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Vessel Preparation May Be Key to Treating Challenging Peripheral Lesions
Proper vessel preparation techniques could address issues posted by calcium and facilitate drug delivery.
Endovascular interventions are becoming more common in patients with peripheral artery disease and critical limb ischemia, even in complex lesions.
However, it is becoming increasingly clear that if endovascular solutions are to be employed for complex lesions such as those with heavy calcification, vessel preparation may be required to produce optimal results, experts said at the International Symposium on Endovascular Therapy.
Help With Calcification
Calcium presents a great problem for endovascular solutions and vessel preparation may be the solution, Brian G. DeRubertis, MD, FACS, associate professor of surgery in the division of vascular and endovascular surgery at David Geffen School of Medicine and UCLA Ronald Reagan Medical Center, said during a presentation.
“Available data suggest that calcification may negatively impact outcomes,” he said. “Calcification contributes to procedural complexity. Calcification patterns within the arterial circulation vary considerably and likely impact outcomes differently.”
While much needs to be done to achieve a better understanding of the impact of calcification, employment of devices and technologies that affect the degree of calcification of change the impact of calcium on vessels is one way to approach the problem, DeRubertis said.
One technology that has been shown to have an impact is atherectomy. A device should be chosen based on whether it can remove calcified plaque, generate a significant lumen gain and reduce complications, according to DeRubertis.
An important study in this area was DEFINITIVE AR, which showed treating a lesion with directional atherectomy (SilverHawk/TurboHawk, Medtronic Endovascular) followed by a drug-coated balloon (Cotavance, Medrad) conferred better patency compared with DCB treatment alone, he said.
Intravascular lithotripsy (Peripheral IVL System, Shockwave Medical) has been shown to promote lumen gain while minimizing vessel wall injury, DeRubertis said.
“Significant improvements have been made in devices used to treat calcified lesions,” he said. “Core lab-adjudicated prospective real-world studies may supplant the utility of randomized controlled trials in further evaluating these devices in calcified lesions.”
Help With Drug Delivery
In another presentation, Andrew Holden, MBChB, FRANZCR, director of interventional radiology at Auckland Hospital, New Zealand, said in the current era, a goal of vessel preparation is to facilitate drug delivery, especially given concerns that there may be a connection between paclitaxel dose and mortality risk.
“Atherectomy provides not only debulking but increases drug delivery to the deeper layers of the vessel wall,” he said. “This has been most clearly demonstrated with directional atherectomy and anti-restenotic therapy. In DEFINITIVE AR, the patency advantage was most marked for patients aggressively treated with directional atherectomy.”
Cutting and scoring balloons, including the Boston Scientific Cutting Balloon, the Angiosculpt Scoring Balloon (Philips/Spectranetics), VascuTalk (Bard) and Chocolate (TriReme Medical) are being tested to see if they can “reduce the incidence of residual stenosis and flow-limiting dissection and possibly improve drug uptake in the vessel wall,” Holden said.
“These technologies can optimize the result of angioplasty and minimize the need for permanent stents,” he said. “Vessel preparation also includes normalizing vessel compliance and increasing the effectiveness of drug-eluting technologies. Given the recent concerns with paclitaxel, this is probably of increasing importance.” – by Erik Swain
- References:
- DeRubertis BG. Townhall.
- Holden A. CLI: The Data. Both presented at: the International Symposium on Endovascular Therapy; Jan. 27-30, 2019; Hollywood, Fla.
- For more information:
- Brian G. DeRubertis, MD, FACS, can be reached at bderubertis@mednet.ucla.edu.
- Andrew Holden, MBChB, FRANZCR, can be reached at andrewh@adhb.govt.nz.
Disclosures: DeRubertis reports he serves as a consultant or on an advisory board for Abbott Vascular, BD/Bard, Boston Scientific and Medtronic, serves on the speaker’s bureau for Abbott Vascular, Cook Medical and Medtronic, receives research funding from Medtronic and serves as a proctor for Cook Medical. Holden reports he has financial ties with Arsenal Medical, Bard, Boston Scientific, Cagent Medical, Cook Medical, Endologix, Endospan, Intact Vascular, Intervene, Medtronic, Shockwave Medical, Spectranetics, TriReme Medical and W.L. Gore and Associates.