Current algorithm about the endovascular treatment of femoropopliteal atheromatous lesions?

L’INTERVENTIONNEL What is your favorite approach? Why? Per SKOOG - We prefer antegrad approach when we recanalize SFA, popliteal or below the knee. However, in obese patients we often prefer retrograde approach cross over due to the increased risk of iatrogenic complications.   L’INTERVENTIONNEL Please describe what types of devices that you use to do it. Per SKOOG - Mostly we first puncture with microsystems and perform an angiography. Treatments are mainly performed via 5 or 6F sheaths. We use POBA in a majority of cases except short occlusions and if significant recoil is seen. Stents, DES or DCBs are used only in selected cases as our experience is that DES/DCB aren’t performing as good as many low-quality studies suggest. In-stent stenosis is also a clinical problem suggesting POBA as primary treatment. Our main femoro-popliteal stent is Everflex (Medtronic) and our main balloon-expandable used in the iliacs is Omnilink (Abbott). When major recoil is noted, we use Supera stents (Abbott).   L’INTERVENTIONNEL What do you think about radial approach? Per SKOOG - Radial approach is seldom performed at our center but in selected cases we use brachial access, mostly when cross-over is not possible due to previous vascular surgery (EVAR) or the anatomical preconditions are challenging. From the brachial artery we often reach femoro-pop segments while it can be challenging with the device length from the radial access.   L’INTERVENTIONNEL Are you a subintimal or intraluminal crossing believer? What are the reasons? Per SKOOG - In our experience subintimal crossings are to be avoided due to bad long-term patency. We aim for intraluminal recanalisations in stenoses and in short occlusions and select longer fem-pop occlusions for primary bypass surgery.   L’INTERVENTIONNEL Could you describe your guidewire escalade to cross chronic total occlusion? Per SKOOG - Often chronic occlusions are crossed primarily with a 0.18 CTO guidewire with moderate tip-load and the use of a dedicated support catheter often adding another macrocatheter outside the support catheter. If failure to cross we escalade to higher tip-load, hydrophilic surface or stronger support (long introducer).   L’INTERVENTIONNEL How do you proceed in case of crossing failure: re-entry device? Retrograde access? Per SKOOG - We have experience with Outback-catheters and believe that a retrograde access with distal puncture of a tibial artery is superior in most cases.   L’INTERVENTIONNEL What are your techniques of vessel preparation? Per SKOOG - POBA in most cases.   L’INTERVENTIONNEL How do you evaluate the quality of vessel preparation? Per SKOOG - Angiography, I-flow (Siemens) and in the last year an increasing number of IVUS-evaluations in selected cases.   L’INTERVENTIONNEL What are your thoughts about atherectomy, IVL or scoring balloons? Per SKOOG - We do not see that there is any advantage in the literature for atherectomy devices. Our experience is limited, but not nil. We are using Shockwave in more and more cases with high calcium burden. Scoring balloons are used in very rare cases, except in A-V fistulas.   L’INTERVENTIONNEL Do you see any interest in IVUS or OCT for the SFA? Per SKOOG - IVUS is, as described above, used in an increasing number of cases where the anatomy and post-dilatation result is challenging to understand even with octagonal angiographies.   L’INTERVENTIONNEL For medium length lesion, what is your strategy between DES and DCB? Per SKOOG - DCBs and in some cases stents. Seldom DES. L’INTERVENTIONNEL For long lesions (>15cm), does it change? P. SKOOG - Primary bypass.   L’INTERVENTIONNEL Do you have still any indication for bare metal stent? Per SKOOG - We use them in many cases as primary treatment when POBA is failing.   L’INTERVENTIONNEL What is the place of self-expendable covered stents in your strategy? Per SKOOG - Rare use in fem-pop lesions.   L’INTERVENTIONNEL How do you treat re-stenosis? Per SKOOG - DCB, sometimes multiple treatments.   L’INTERVENTIONNEL Any ongoing/future studies that would help clarify femoropopliteal treatment? Per SKOOG - Our center is PI for the SWEDEPAD-study that evaluates DCB and DES vs. POBA and bare-metal stents regarding longtime results in a national registry (registryrandomised controlled trial) with upcoming results next year from 3500 patients.   L’INTERVENTIONNEL What are your thoughts on Limus technologies? Per SKOOG - As the risk with paclitaxel has been downgraded I do not think that sacrolimustechnology will make a big difference.   L’INTERVENTIONNEL BASIL BEST CLI have modified your strategy in CLTI patients? Per SKOOG - No, we already select a large part of our patients to primary bypass with saphenous vein graft.   L’INTERVENTIONNEL Any reactions about SPORTS? Per SKOOG - No.   Per SKOOG    « I trained 2003-2010 to become a general surgeon first at a small local hospital and the last three years at a university hospital. Between 2010 and 2013, I held a residency in vascular surgery. 2007-2013, I also did my PhD, focusing on abdominal compartment syndrome following aortic rupture. 2014-2015,I worked as a vascular surgeon and research fellow at St Olavs University Hospital, Trondheim, Norway and since late 2015, I’m holding a position in Gothenburg. Research-wise I’m interested in post-operative complications both after aortic and femoro-popliteal surgery. In Sweden, all arterial vascular surgery is performed within tax-financed public healthcare. We have no shortage of surgeons or material, but experience shortage of staff, especially within the postoperative and vascular wards and sometimes patients experience bad accessibility due to inefficiency within the public organisation. There is very few private out-patient vascular clinics within Sweden. The median age of our patients is 79 years and we therefore perform a lot of our procedures in octogenarians. We are a tertiary vascular center for 1.7 million people with another 3 vascular centers in our region. At Sahlgrenska, 11 seniors vascular surgeons and 4 juniors treat all vascular patients, and all consultants are performing both open and endovascular surgery. Approximately 40% of aortic surgery is performed with open technique and 30% of the fem-pop procedures. We have teams that specialise in more rare procedures (FEVAR/BEVAR, pedal bypasses, venous recanalisations, open advanced aortic surgery [NAIS]) but all common procedures like bypasses, infrarenal aortic procedures... and all on-call procedures like symptomatic aortic aneurysms, acute ischemia, carotid surgery... are performed by everyone. Our center is the major transplant center in Sweden and one of the major onco-surgical centers and therefore we perform relatively high volumes of assisting onco-vascular surgeries. We have a vascular ward with 14 beds and place sometimes vascular patients in other surgical wards when necessary. We perform endovascular femoro-popliteal procedures in 2 angio suites, bypass-surgery and EVARs in a hybrid suite and other procedures in ordinary ORs within a joint surgical operative ward. We have a good relation to the interventional radiologists at our centra and they perform all bleeding angios, some of the visceral vascular interventions and all liver and onco-interventions."