Chapters Transcript Video Global Consensus Back to Symposium So, uh, thank you again to be here and I'm very proud to present this, uh, uh, work that, uh, we did with a group of friends and colleagues to understand better how we can improve the, uh, our vessel preparation and improve the outcome. Um, The, the goal, uh, is pretty easy because we know that, uh, nowadays, uh, you know, vessel preparation is pretty familiar for everyone, and we are almost doing in uh all our cases, but, uh, the, from one side, we are very happy because We have a lot of devices available, but on the other side, sometimes this makes it a little bit of confusion because we don't know exactly which device can be considered the ideal one or can perform better in a specific situation. So this was the, the goal that uh was at a basic, uh, at the, you know, when we start this project. And we use a modified Delphi uh uh method that was uh based on the selection of the panelists, then we did a pre-consensus survey uh to understand, you know, the baseline of All the information, all the, what we are doing in our practice. Uh, obviously, we review also the literature to see the data available for each single device and also according to the lesion morphology, and then we started with uh two different rounds of questions uh that was done in an anonymous. way and very important. Everything was analyzed by a rigorous statistical analysis to create this consensus that was based to define which treatment modality can be, must be used for a specific plaque morphology for best preparation, but also give some information. Regarding the final treatment, uh, modality. This is the list of the uh key opinion leaders that were involved, 22. What I would like to underline to you is that if you check the, uh, the, the area where they are coming from, you see, we cover almost all the globe going from North America, South America, Europe, but also the Asia-Pacific region. And this is important because it gives us a lot of information about the different approach, different way of how to perform the procedure. Uh, just to, uh, keep you informed that we do not consider the cost, a problem, I can say, because obviously, you know, there are so many differences between one nation and another nation, but also within the same nation from one city to another one. So we define this consensus based on an ideal world where everything was cheap or free for everyone. The consensus was based also on 2230 colleagues from 27 countries that we asked them to participate in the survey in the two rounds of voting just to collect more information and have and have more data regarding how to perform the procedures and again this was collected in an anonymous way. What about the questions we work very hard on to create 53 questions that were divided in 4 different groups. The first one was related to the modality that we generally use to validate the plaque morphology. So it's more and uh in a pre-procedural evaluation. Then we have a group of questions related to the endovascular uh procedure and especially where we define the different types of plaque morphologies, acute thrombotic, soft plaque, fibrotic, um, mixed morphology, and also calcification. We also define the lesion according to the length, less than 10 centimeters and uh greater than 10 centimeters, so that we can also simplify in the short lesion and long lesion. We also analyzed a little bit about the safety, so we put some questions regarding the risk of desalinbodization uh when we perform vessel preparation, but also which, in which condition maybe the use of protection device that can be considered uh appropriate or mandatory. And finally, a few questions regarding the treatment of instantly stenosis related to the Tossaka classification. This is the priority definition of appropriateness, that was done with two different score rating, uh, 79 points. Very important to define the appropriateness for each single modality. Let's have a look to the results that are, uh, obviously the most interesting part of this uh uh uh of this uh project. This is the determination of the plaque morphology. You can see that there was a very strong agreement between all the participants regarding two modalities, ibis and the optic fib. Obviously, we perform a lot of discussion regarding ibis, you know, because the debate was that it's not available in all the, the hospital, in all the cath lab, whatever, but uh, Everyone realized and underlined that Argus is the only method that can give a specific evaluation of the plaque morphology in terms of plaque characteristics, so there was a complete agreement from all the participants. What about now the vessel preparation, so the, the core of our, our project. This is for the acute thrombotic lesion. You see, there is a little bit of a disagreement, but there was an agreement or a consensus that aspiration thrombectomy in the analysis can be performed in a proper way. There is Also an agreement regarding aero thrombectomy, but on the opposite for mechanical thrombectomy, there was an agreement for long lesions longer than 10 centimeters, but not for the short lesion. You can see that all the other categories like all the angioplasty, special balloons, whatever were considered not valid in the case of an acute thrombotic. Suback. Um, there is also here a little bit of discussion, but you see that, that the only method that we consider appropriate, and there was a, a full agreement between all the participants is the utero thrombectomy. There was some consensus regarding the use of conventional balloon for a short lesion with a soft plug, uh, as well as using the use of a laser erectomy. And then there was some disagreement for rotational and directional arterectomy, but I think the picture is pretty clear to understand that arter thrombectomy is the safer or the valid method that we can use for long and short lesion in case of a soft plaque. Fibrotic lesion. This is more, I can say easy to manage, you see. We can use all kinds of angioathy, high pressure, special balloons, squatting, cutting balloons, but also we can jump into the family of erectomy. This is for. This is for rotational, directional, and also for aerothrombectomy. There is a little bit of disagreement for orbital arterectomy, especially for short lesion, and there was another agreement for the standard angioplasty and orbital terectomy for long lesion. Uh, we also defined that all the aspiration, cadida or the lysis and mechanical thrombectomy were not considered valid for the fibrootic block. Mixed morphology. This is the most difficult condition because, you know, it's also the definition of a mixed morphology is not a clear 100%, but again, you can see that the thrombectomy in terms of auto thrombectomy, laser, rotational, and direction, the directional were considered up to date for this kind of lesion beside the lesion length. For short mixed morphology, we can also use special balloons as well as a high pressure balloon, but again, aspiration, lysis, and mechanical thrombectomy where there was an agreement that it cannot be considered idle or valid in this condition. Calcium, uh, this is, you know, uh, a very challenging condition, but you see, there was a, a strong agreement for which morality can be used and which cannot be used. All the balloons can be performed pretty well, and there was an agreement as well as for laser, orbital, rotational, and directional arterectomies. There was a little bit of discussion regarding arter thrombectomy that we can consider valid for short lesion with a small amount of calcium, but for severe calcification, we cannot use it. What about the, uh, uh, also the digital embolization? Again, as I told you before, we would like also to look a little bit on the safety side of the procedure. And you see that the use of a protection device can be considered uh mandatory. Every time we are going to use an orbital arterectomy or a rotational or directional arterectomy device. There was also an agreement for in case of acute thrombotic where the filter can be considered very useful when we perform angioplasty using standard balloon, but also when we use a high pressure special balloon or scoring cutting balloon. There was a little bit of a disagreement regarding IDL, but we also underlined that IDL cannot be considered valid, you know, or high risk for embolization when we're using other morphology type of morphology lesions. Just to focus a little bit more in the acute thrombotic that we know is a more challenging situation. You see there was an agreement for those uh uh methods that require a filter or a protection device, atherectomy, but also what we cannot, we have not, uh, is not required to use as the aspiration uh thrombectomy or some other devices. Now, what about the instant rest stenosis? We focus, you know, according to the Tosaka classification for the vessel preparation, and you see there was a strong agreement in the use of a high pressure balloon angioplasty, as well as a special balloon and also the scoring and cutting balloon. There was also an agreement that we can use the other thrombectomy device as well as the laser erectomy and the rotationalarterectomy. There was a little bit of disagreement for the orbital and the directionalterectomy, but everyone, there was an agreement to do not use all the lysis or aspiration cathedrals or systems. This is just a, uh, you know, a pretty easy way to understand better and recap all the results, and this is also what we put in the publication that we just performed on the Journal of Vascular Interventional diology just to give a clear message of the consensus to all the operators what is useful and what cannot be used according to the lesion characteristics. Regarding the final treatment, we focus on the, what is the most popular devices, so the uh simple angioplasty, DCB, DS, uh, bare metal stent, but also cover stent graft and combined therapy. As you can see that, uh, you know, uh, the standard angiopathy, there was a, a big disagreement to use uh in uh uh some uh condition like acute thrombotic plaque, soft or fibrotic plaque, uh, but, uh, in the majority of the cases, there was an agreement. That DCB DS bare metal metal stent, uh, can be used as well as a cover stent and also a combined treatment, uh, like, you know, DCB plus uh uh bare metal stent or DCB plus uh drug eluting stent. Regarding instantly stenosis, this was a pretty, uh, clear, pretty easy. You see, POA, everyone defined was not an ideal method for the final treatment. On the opposite, DCB, DES, and a cover stent graft and also combined therapy can be considered valid with 100% of, of uh of uh uh evaluation from all the participants in all conditions. On the opposite, you see that bare metal stand, uh, there was a disagreement regarding Tosaka 1 and Tosaka 2, and then an agreement to use them for Tossaka 3 lesions. So in conclusion, we can affirm that we know that the uh the treatment of the FEMA lesions is not very easy. What is important is to define the treatment modality for each single lesion, each single patient. This consensus was created to give some indication to the, all our colleagues and all the operators to define which treatment modality can be used in a better way in as according to the lesion characteristics that definitely can improve the final outcome. All the tenants uh agree that obviously we need a further evaluation. We have to standardize standardize a little bit more the treatment modality and also we need maybe some multi-center trials comparing one modality to another one, you know, to define, you know, to improve the results. Thank you for your attention. Published Created by
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