Current algorithm about the endovascular treatment of femoropopliteal atheromatous lesions ?

L’INTERVENTIONNEL Algorithm for treatment of femoropopliteal lesions? What is your favorite approach? Why? What types of devices that you use to do it? What do you think about radial approach? Mercedes GUERRA - When we approach a case of femoropopliteal sector we make the plane before surgery in our vascular lab and we test the femoral and radial access. We select radial access in cases that I have to treat the proximal superficial femoral artery, or when the patient has a previous intervention at the groin, but this approach still has several limitations mainly due to the length of the devices. On the other hand, the radial access could be useful when the contralateral femoral access is made difficult by aortoiliac stenting or previous CERAB technique. I prefer a controlateral femoral access to treat femoropopliteal sector. Only in those cases where the distal vessels are associated, do I use ipsilateral femoral approach. In cases of ipsilateral anterograde approach, I use the micro puncture set and Minx® Cordis as a closure device. Currently I like to use a hybrid wire Advantage® Terumo for putting a long sheath in contralateral femoral approach. It allows the uses all devices in complex cases of femoropopliteal CTO. As I mentioned I think sometimes the radial access can be useful but for our team the minimum required diameter of the artery is 2mm. It´s a safe access and it allows an early discharge for the patients, on the same day of surgery. But 6F devices are the biggest that can be used so it is a limitation in cases where we have to use 7F devices. Another consideration is the length of devices when we need to treat the lesions in the distal superficial femoral artery, even the popliteal artery. I use a catheter balloon of 180 or 200mm in length and 4m wire, but there aren´t devices long enough to treat total occlusions so I discourage this approach in cases of complex femoro-popliteal lesions.   L’INTERVENTIONNEL Crossing. Are you a subintimal or intraluminal crossing believer? What are the reasons? Could you describe your guidewire escalade to cross chronic total occlusion? How do you proceed in case of crossing failure (re-entry device? Retrograde access?) Mercedes GUERRA - The strategy to cross femoro-popliteal lesions changes according to the complexity of target vessel, obviously. I generally cross with 0.35 standard wire supported over MP catheter. When we have a long total occlusion with hard calcium, we try to cross with 0.18 wire V18 from Boston Scientific, as second step I performe “drilling technique” with HT Command® 18 from Abbott. HT Winn® and Proceed® (Abbott) are used as last resources and increase support with low profile catheter balloons. These balloons allow us to make angioplasty during the cross but sometimes increase the risk of subintimal entry. My initial strategy is keeping intraluminal entry to use different recanalization devices options. Last year we incorporated Oscar® Biotronik catheter to our tools with very good results in this kind of lesions . When the cross fails, we use Go-Back® (Bentely) at the point of reentry. If that isn’t possible I change to retrograde access whenever the conversion to open surgery is not an option. For us, it's very important not to sacrifice open surgery options to force endovascular treatment. Of course we don´t do open surgery below the knee in claudicants patients. Sometimes, in cases unintentional subintimal entry I use Pioneer IVUS® (Philips) catheter and it can be useful for running the needle to the true lumen with direct vision.   L’INTERVENTIONNEL Vessel preparation. What are your techniques of vessel preparation? How do you evaluate the quality of vessel preparation? What are your thoughts about atherectomy, IVL or scoring balloons? Do you see any interest in IVUS or OCT for the SFA? Mercedes GUERRA - With regard to vessel preparation I use angioplasty balloons with low profile and I use progressively bigger diameters and 2 minutes for inflating. The initial evaluation is by angiography but in cases of a suspicion of dissections I review with IVUS. IVUS offers several aspects of the lesions, such as grade of calcification, dissections, diameters of lumen, but sometimes this can involve overtreatment. In our current clinical practice we don´t use atherectomy or scoring balloons for preparing the vessels but I think the future will be the use of IVL in very heavy calcified lesions.   L’INTERVENTIONNEL Treatment. For medium length lesion, what is your strategy between DES & DCB? For long lesions (>15cm), does it change? Do you have still any indication for bare metal stent? What is the place of self-expendable covered stents in your strategy? How do you treat re-stenosis? Any ongoing/future studies that would help clarify femoropopliteal treatment? Mercedes GUERRA - In our team we have very good results with DES, so for us we only apply the concept “leave nothing behind” in short lesions and in those we try with DCB. In lesions of more than 10mms and total occlusions I prefer to perform the treatment with EluviaTM Boston Scientific stent. The use of bare metal stent is reserved as back-up for dissections after angioplasty with DCB. Other options, such as of self-expandable covered stents, have been proposed but in my opinion the occlusion of collateral arteries is very relevant in these patients. If I have an unexpected rupture of the artery I use it, but in a past we found that this type of stent had a very low patency at the midterm in our series. Re-stenosis is another frequent problem without good solutions at the moment, especially when it appears after the use of drug eluting devices. In our protocol, we indicate DCB for restenosis intrastent to avoid leaving more metal in the lumen of the artery. When the restenosis appears after angioplasty with DCB we do stenting. We select DES after 6 months of treatment with DCB and I put bare-metal stent when the time is shorter. The doubt is what is the best treatment for early re-stenosis intra DES but fortunately there are few cases, and we treat them with another DES.   L’INTERVENTIONNEL Future and perspective. What are your thoughts on Limus technologies? BASIL BEST CLI have modified your strategy in CLTI patients? Any reactions about SPORTS? Mercedes GUERRA - New Limus technologies still haven´t demonstrated superior efficacy against paclitaxel. With similar patency results we need a complete platform of Limus devices to avoid mixing technologies because we have different diameters of Limus coated balloons but we lack the full range of stents with Limus to treat different lesions (Iliac and femoropopliteal or distal stenosis) at the same time in the limb. After the results from BASIL2 and BEST-CLI trials appeared, our clinical practice was supported in reference to BEST-CLI results: When the patients are fit for open surgery and they have a suitable single great saphenous vein we prefer this as a first option. However we indicate endovascular treatment before we use a prosthetic conduit because we haven´t had the same results with both techniques against the results for cohort2 of BEST-CLI trials. Perhaps ours results were due to the fact that infra-popliteal lesions were involved in the vast majority of the critical ischemia cases, while the BEST -CLI included this lesions in only 53.2% of cases. As I said we usually do DES in long lesions and long total occlusion for the superficial femoral artery. We call this type lesions “ELUVIA lesions”. This had been our current clinical practice from 2016, even against other current opinions. Therefore, SPORTS trial serves to support this position of our department over time.