Cardiovascular Business - January/February 2009 - (Page 14)

InterventIonal Update CT angiography (CTa) is beneficial in the overall management of patients with peripheral vascular disease. CTa helps to identify unknown anatomic challenges, such as this ulcerative plaque in the common femoral artery (CFa), seen as a 3D volume-rendered image and curved multiplanar reconstructions (MPRs). 3D volume-rendered CT angiography shows severe superficial femoral artery calcifications, as well as mid-graft stenosis kinking, which also is shown as curved multiplanar reconstructions (MPRs). fluoroscopy time and contrast use. CTA identifies unknown anatomic challenges (tortuosity, ulcerative plaques, thrombus, etc.), facilitates PVI follow-up and potentially decreases vascular access complications. For these reasons, peripheral CTA has totally replaced traditional diagnostic catheter peripheral angiography in our practice and most PVIs today are preceded by CTA. This strategy has optimized preprocedural planning, periprocedural case execution and improved our overall PVI outcomes. Optimal vessel sizing is a prerequisite for percutaneous coronary intervention (PCI) and minimal lumen diameters are associated with improved short and long-term PCI outcomes. Intravascular ultrasound (IVUS) during PCI is commonplace, reimbursed and associated with improved PCI outcomes. Minimal lumen diameters are rarely mentioned during PVI and peripheral vascular IVUS is not reimbursed, therefore rarely used during PVIs. Little attention is given to precise/optimal vessel sizing during PVI, especially when treating infrapopliteal artery disease. Precise infrapopliteal artery sizing is complex, challenging and, unfortunately, “guess work” is often used in PVI device decision-making, certainly much more so than during PCI. It only stands to reason that if we had a simple, cost-effective, accurate technology to precisely size infrapopliteal arteries, outcomes would similarly improve as PCI outcomes have. This is especially important now that we have small profile PVI technologies and dedicated infrapopliteal stents. As a peripheral IVUS equivalent, we have utilized the Metricath Libra balloon (Neovasc) as a vessel-sizing balloon to precisely measure vessels, especially infrapopliteal arteries, to the hundredth millimeter. The Libra balloon inflates to 1/3 atm and uses a small computerized console to simply and quickly inflate in the reference vessel of interest and calculate the diameter of the vessel. We recently reported our experience in approximately 100 infrapopliteal arteries where about 50 percent of the vessels were oversized or undersized by > 0.50 mm as predicted by the operator before Libra vessel sizing. In our experience, this additional accurate vessel sizing has facilitated our choices of all of our definitive treatments during PVI including atherectomy devices, PTA, specialty balloons and, especially, infrapopliteal stents. Atherectomy in PAD and CLI Several atherectomy technologies are now available for PVI, as interventionalists appear to have lowered their threshold for atherectomy in treating PAD. The Spectranetics TURBO Elite line of excimer laser catheters is available in 0.9 mm to 2.5 mm lengths. The Elite catheters have achieved optimal laser efficiency with 30 percent more fibers and an advanced hydrophilic coating. The Booster laser catheter allows directional 360° rotational laser atherectomy, which can improve the athero- and thrombo-ablation capacity of the laser by increasing the atherectomy diameter by 50 percent to 60 percent. We have found laser therapy to be especially helpful in long, diffuse, minimally calcified atherosclerotic disease, including chronic total occlusions (CTOs), along with in-stent restenosis and any lesion harboring a moderate to large thrombus burden. The SilverHawk plaque excisional (ev3) line of treatment includes the RockHawk, which allows for atherectomy in more calcified vessels. Likewise, a lower profile MiniHawk will allow plaque excision in vessels between 1.5 mm to 2 mm. The CSI Diamondback 360° orbital atherectomy device is now available and provides excellent atherectomy in highly calcified vessels. This device uses a series of diamond-coated crowns that spin at up to 200,000 rpms to “sand” or perform differential plaque atherectomy. The CSI system is particularly useful in patients with both localized and diffused highly calcified lesions. Pathway Medical Technologies recently released the Jetstream atherectomy catheter, which provides simultaneous atherectomy with aspiration to remove thrombotic, atherosclerotic and atherectomized de- 14 Cardiovascular Business January/February 2009

Table of Contents Feed for the Digital Edition of Cardiovascular Business - January/February 2009

Cardiovascular Business - January/February 2009 Contents First Word Electrophysiology Roundtable Forum: A Candid Conversation about Profits, Procedures and Patients Heart Failure Care Gets Boost from Technology Emerging Technologies in Peripheral Vascular Interventions Stent vs. Graft: Choosing the Best Path for the Diabetic Patient with Multivessel Disease Cardiology Groups and Hospitals Strive to ‘Connect’ Seamlessly CT Beyond 64 Slices Clinical Study Digest: Kidney Disease & PCI; Women and Valve Disease Compact Echo Systems Come Up Big in Cardiac Care News & Views Reader Resources The ACC Corner

Cardiovascular Business - January/February 2009

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.