as your host today, and I'd like to welcome Dr. Dr. John Rundback Bryan back and interventional radiologist from American endovascular and amputation prevention in Teaneck, New Jersey.Welcome Dr. John Rundback.

[Dr. John Rundback]:
Thank you Sabeen. It’s a pleasure to be here.

[Dr. Sabeen Dhand]
Absolutely. We're excited to have you on the show. Today, we're going to talk about a real tough spot to treat that dreaded distal femoral, popliteal segment. It's a challenge. It's a challenge for many reasons, which we're going to go into, but before that let's have our listeners get to know you a little bit better. How'd you end up in New Jersey and, and tell us a little bit more about American endovascular?

[Dr. John Rundback]:
Sure. Well, first of all, shout out to you and new dads. Congratulations on that.

[Dr. Sabeen Dhand]
Thank you.

[Dr. John Rundback]: Our listeners should know about that. So, you've taken time out of your new family to do this, which is amazing.

[Dr. Sabeen Dhand]
We're getting discharged today, actually. So I came back to record.

[Dr. John Rundback]:
Okay. Amazing. Amazing. Yes, so I'm an interventional radiologist for 30 years now. Hard to believe time goes quickly and I've always been very active in peripheral arterial disease. I tell the story that when I started doing this, there were very few people, other than IRs who were doing PAD, and we've sort of developed a lot of skill sets. I've seen a lot of things change over the years, but certainly it's an exciting time to be practicing now. At American endovascular and amputation prevention we focus on the critical limb ischemia population. It's probably 70% of what we treat. But inherent to that and relevant to this talk, there's a lot of femoral popliteal disease. Our patients, and probably much like yours tend to be the most complex patients; patients with chronic kidney disease, diabetes, heavy smoking and other patterns, which are associated with calcification and long segment occlusions in life. So that's what we're treating on an everyday basis. It's a real challenge, but it's fun. And like you we've been getting some pretty remarkable results, which has helped with some of these new technologies.

[Dr. Sabeen Dhand]
Yeah the new technology has helped us a ton. We’lll agree that just angioplasty alone now in that segment is probably not durable.

[Dr. John Rundback]:
Yeah. You know what? I think you're going to get to this, but with the advent of the drug coated balloons and the drug delivery technology, there was this whole idea of “leave nothing behind”, and I'm sure we’ll have a chance to talk about that. I'm not sure if I was ever completely on board with that nor did it ever completely make sense.And of course, if you even look at the drug coated balloon data and a lot of lesions, 40% or more of those patients need scaffolds anyway. So.

(1) Difficulty of the Femoral Popliteal Region

[Dr. Sabeen Dhand]
Absolutely. Absolutely. The pathophys of fed pop that, that whole distal fem pop area, what makes this area so tough? Why can't I just do a poll and call it a day?

[Dr. John Rundback]:
Yeah, well, you're probably familiar with the biomechanics of the femoral popliteal artery across the doctor canal. It's unique and we've all seen those really nice pictures with patients with their knees bent and you can get a sense of the torsional and, and the compressive and the elongation of the forces. It's a very dynamic part of the artery, but they've actually done some studies and you get compressive forces right across the adductor down just below that up to 15 to 20% compression of the artery for shortening of the artery. And if you think about it, this has always been my feeling, traditional slotted nitinol tubes are rigid stents. They can't shorten. They can't rotate in response to those physiologic stresses and therefore they're inherently. It can never endothelialize as well. And it is always leading to this activation of the recent, not a cascade.

[Dr. Sabeen Dhand]
Hmm. Okay without a stent, and when we're doing our angio, initially, almost at Hunter's canal, there's some sort of, it could be a mild stenosis or a really severe stenosis. I mean is the artery subjected to a ton of injury during someone's life susceptible to PAD? Why do you always see it? I've always wondered, like what's going on right there.

[Dr. John Rundback]:
Yeah if you look at patients with atherosclerosis often, there's no rhyme or reason why they have disease, where they have it, but that's a relatively constant, that's the location where you get disease. And for SFA CTOs, that's the point most of the time of reconstitution, indicating that's where the culprit lesion is. I think one is crossing the adductor magnus and the abductor canal, and, that's an external forces, so there's probably some factors like that, like external constraint on the vessel. But more importantly than like I said, that's the most physiologic or biomechanically dynamic location in SFA.And therefore it's subject to these twists and turns and compression that you just don't see elsewhere in the SFA. As you get disease that's where you're going to get plaque rupture. That's where you get your unstable atherosclerosis. That's where you can get occlusions.

[Dr. Sabeen Dhand]
Yeah. When I started delving in PAD, I used to think that the main flexion is right behind the knee joint, where you see the femur and the tibia. Like you think that's the flexion point, but it's a whole long segment that's going through twisting, movement, compression, like you mentioned, right? Other than that what parts of the distal femoral popliteal segment are affected? Is it all of it or the distal end?

(2) Forces in the Femoral Popliteal Segment

[Dr. John Rundback]:
Yeah, it's pretty much, starting at, or just above the canal and extends down into that P1 segment. And interestingly, and this was new to me in a sense, sensors looked at this more recently, the predominant force as a compressive force.

[Dr. Sabeen Dhand]
Dominant is compression. Okay. Okay. It's not bending. It's not flexing. It's compression.

[Dr. John Rundback]:
All right. And so it's really that artery is really foreshortening. And to do that, if you look at it you already kind of spins it, rotates, it kind of gets this wavy configuration to allow that foreshortening, imagine a rigid stent in an artery.

[Dr. Sabeen Dhand]
Yeah. That's why we've seen these stents fracture. Just a normal bare metal stent. We've all seen those fractures and, and they don't do too well.
[Dr. John Rundback]:
Yeah. And DCB is great, if you get an ideal result.

(3) Adjunctive Techniques in Treating PAD

[Dr. Sabeen Dhand]:
So let's go into that. You mentioned it earlier. “Leave no metal behind that”. That was a big phrase that got into the whole adjunctive techniques such as DEB and even newer lithotripsy. What are some adjunctive techniques that don't involve metal? Do you do atherectomy a lot?

[Dr. John Rundback]:
Yeah. But first let me sort of make the comment with the leave no metal behind. I always use as reference, one of my well known colleagues would say when doing tibial work, I never finished a case until I feel a pulse. Now of course, you and I both know that, that's not always possible, but, as we discuss it, it makes a point that should be your goal, right? Ideally you should never leave a case until you have a pulse, right? And the same thing I think applies here by sort of having the expression, leave no metal behind. We who speak about those things we're trying to make the point that the goal. Ideally if you could get a perfect result without having to put a scaffold, particularly a slighted nitinol tube, provocative scaffold, that was a reasonable goal, but it was never intended to be the be all end, all.

[Dr. Sabeen Dhand]
yeah. Like a rule basically.

[Dr. John Rundback]:
Right. And, obviously it turns out that in the majority of cases you can't do that, but we still do everything we can to try to optimize our results before we put a scaffold. So we will certainly go in, we use a lot of IVIS, first of all, to confirm that intra-luminal, or to see if for sub intimal. If you’re sub intimal, you're gonna need a scaffold, and you're not going to change that recanalization channel just to now avoid the scaffold.

[Dr. Sabeen Dhand]
It's funny you say that because I've seen some people, when they do a whole Southern Timo recanalization of a long, long segment, fem pop and sometimes they think, oh, can I just do drug coated balloon after that? But you need a scaffold. That's not going to stay open.

[Dr. John Rundback]:
Yeah, it's a shame this is not a visual presentation on the podcast. Because I just put together some cases just from last week, and we're doing now in the OBL somewhere between seven and 10 PAD cases a week. And, there are these two cases back to back. One was a long sub intimal, SFA recanalization, but spontaneous reentry. and, only by IVUS that we see. We went ahead and actually there's a lot of calcium, hard to cross things. And it was a lot of medial calcium, but we went ahead and did some very gentle laser atherectomy to make some room, even though we were subintimal. And then we did our balloon and you could see after that with IVIS of course it's essentially still 70% stenotic, although the angio looks great. The next case was a long SFA CTO Intraluminal recanalization. You think it is going to be much different. But in fact, the cost of the burden of luminal plaque and luminal calcium in these cases, the recoil was just as bad. So even though the angio looked amazing, the IVIS,, there was a large amount of recent emphasis, a little more spotty, not the entire life, but still requiring long segment scaffolds.

[Dr. Sabeen Dhand]
Yeah, And again, those are the lesions that if you leave those behind they're going to take all that work you just did down, a lot of times.

[Dr. John Rundback]:
IVIS is so important to really understanding what we're doing, but I didn't answer your question. So, we do the best we can. We determine if we're intraluminal. We do believe in atherectomy and we choose our atherectomy based upon Jack Black morphology. So there's no single atherectomy device that we use.Yeah. Obviously it's a whole algorithm week. We talk about why we choose what we choose. We actually believe increasingly in thrombectomy, so very often I'm sure you've seen these cases and we've been popularized CTOs, and you go forward with some sort of aspiration device, either incorporated, an atherectomy or standalone thrombectomy. And now you create a lumen, to get rid of potential debris. After that we vessel appropriately with that. We'll go ahead and do POBA unless it's a very short lesion and if it looks great with POBA now we'll go with DCB. You know, if we don't have flow limiting dissections and things like that. Otherwise we're looking at using some sort of biomimetic stent platform for most cases.

[Dr. Sabeen Dhand]
Yeah. Perfect. That's great. That sounds good. I was just going to ask you about your approach algorithm, but that sounds great. So say you need to put a scaffold. I mean, what, what the metal, the kind of metal scaffolds we have, the least metal that's going on is the TAC device, right? Which has been great and an acute tiny dissection flap. I've seen tax being used in a very high recoil situation. And that is obviously not the proper place to put a tax. Correct?

[Dr. John Rundback]:
I think you're right. Yeah. I'm actually pretty hot on the tax, but early on like old technology, when we got it, we were trying to use it. And as we've grown on our learning curve, now we realize it really is for focal dissections and it could be in inflow and outflow. It's also very good in, certain sort of areas where you may be concerned about a stent or as you get into the lower popliteal, of course, various osteon things like that, that you may not want to compromise, but, and like stents, we're not uncomfortable opening two sets of tax if needed. It's really used for focal, discrete dissection repair at the inflow or outflow or as a single solution. And it's really great. Particularly when combined with DCB, I'm sure you've seen some of the Tobar 3 data, and they're running 95% primary patency out of the year.

[Dr. Sabeen Dhand]:
When used right it's great. I personally have used it wrong where I thought maybe it was not that elastic of a, a lesion or a dissection, and then it's, you know, it, it, I was like, oh, that's what, you know, you live and learn. And then if you use it right, it looks really good and works really well. Do you typically use IVIS to determine for tax?

[Dr. John Rundback]:
Yeah, we're using IVIS in almost every case. I mean, it's, it's amazing how much we've learned. Now that we use either send it's part of our optimized angioplasty routine now.

[Dr. Sabeen Dhand]:
There's so much. I mean, I mean, we've talked about it endless times. I mean, how much more information IVIS gives and, and so you always get more information and just need to learn how to interpret that Right?

[Dr. John Rundback]:
Yeah, that's true because it affects your end point. Right. Often you think You're done and you're happy and you're ready to move on

(4) Stent Grafts

[Dr. Sabeen Dhand]:
Yeah. I didn't want to see that. So more metal, heavy scaffolds. Really the two stents that come to mind in the distal fem pop are supera, which has been around quite a while, and a newly developed stent that's available now, which is bio mimics. Other than those two, I personally don't use via bonds that much, in the end for the inguinal segment for just your typical CLI patients, but are you using stent grafts?

[Dr. John Rundback]:
Yeah. I mean, again, like you, we don't use them as much as we used to, but now we'll use them. And sometimes you get patients who you want to avoid a lytic aspiration doesn't work. You need to relined strategy, you know, something like that. sometimes you get patients at other things that will fail, so try something different, but it's certainly not our go-to. I think you're right. We're pretty much 50% now probably supera and biomimics. And we found that biomimic stent to be a really, really great stent. Obviously there's a lot of precision in deploying it and although we like to think we're perfect with the supera, there are definitely more challenges in it, you know?

(5) Supera Design and Use

[Dr. Sabeen Dhand]:
Totally. Oh, good, good. So you're 50, 50 the supera. I mean, these stents, the supera and bio mimics are different. We were talking about rigid nitinol tubes in this area that just don't work. I mean, we had FDA indicated life stent in,that I used a couple of times and each time each fractured. I will not use those in that segment. But the supera we've used for a long time and I have yet to see a fracture, but it's hard to deploy. I mean, what's the design of the Supera. And how is it delivered for our listeners?

[Dr. John Rundback]:
Yeah. So the design of supera, as you know, it's a woven nitinol stent. So it's like a spring and a big pen. Right. and you know, obviously since its nitinol it's got thermal memory. The big thing about Supera is you need to be extraordinarily aggressive about vessel prep. I remember seeing Andre Schmidt, it's been 45 minutes on doing focal force angioplasty to kind of fully dilate an area before he went ahead and deployed a supera and we try to be almost as rigorous as that. I mean, you really have to go down there, you have to do some plaque modification. You can do that, whoever you want, we can use atherectomy. and then you have to go ahead and dilate and they say one-to-one, but often where 1.1 or one millimeter bigger, which is interesting because when we use these in the popliteal, we find we're using balloons that we would not normally have used, because we were able to be causing injury,

[Dr. Sabeen Dhand]:
I know exactly. Yeah. Could you almost think like, okay. If I do cause an injury it's okay. I'm already gonna stent, right? So you have that plan, so it's okay.

[Dr. John Rundback]:
Right. You're already committed. You're down that road. So, and you have to make sure you don't have any residual waste on the balloon as best as you can – it's very important. And I think, there may be a role here for shockwave to get these very, very dense calcifications so you get now, as you said, a more lasting vessel. And once you get that vessel prep, well, then these deployments much better, but, it's a combination of forward force on your front hand. and then of course, the thumb motion on your backhand, and if you're going to cheat, you want to compress rather than elongate. And, they have very nice pictures, where you can sort of see the stent margins lining up like little soldiers. That's optimal. And it's a lot of work. We really liked them, but it's definitely more work. On the other hand, it is very gratifying when you get a great result. And, you know, I know, from the Viva OPC and the popliteal segment, there are above 85% primary patency out of the year so…

(6) Biomimic Stents

[Dr. Sabeen Dhand]:
Oh, yeah good. And, and yeah, so vessel prep is so important. Sizing is important. I mean, there's where IVUS you can't, you really can't just measure on angio and say, okay, this is the appropriate size for a Supera sizings. And yeah, that deployment takes a while. but it is very gratifying when you have that, now you're like, okay, like this is going to do well. We actually just got it in the lab a couple months ago, a pretty interesting design. What makes the design different than other stents?

[Dr. John Rundback]:
Yeah. So the biomimic stent has this sort of central line, long it's a configuration and therefore, and there are great videos of this, as the biomechanics change in just let's say pop 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, they say swirling flow, but I kind of think of laminate or parabolic flow. And we all know that that's key. You know, 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 leads to the formation of a conflict endothelium. So the structure itself promotes good healing and prevents intimal hyperplasia.

[Dr. Sabeen Dhand]:
So you mentioned central line or a helical designer. 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 or bottlenecks that. 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.

[Dr. Sabeen Dhand]:
And what about in a non flex position? Is it causing any stress to the artery when it's supposedly straight ?

[Dr. John Rundback]:
Yeah. I mean no, not really. I mean, we're not really straight that often we're both sitting here. Our knees are bent.

[Dr. Sabeen Dhand]:
Yeah.

[Dr. John Rundback]:
Right, exactly. So, I mean, it does not seem to, I mean, if you've seen that mimics 3d data now, which is out three years and they're over 75 primary percent patency with a lesion length, which is longer than most studies. And then in fact their primary patency rate to three years is essentially the same as Eluvia and a lesion length is slightly longer. It's about 12 and a half sonometers. Freedom from clinically-driven TLR is over 80. So, the idea of using drug delivery technology to get better patency is only true before you had these, I guess third or fourth generation stents which have comparable patency.

(7) Biomimics Stent Utility

[Dr. Sabeen Dhand]:
Yeah, that's right. That's right. What about now? We talked about the delivery of supera is a little hard. What's the delivery system to the bio mimics. What do you do? Exactly? I love it. not even a wheel or anything. Just standard pin and fall, which is, which is,great. Right.

[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 are dense stents, calcification, those dense, dense calcification, circumferential, calcification. You're still leaning more towards the supera. But again, if you look at the, y the biomimicry data, I think 40 or 50% of those patients, all about 40% had moderate calcification. So, you can use it in calcified arteries, you know, quite well with the vessel prep

[Dr. Sabeen Dhand]:
Yeah. What about it's sizing, you know, supera you want to size one-to-one. Is the biomimic 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 so... I mean, obviously, I'm not putting seven millimeter sense in a vessel. I'm not a dilated to six. That's probably some over dilating. The vessel, the vessel is a five. I'm doing a lot of vessel prep for that and putting a six millimeter stenting.

[Dr. Sabeen Dhand]:
got it. Got it. I've never seen a supera fracture, that thing does not want to fracture. I'm sure there has been, but I haven't seen. Is the bio mimics the same? Is their fracture reported in that segment or? Or no?

[Dr. John Rundback]:
Yeah, essentially, no fractures with the biometrics and a very, very low rate with supera, actually just so one, two weeks ago, you know, a patient who had had a supera in for eight years or so, something like that. And,there was actually fractures in two spots. I hadn’t seen that in a very long time.
[Dr. Sabeen Dhand];
He must've been doing lots of jumping jacks and that's, that's tough.

[Dr. John Rundback]:
He was a truck driver. I asked him, I said, are you crouching down a lot? Or what are you doing? You know, get a job, you know?

[Dr. Sabeen Dhand]:
One of my questions is going to be, you know, what lesions do you use the para for and biometrics, you touched on it. You said, you know, potentially the heavy calcium that are elastic, you would maybe do supera to get that radial strength. Those, 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, I mean, so absolutely. So certainly again, although we're perfect at every time as we get lesions that approximal SFA and ostium or lesions, where I need to be very precise landing before a big collateral, you know, which I may not want to compromise. I'm going to go ahead almost always use the biomimicry, the precision of placing that there's very very, little foreshortening and it's reliable. There are also interesting, and this is not talking about, cases where I just can not get, you know, adequate vessel prep. I just can't, you know, I just, can't dense calcium. I've done everything and you know, you know, it happens in those cases, you know, once you elongate supera you definitely lose patency and you can't now go in and, you know,

[Dr. Sabeen Dhand]:
can't plastic. Yeah, no,

[Dr. John Rundback]:
Yeah, right. You're done, right? Yeah. That's it. your hands are tied. So in those cases, you know, we will go ahead and, also, even though it's dense calcium lean towards using biomimics and said, you know, even if we could then go ahead and sort of rewind or, you know, crack and pave, or I guess pave and crack strategy in that case.

[Dr. Sabeen Dhand]:
Describe that more, the pave and crack. You actually stent in, then crack it after?

[Dr. John Rundback]:
Yeah, exactly. I mean, you know, we're talking about patients who are my normal balloons, which go to 20 atmospheres, you know, her not really got it. So those cases that are coming back, it's just a really flow limiting lesion. And I'm going to have to take out a conquest 40 type of thing. You know, it doesn't happen too often, but you know, you can do that all you want inside an elongated supera and you're not going to change it. You got a perforation, but you won't get changed results. You know, so you can change the configuration, you know, with the environment and that's, you know, it doesn't warrant too much discussion cause a less common scenario, but, I think what I want to say is we don't necessarily avoid the biomimic stent in circumferential, dense calcium, and as we get good vessel prep, we may want to use it more: One in the lab, it's very cost-effective for us. The lengths are a good reliability deployment is, is very good. So that's pretty good if you think about it.

[Dr. Sabeen Dhand]:
There is a lot of good pluses. I mean, you know, in our experience so far, we've been pretty happy. I mean, it's essentially, It's new experience. So I'm looking forward to see how my patients do, but it's like, well, I was able to stent that 20 centimeter segment like that. Whereas I'd still be stenting with the interwoven stent because it takes so long to deploy.

[Dr. John Rundback]:
Right. Exactly.

[Dr. Sabeen Dhand]:
Now, what about distal, let's go distal to the pop trifurcation disease. Have you been using this? know it's off label, but have you been, since it's five millimeters and you can oversize, have you been using it in the TPT, or doing sort of, you know, crazy revas of kissing, coronary DS is barreling into the stent.Have you had experience doing that type of work with the stent yet?

[Dr. John Rundback]:
Were you watching our live cases?

[Dr. Sabeen Dhand]:
I was not. Was that what you did?

[Dr. John Rundback]:
Oh, yeah. It sounds like something like that, crazy.

[Dr. Sabeen Dhand]:
I love kissing coronary and

[Dr. John Rundback]:
Right.

[Dr. Sabeen Dhand]:
That's

[Dr. John Rundback]:
Crazy. Recanalization colliding stance one into another, you know, coming across native arteries that have failed bypasses

[Dr. Sabeen Dhand]:
yeah, love it. love it. Those make me so happy when I get to do this. But yeah, how's your experience with that? with the bio mimics?

[Dr. John Rundback]:
yeah. So, we've used the bio mimics down into the P3 segment and a little bit of the tibia peroneal trunk, Although not that much, you know, I mean in that segment, Right. You know, we've done some tax and of course we used some Carnegie if the anatomy allows it, you know, we are doing again, a lot of IVIS a lot of atherectomy, a lot of angioplasty.but you know, if we're going to do kind of some sort of kissing technology there or clotting, usually it's going to be, off-label use a card or.

[Dr. Sabeen Dhand]:
Got it. And you know, back in the day, I don't do it as much, 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. Do you, have you done that at all ordo you, do you believe in that?I haven't done it in a while now, especially when DEB kind of went down a little bit, but when the one before I definitely had tried that.

[Dr. John Rundback]:
Yeah, well, you know, that's the DEBATE SFA approach. Dr. wrote that paper and you know, 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, you know, we'll use DCB.No 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, you know, we're also very comfortable because of the excellent results of the biomimic supera platform, you know, just sort of wait and see, do surveillance and if need be come back and use DCD as a secondary technology.

[Dr. Sabeen Dhand]:
Got it. Got it, got it. Not the other way around, do DCB first, then come back. And if it doesn't work, then stent? Which is kind of where the leave no metal behind kind of concept, right?

[Dr. John Rundback]:
Right, right, right. I mean, as a primary approach, we'll get those lesions with DCB is perfect. Right. You know, with just the vessel on angio and IVUS is completely normal after you've done your proba DCB. And that's great. I love that

[Dr. Sabeen Dhand]:
Those are, those are the ones that are durable with Leave No metal. Absolutely.

[Dr. John Rundback]:
Exactly.

(8) Future Advancements in Stents

[Dr. Sabeen Dhand]:
So future tech…People have talked about absorbable scaffolds. Are those ever, in your experience, I know you have your hands in a lot of things, but do you feel like that's going to be a viable option in the future, or that's kind of a vanishing goal?

[Dr. John Rundback]:
Yeah. And well, obviously, below the knee, we participate in the Saval. We participate in life BTK and we participate in stand, which is micro medical, which is sort of the Supera of the tibial arteries. Again, it's a woven nitinol stent. so. yeah, I mean, look, those technologies, you know, the tibial circulation, as you know, we don't have other great options.You could just get it in the mid and distal tibial arteries. We've used tax in that segment because you can't use Luna expandable stance, which is subject to plastic defamation and crush, but we definitely could use some other options. I do think there's probably going to be a role for bioabsorbable platforms or other stents in general below the knee. Above the knee? I don't know. Your value proposition now would have to exceed what we're seeing now with these third and fourth generation biomimetics stents. That's going to be hard to do.

[Dr. Sabeen Dhand]:
That’s hard. I mean, we're at 80, 85%, 75 to 85%, three years.

[Dr. John Rundback]:
yeah. Yeah, exactly. So, I mean, you know, the likelihood that we're going to gain much utilizing potentially very expensive technologies, is not certain at all.

[Dr. Sabeen Dhand]:
Anything else you want to kind of discuss about this distal fem pop segment? Anything we didn't cover, and we covered a lot, but something, you know, people, operators, maybe early operators or people who are getting more experienced about the segment what to do? Obviously IVUS is huge in your practice and should be, and everyone doing PAD. Any tips and tricks that you want to tell our listeners?

[Dr. John Rundback]:
Yeah. You know, particularly for early operators you should probably get comfortable doing some of these sort of flexion angiography, angiograms. You know, we don't routinely do that unless we're treating popliteal artery aneurysms. Funny, every time you treat a popliteal artery aneurysm, you do this to see where to lend your graphs and make sure you don't have any kinking, but we don't do it for an atherosclerotic case.

[Dr. Sabeen Dhand]:
Yeah.

[Dr. John Rundback]:
Right. Yeah. I mean, so it's not a bad idea until you get comfortable with these things and understand your patient and where that compression is occurring. After you put that stent, you know, go ahead and do that flexion angiogram, and you might learn something really valuable in terms of whether you have enough metal, you need more metal, you need less metal, you know, and how you can optimize your results.

[Dr. Sabeen Dhand]:
That's great. Actually, I'm going to incorporate that tip in my own practice. You’re right. I don't do that many flection views unless I have to, but doing it more routinely, I'll probably learn a lot more.

[Dr. John Rundback]:
Right now you do it when you have a talk coming up.

[Dr. Sabeen Dhand]:
Yeah, exactly. I'm gonna do it tomorrow. Dr. John Rundback, it's been great having you on, I mean, this is definitely, it's exciting to have new technology. I mean, with our non-metal options, atherectomy, lithotripsy, Deb, and, having new stents available to us like a biomimics and supera. I mean, it's nice to have a lot of options to treat these patients that otherwise may lose their foot or leg. so thanks a lot. Thanks for being on our show. We really enjoy all the stuff that you're doing and changing the field of PAD. So keep doing what you're doing.We love it.

[Dr. John Rundback]:
No, I appreciate it. It's very kind. And, what you're doing is also spectacular. You really are a very popular platform and I admire everything you've done and thank you enough for allowing me to talk to you

[Dr. Sabeen Dhand]:
No, thanks. It's all because of our great guests. So thank you so much and thanks to everyone. Thanks to our sound engineer, Kayla today and everyone else at back table. Thanks.

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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