Chapters Transcript Video Choice of Atherectomy Device in ISR – How Do I Choose Back to Symposium It's incumbent upon us to remember. I, I know Kim, I think I can't see. I think she's probably in the room somewhere. Um, the hard work needs to be done outside of the lab, outside of the operating room, and we're talking about instant restenosis and outcomes. Well, in the real world, these people aren't doing the things that they really need to do, and, and that's something that we really need to focus on to change because that's probably a big portion of why they're coming back as soon as they are. And, and I didn't talk about it, but I'd be curious how many people will then add lossal to their patients when they start having instant reenosis. There's pretty good Japanese data that it's helpful. Uh, I find it's poorly tolerated unless you pre-talk with them about either the headaches, the tachycardia, or the diarrhea. Uh, but I think anecdotally it does actually in my practice sometimes help. I would say 15% of people benefit, 50+% have a side effect that makes them stop. So, all right, Tina, we're going back to you, um, and it's your, your mic. Great, can you hear me? We can hear you. We can put your slides back. Fantastic. Fantastic. That was a great talk, Sean. Fantastic. Um, we're gonna talk a little bit about a choice of artheric device, uh, artherecty device, which one do I choose for instance, stenosis. So as we already heard in terms of neoinimal hyperplasia, really what we're looking at is this constructive links between the stent. You may have some plaque and then smooth muscle. We know that in stents, even with dual antiplatelet therapy, you can get 20 to 40% 1 year, uh, incidence of, uh, of rest stenosis. We've heard a little bit about why angioplasty is ineffective. We discussed a little bit about the role of DCB over angioplasty. We talked about covered stents, talked a little bit about atherectomy, and. The combination of atherectomy plus DCB seemed to offer the best response. Here's my approach to instant re-stenosis, at least in the femoral popliteal region. I like to look at the length and the severity. Is it occlusion or is it a stenosis? Um, I'd like to have an idea of what's the time of that first TLR and what's the time from the last TLR. And I think you'll notice that at least when we, when we had nothing but angioplasty, you would see that that time would get shorter and shorter and shorter, and it was very frustrating. It's very similar to what Sean talked about. Uh, shorter lesions, uh, I can see myself going to angioplasty and DCB. However, once I get to longer occlusions and recurrent lesions, really go for atherectomy, some type of debulking, uh, strategy. I think if I, I like to look for stent fractures and very long lesions, consider reigning them. Uh, and we, we heard a little bit about the Reign trial and then atherectomy, uh, I, I like to use rotorect or a laser as our first, my first option, but there's plenty of data with many other artherectomy devices. So directional, uh, rotational, um, really the one that I don't like to use in stents is going to be oralarterectomy, but for the other ones, I think, uh, I have used, and you can use them, you just have to, uh, you know, have your choice of how you want to use them. So here's a case of a 75-year-old male, Rutherford class 3 disease on a 100, he had a 100-foot claudication. No improvement over the last few months on exercise and silostazole, and the non-invasive examination showed a pretty severe instant uh left SFA stenosis with the changes in the wave form and high velocity. You can see here what his angiogram looked like. There was a profunda stenosis. You have to see some irregularity in that mid-stent looked pretty focal, uh, and high-grade stenosis and preserved a runoff. My question, at that point, we did form an ivis, mostly a fibrous type lesions, which we see with instant restenosis. And I really wanted to get an idea in the three dimension, you know, how tight was this right up to 80%. And really, I use ibis to really have an idea and where am I gonna treat from where to where, where, what, and what diamemeter. In this case, I have a stent. Looking at the patient's bifurcation, I think it's always a concern as you start looking at bifurcation, especially if you see a type bifurcation such as this, and especially if you're gonna be using, uh, the Rotorex device or any device, you wanna make sure you can get it up and over the bifurcation if you're working, um, a retrograde from contralateral side. Here you can, uh, basically see, uh, and my thought is if I can get the sheath in, usually I can get the device to follow it. I like to watch it as it goes over, and, and make sure that it goes over well. Um, my technique in terms of using this device, I like to go slow. I like, very similar to what Pete said. I want to listen. I wanna look at the bag. Uh, if, if there is no flow, I'm really gonna be very careful. I wanna make sure it doesn't overheat. A pressure bag technique. I've used that as well. But again, really going slow, listening to the device, making sure there's stuff coming out of the bag, I think is really important when you use this, especially instant restenosis, especially for lung lesions. You can see when you get your first Pap smear what you've done here is really the bulk. You're not looking at, you're, you're gonna have your maximum diameter gain here. This is really the the bulk, and then I usually follow this up with an angioplasty and then a DCB as you can see in this patient, uh, 6 millimeters. At DCB with a very good result. Here's a second example, a 62 year year old male with a left foot wound and left SFA occlusion. Uh, you can see a really, uh, a patient had uh SFA stent, really, the entire SFA was stented and was occluded and had single vessel runoff via the uh the, the anterior tibial vessel. Now, the question is here now, you know, do I have enough runoff? What am I trying to do? You can see the rich collateral, so this is probably going on for a while. Uh, I, I think trying to get in line flow is really our, our goal here. So, what's the approach here? Again? How long has it been occluded? Is there any, you know, what's the potential for thrombus? I've had a lot of discussion, a lot of time we always talk about there's always some amount of thrombus in these lesions, so you have to be aware of that. The question is, is there very minimal or could there be significant? So as you cross a lesion, it's really important to get an idea of how easily it. Cross is if there's any thought about thrombus and you, you want to either uh aspirate lice or use, you know, try to protect yourself in terms of any distilization, I think the length is important and again previous treatments. You can see here crossing lesions as you can see with the wire, a buckled wire getting across into the stents. And then advancing, uh, in this case, a rotor X device and going slowly. So I didn't show you the reconstitution, but there was a disease below the stent and you can see kind of we went into the native vessel as well and try to get the best possible result there. Then we treated this patient with angioplasty and then followed the patient with a lung 300 DCB. And you can see what uh post-procedure, what it looked like. Again, these patients we're gonna treat with maximum medical therapy. Uh, I wish I had a, uh, you know, I, I'm looking forward to see Doctor Dua's uh publication and see how we can start instituting, uh, best possible, uh, you know, in terms of antithrombotic, uh, medications because I think she's right. It's really requires a personalized, uh, probably plan for each patient. Uh, this particular patient again, getting down into the DP. Uh, a third case. Here's an 82-year-old male, Rutherford class 5 CLTI, ulcers in the left foot. You can see the toe bracal index, uh, really abnormal, 0.7. Patient had ALI in the past, had, had stents placed about 8 years ago. At one time, we had lysed the stents and then had to extend one of the stents with a smart stent, um, probably at the time when we couldn't use os and then, um. Angioplasty to 6 millimeters and this is what this patient came in with. You can see here again, really uh calcified common femoral artery. You see here almost like overlapping stents in that proximal SFA and you see the stent construct going down to the popliteal artery. It looks as though there, there may actually be a super stent down in the, in the, uh, uh, distal in the proximal popliteal artery with a two vessel runoff. Again, trying to get through and through on this patient, you can see here we had to go retrograde. We couldn't go antigrade to get through into that stent, uh, punctured retrograde, and was able to snare the wire and then bring down in this particular case, we chose to use a filter and a lot of times if there's any question, especially in stent restenosis, we will place a filter device. You can see her place that. Filter device and then went ahead and in this case used a laser so you can see using a laser again very similar technique is going really slow using that photoablative effect of the filter to attempt to uh to get some debulking and then followed that with angioplasty and treatment with DCB. See the our post results. So I'll conclude by saying, I think a treatment algorithm for instant re enosis is really important. I think there's probably more personalized care here as everything we've talked about today, understanding the lesion, how long it is, what's, how long a stent's been, what kind of stents, look for stent fractures. Again, I try not to reign them unless there's a really Significant stent or there's a stent fracture or there's kind of real recurrent disease, I think that narrows my I mean luminal diameter. I think atherectomy for debulking for that hypoplastic tissue really has made a difference in our treatment strategy. I think combination of atherectomy with DCB appears to be synergistic and most effective, and I think you have to be knowledgeable and comfortable. Certain with atherectomy, it is important to fill it with a device that you're reliable that you feel most comfortable with to get the best possible results. For us, we like to use Rotorex and laser options and again, very low threshold to use filters for for instant restenosis, particularly as you start getting experience with different devices. So thank you very much. Thank you Published Created by
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