Paradigm to treat superficial femoral artery, popliteal disease with high calcification remains unclear

SAN FRANCISCO — In a session focused on lower-extremity intervention in superficial femoral artery and popliteal disease, one presenter highlighted possible treatment approaches in two calcification populations.

Gary M. Ansel, MD, of OhioHealth Riverside Methodist Hospital, Columbus, Ohio, reviewed what he calls a “good paradigm” to treat patients with less calcification and covered methods that may be used for more calcification but still lack clarity.

Gary M. Ansel

“If I have a patient who has no or moderate calcification, I’m probably going to predilate with balloon angioplasty,” Ansel said. “I’m not going to debulk that patient.”

With successful angioplasty, continuing to use a drug-coated balloon makes sense unless new data suggests otherwise, he said. If angioplasty is unsuccessful, clinicians can opt for a drug-eluting stent, a stent graft or a DCB followed by a bare-metal stent.

For moderate to severe calcification, Ansel said there are two potential approaches.

“You could use a woven stent, and it has pretty good data up to 3 years; but you use a [DCB] before that, and I don’t think we have any data to know that yet,” he said.

“The other that we’re seeing … a little bit of vision that may or may not be real, is atherectomy to debulk the lesion, and then use a [DCB] to try to get the drug up into that.”

Ansel said further investigation is needed on the latter approach. “We’re actually being retrospective on our own data to try to get real results on this.”

Regarding other treatments, Ansel noted a decreasing role for “plain old balloon angioplasty” and a hesitancy for using atherectomy due to a lack of randomized clinical trial data. He also discussed self-expanding stents.

“Intimal vs. subintimal — nobody really knows,” Ansel said. However, the VIBRANT trial offered “a lot of neat input” and the SUPERB trial “changed things” with the wire-woven nitinol stent.

“The nitinol stents don’t have enough outward push on some of these calcified lesions,” he said. “You put in the woven stent and it has a lot more resistant force to crush. It resists that resistance.”

On stent grafts, Ansel noted they are the only technology so far in which patencies are not affected by legion length and was comparable to prosthetic polytetrafluoroethylene bypass in a randomized trial.

Ansel put the totality of the information into context for the audience. “Some of the things you want to consider are vessel size, disease length, calcification severity, location with respect to the ostium and the [superficial femoral artery] profunda, the patency duration required and valued care.” – by Allegra Tiver

Reference:

Ansel GM. Evolving endovascular treatment strategies for femoral-popliteal disease in a DES and DCB world. Presented at: TCT Scientific Symposium; Oct. 11-15, 2015; San Francisco.

Disclosure: Ansel reports no relevant financial disclosures.