Chapters Transcript Video Contemporary Data on Endovascular Back to Symposium Thanks once again, Eric. Uh, since some of this was actually covered during Eric's talk, I'll try and be brief and maybe gain some of our time back for everybody so no one has to worry about missing their, uh, flights. Let's get forward to. That talk. So here's all my consulting. You guys can decide if they're relevant or not. Uh, so, as Eric talked about, you know, what is in sensory stenosis, uh, and, you know, that is mostly a neon hyperplasia, which is the endothelial injury from whatever, uh, device you've used which causes smooth muscle migration, proliferation, and extracellular matrix accumulation. So if you look at it, it's very smooth-walled, it's very acellular, and it causes progressive lumin layering. It generally happens within the 1st 2 years from intervention, but most commonly within the 1st 6 months. Where does it happen for covered stents, it happens on the edge. Uh, if, uh, happens mid-stent, more common with, uh, uh, drug eluting stents and self-expanding stents. Self-expanding stents, the first generation ones, they tended to cause it both within the stent and above and below the stent because of its inflexibility, uh, uh, and then it's, uh, very common that you'll have it diffusely within just the, the bare metal self-expanding stents. And so why is that? Well, you know, there's a lot of theories of why that's out there. One, it's because the SFA is a, a mobile vessel. It undergoes both axial compression, elongation, torsion, uh, bending, but there's also the continued outward force on the stent. There's a lot of theories that if you oversize your stents by excessive amount that it continues to put fatigue against the wall and continues to create micro injury. We also know these forces can lead to stent fracture, and stent fracture can be inciting to continue to have active vessel wall proliferation. So there's a couple of things that, you know, our etiology that have more likely both CTOs are more likely to get it if you have moderate severe calcium or diffuse atherosclerosis, you're more likely to get it. It has more common in diabetics, chronic kidney disease, people that are still actually smoking, uncontrolled hyperlipidemia, and as we heard earlier from Doctor Dua, people that are of female sex, and that may be due to coagulabid factors. So if you think about how we used to treat it when we first, I first got in practice, it was really. Uh, angioplasty and angioplasty, all you were doing is squishing the fluid out of the lesion. It would look good during the procedure, but sure enough, by the time you saw them back for the one month appointment, a lot of times it was still back again, and so recurrence was very, very common. Uh, it's now progressed to now DCB data. It's better than angioplasty, but it's still, uh, not perfect. There is use of DES, which Eric alluded. We'll talk about that, uh, coverage stents, but it really still has, uh, issues edgere stenosis, and then we'll talk about both laser with laser with, uh, plainople and angioplasty versus laser with DCP, and then the Rotorex devices, uh, as we just heard about. And then one other thing I'm gonna put forward is, uh, PQ bypass, and, uh, in disclosure, I was a national PI for that trial. So if we look at POBA. Uh, once we had PBE, it didn't work. We tried to use other things. We use cutting balloons and we scoring balloons and really thinking the advantage of that is at least it wouldn't slip up and down on the lesion and it would actually engage. But if you look at it, it was really a very minimal increase in patency over POBA alone, so really not any help. And then there's also been use of directional e even though it's contraindicated. There's been studies of directional artherectomy for femoral pop. Lesions, uh, I was very enthusiastic about artherectomy when it first came out and did a lot of direction arthorrectomy. You can engage stents. You can get cut on stents. You can fracture stents, so it's not indicated, and, but it, it has been done in both my practice and other people's practices, uh, successfully. But you have to really watch out. And now we do actually do laser and, and rotation arthorectomy, guys, rotorex are actually indicated for it and work through a different mechanisms which are a whole lot safer. But if you look at de novo lesions versus instant lesions, you can look at that, uh, when people are treating instant lesions, they don't do as well as a de novo lesion. And so, the other thing is people have looked at is using drug eluting stents. So this is the, uh, patents that you can see through 12 months for silver PTX for patients who were just treated for, uh, just de novo lesions versus patients that had, uh, had, had a secondary PTX stent for instant restenosis that does pretty well, but not as well as a de novo lesion. And then as Eric talked to, there's been a lot of work with exper laser which does photo ablate the tissue and it has to be done with adjunctive angioplasty. And then there's also been work with uh this salvage study that compared using the Vyvan for instant restenosis. You can see that 81% were TA C and D lesions, but the 12-month primary patency was uh not really all that great at only half of the patients. So, we do know some things from DCB. This is from the Impact Global Study looking at the long lesion cohort. You can see that there are 149 patients with instant resinosis. Uh, and you can see the mean lesion like was just under 20 centimeters and the primary patency was actually excellent at 88%. Uh, we have a lot of data with Vybon. This is one of the bigger studies that's out there, uh, uh, just under, uh, 750 patients with, uh, 1500 interventions. You can see in these patients, 4, 48 patients had 143 Vbonds, and, uh, looking at instant reenosis, the primary patency rates were improved at 44 54% versus 33%, and the TR rates were just above 57%. Uh, versus 27%. So you can see that uh it does work and then some of those patients still actually still go on to have surgery, so it does still work. This was uh looking at Vonn versus angioplasty was for instant re enosis called the Reline trial. You can see that the patency here at 12 months at 75% for Vyvon versus uh 28% for angioplasty, which we know angioplasty doesn't work, showing the effective of that. Here's another laser plus DCB trial. Uh, so instead of laser angioplasty with DCB trial, but if you look really at the end of 12 month freedom from, uh. Uh, TLR renos was 66% for laser angioplasty with DCB versus 6% for laser angioplasty with plain obalo angioplasty, about 20% increase in patency, and that sort of continued out through two years. The last thing I would say is uh PQ bypass. If you do see a lot of patients in your practice referred to you that have had long segment occlusions, uh, the average patient in this trial was 33 centimeters length. Most of them were CTOs. Many were, uh, stent occlusions. So the whole idea is instead of trying to reign through that instant resinosis to go around it, to go through the, uh, SFA origin to get into the femoral vein, travel through the femoral vein, and get down into the poptail segment. And to treat it, the primary patency was 58% at 3 years, uh, but if you look at the way we do a surgical bypass, open or not, it was much higher, uh, and the freedom from DVT. So when you travel through the vein, it doesn't really provide much risk. There was only 4% of the patients had a symptomatic DVT through 3 years. So what else is out there, and Peter talked a little bit about that and I showed some cases of it, so I'm not gonna spend a lot of time on it. The rotor exoterectomy system, uh, this was 215 patients, a two-center study. Uh, they were, uh, the Saka 3 lesions which are total occlusions in 165 patients. You can see that there were no perforations and a very, very low embolization rate, which is very different from many of the other arthorectomy devices, and you can see that only 13% of the patients underwent a CD CDTLR with a primary patency of 80% at one year. Uh, the other new, uh, drug code devices out there are the from China. It's ACORTCB device, and this is their data with, uh, 50 patients instant resinosis, and you can see over a two-year period, the patency rate was, uh, considerably higher than angioplasty, not surprising, but you can see the 12-month patency was 87%, uh, and at 24 months was 54%. So there has been a, a study looking at Rotorex versus surgery. As a surgeon, I'm always interested when people sort of compare the two because uh I don't find my patients, if there's an endo option they ever want uh surgery, and I'd send you surgery as the last result, but you can see that there's actually a savings uh over. Surgery when treating instant resinosis and my philosophy is if I can treat him without a distal embolization risk I'm gonna continue to endo as long as I can. And so having this in the toolbox actually helps and I think now it's really rotor X plus DCB. So I think you have to debulk, but then you wanna put in some mechanism to, uh, provide long term patency and stop the secondary resinosis so. In the end, as Eric covered this already, there's a lot of methods to treat instant restenosis. POBA is, uh, really not helpful. Drug elution is helpful, but I think debulking adds quite a bit to it, whether it's, uh, laser or rotational now with Rotorex and drug eluting scent versus covered stents. I think it's a little bit to be determined. I think when you've gone back and done a lot, I think the thing I look at is time from intervention to re-stenosis. So if I get a 11 year and a half, I'm gonna go back and do what I did the first time. If it's getting shorter and shorter, I'm gonna generally change my algorithm, trying to do something. Uh, different, and I would say that if you asked everybody in this room, everybody will have a different consensus on what they want to do, which means there is no consensus. Thank you. All right, great. Thanks, John. Published Created by
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