Cath Lab Digest - September 2007 - (Page 17)

17 atherosclerotic plaque material to cross coronary and peripheral CTOs should be available. The CROSSER system (Flowcardia Inc., Sunnyvale, CA) is an investigational, monorail catheter delivered over a .014” or .018” wire. The Peripheral Approach To Recanalization In Occluded Totals (PATRIOT) trial is an 85patient U.S. trial to determine the safety and efficacy of the device for lower-extremity CTOs. This device may be useful in smaller vessels where reentry devices cannot be used. A feasibility study in 55 coronary CTO lesions showed clinical success of 76%, without any perforations.35 COMMENTARY * Percutaneous Revascularization of Peripheral Chronic Total Occlusion — Which Patients, Why, and How? Aravinda Nanjundappa, MD and 2Robert Dieter, MD 1 Division of Cardiology, East Carolina University, Greenville, North Carolina and 2 Division of Cardiology, Loyola University, Chicago, Illinois Durability of Peripheral CTO Interventions Acute procedural success for peripheral CTOs has greatly increased with the use of the specialized devices described above, with low reported complication rates. Now the challenge in treating patients with long CTOs, or TASC type C and D lesions is maintaining patency over the long term. Unfortunately, PTA alone for CTOs is usually suboptimal, due to the large plaque burden and calcification, which leads to high dissection rates and significant vessel recoil. Also, rates of restenosis due to neointimal hyperplasia of total occlusions are typically substantially higher than those of subtotal lesions. In femoropopliteal lesions, PTA primary patency is lower for CLI than for claudication, 40.8% versus 64.8%, and lower for TASC type C and D lesion, compared to TASC A and B lesions.36 The 3-year patency rates for PTA are very poor and are as low as 20% for long lesions and in patients with poor runoff.37,38 Due to the limitations of PTA, both stenting and non-stent treatment options have emerged. Stents. Self-expanding nitinol stents have become an important component of the treatment of CTOs. The ability to prevent elastic recoil and stabilize PTA or other device-induced dissections has improved upon acute success rates. Stenting, however, still has limitations with regards to long-term patency, particularly in the SFA. Although restenosis rates appear lower with current nitinol stents, treatment of restenosis remains an unsolved problem. There is also an issue with stent fracture that may be variable with specific stent designs, but it has been associated with restenosis rates as high as 67%.39 Patency rates for stenting in CTO Recanalization of peripheral arterial total occlusion in lower extremities plays a pivotal role to improve claudication symptoms and limb salvage. Coronary chronic total occlusion (CTO) recanalization has recently gathered controversy with the publication of the occluded artery trial (OAT). However, in peripheral vasculature, specifically in the superficial femoral artery (SFA), occlusion predominates stenosis. The predominance of occlusion is due to limited collaterals, namely the profunda femoris artery and the diffuse nature of the disease.2 The constant endothelial injury, due to twisting, contraction and kinking of the arteries, results in accelerated atherosclerosis. Diagnosis of peripheral arterial occlusive disease (PAOD) is by history and physical examination.3 The site of pain in limbs can localize the location of occlusive disease. For example, SFA occlusion manifests as calf pain. Claudication results in the aching, throbbing or cramping pain in the feet, calves, thighs, or buttocks during ambulation. The pain occurs after walking the same distance each time. The pain should subside in a few minutes, following the cessation of walking. The severity of claudication is best described by Fontaine classification I to IV, ranging from no pain to ulcer or gangrene. The class II is further subdivided into IIa and IIb for the ability to walk > 200 feet and < 200 feet. Physical examination can localize the site of occlusion easily. An absent popliteal artery pulse denotes SFA occlusive disease, while an absent femoral pulse indicates aorto-iliac occlusion. Treatment is warranted for all classes of PAOD, which includes control of hypertension, diabetes mellitus and hypercholesterolemia, cessation of smoking, antiplatlet therapy and exercise. Revascularization should be considered for persistent claudication despite medical therapy. Revascularization with optimization of medical treatment is needed for patients with rest pain, ulcer or gangrene. Ankle brachial index (ABI), especially exercise ABI is helpful in the diagnosis of PAOD. Duplex ultrasound and segmental pressures can be complementary. Angiogram remains the gold standard to define the anatomy. Computerized tomography angiogram and magnetic resonance angiogram can be beneficial in selective cases. Percutaneous revascularization of CTO in the peripheral arterial tree is unique across iliac, femoral popliteal segments, and tibio-peroneal arteries. Despite TransAtlantic Inter-Society Consensus (TASC),4 recommendations to treat TASC A and B with the percutaneous approach, TASC C and D are being increasingly dealt with using the percutaneous technique. The key is to keep the procedure low risk and safe, as well as to minimize complications. The total occlusions are usually crossed with a 0.035-inch Glidewire® (Terumo, Somerset, NJ), with a catheter support from 4 Fr or 5 Fr multipurpose catheters. Alternatives include use of an 0.018” wire and the use of Quick-Cross® catheters (Spectranetics, Colorado Springs, Colorado) for support. Difficult cases involve *Reprinted with permission from Vascular Disease Management 2007;4(4):141. the use of laser (Spectranetics) assistance, reentry catheters, and the use of ultrasound for recanalization of CTO. Additional atherectomy with laser or SilverHawk SXL® (FoxHollow, Redwood City, CA) can debulk the lesion. Adjunct balloon angioplasty is needed in a majority of the cases. Cryoplasty (Boston Scientific, Maple Grove, MN) appears to be a promising technology and might prevent the use of stents, especially in arteries across the joints. Regular balloon angioplasty has a high rate of restenosis and reocclusion; hence CTOs are best treated with stents. The success of revascularization depends on the length of occlusion, calcification, and operator experience. CTO in other vascular beds, such as renal arteries, has a limited role and can be harmful, due to embolization and contrast-induced nephropathy. CTO of the carotid artery has been reported in few case reports; however, embolization can have devastating outcomes. Revascularization of CTO carries several risks.5 Perforation or rupture of iliac artery carries a high mortality if not treated urgently. SFA recanalization failure can jeopardize collaterals and worsen limb ischemia. Tibio-peroneal vessel perforation can lead to compartment syndrome. If a single tibio-peroneal vessel is compromised, limb loss is imminent. Embolization of iliac and femoropopliteal vessels can lead to levido reticularis, tissue, intestinal ischemia, and limb loss. Various techniques, such as balloon tamponade, covered stents, coil embolization and reversal of anticoagulation can treat perforation. Peripheral embolization can be treated with the use of mechanical suction, rheolytic thrombectomy or thrombolytic infusion. In summary, CTO of peripheral vasculature is common. Symptomatic occlusions need to be considered for revascularization. Percutaneous revascularization can be safely performed in a majority of the cases. The judicious use of Glidewires, low-profile catheters, and appropriate stents can revascularize peripheral arterial CTO. Adjuvant use of atherectomy, reentry devices, and cryoplasty are complementary. A thorough knowledge of complications, tips, and tricks to handle them are essential. The authors can be contacted at dappamd@yahoo.com References 1. Hochman JS, Lamas GA, Buller CE. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006;355:2395–2407. 2. De Vivo S, Kalin B, Wahlberg E. Risk factors for poor collateral development in claudication, vascular and endovascular surgery. Vasc Endovascular Surg 2005;39:519–524. 3. Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA 2001;286:1317–1324. 4. Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC). J Vasc Surg 2000;31:S1–S296. 5. Axisa B, Fishwick G, Bolia A. Complications following peripheral angioplasty. Ann R Coll Surg Engl 2002;84:39–42.

Table of Contents Feed for the Digital Edition of Cath Lab Digest - September 2007

St. Dominic Hospital The Genous Bio-engineered R Stent Percutaneous Treatment of Peripheral Arterial Chronic Total Occlusions: Device Options and Clinical Outcomes Contents Clinical Editor’s Corner Percutaneous Revascularization of Peripheral Chronic Total Occlusion — Which Patients, Why, and How? Myocardial Infarction and Syncope: A Manifestation of the “Raynaud-Prinzmetal Syndrome”? Essential Technical Components of the Transradial Approach If You Build It, Will They Come? Evidence-Based Medicine with Drug-Eluting Stents Back to School: The Value of Education in Cardiovascular Services The ACVP Standards and Competencies: Are You Using Them Effectively? What Do You Think? My Experience with Fibromuscular Dysplasia and Stroke A Brief Review of Fibromuscular Dysplasia Letter to the Editor A Look at On-the-Job Training: Perceptions, Reality and Our Profession Doing the Wave: Inventory Management with RFID The Ten-Minute Interview with… Paul Pinsker, RCIS CLD’s Annual Salary Survey Harrisburg Area Community College Volunteer Survey CEU Education Center SICP* Section Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Clinical & Industry News

Cath Lab Digest - September 2007

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