Chapters Transcript Video Interventional Tools Back to Symposium I was asked to speak about interventional tools and I'm really gonna focus today on use of the Rotorex. But before I even start, I love the fact that everybody's here. I'm gonna try and change energy a little bit. I'm a little outspoken. I'm a little wild, but I do wanna say this, and I think this is very important. Everybody here has chosen to come whether it's because of weather or whatever else there are excuses you couldn't come you guys are here. I wanna challenge everybody in the audience to choose to be exceptional. OK. Choose to be extraordinary for yourself, for your patients, for everybody who put their efforts in to train you, so make the best choices and sometimes, and a lot of times the best choices are not the easiest choices, definitely not the cheapest of choices, OK? So, uh, my, my disclosure, I am but a humble plumber here for, here to work with you guys today. We've said it before. I stand and will die on the fact I think that Ibis is critically important for a full evaluation before treating anything. I, I personally routinely use Ibis in every case, and I do that because it's critically important to understand what your lesions really look like and, and to, to size because you wanna be able to make sure you're not undersizing and undertreating, and I think we've all seen that. Ibis in this case is critically important for understanding the severity of calcification. I think it's very easy to say angiographically this looks severely calcified, this looks OK, but you'd be shocked in in determining the the difference of your own personal evaluation of severity of calcification through angiography versus IIS alone, and I think that's been shown in several trials. Um, it gives you vessel and lesion dimensions. Uh, you can confirm the type of plaque you're dealing with and, and make sure that you did your best to be intraluminal when you're crossing a CTO. That brings us to choice of our atherectomy and thrombectomy device. In this case, I'm, I'm very, uh, dedicated to the utilization of Rotorex. Uh, absolutely transformed my practice since I first saw it in 2019. Um, these are the indications, um, for use in the peripheral arteries. I would say just by a show of hands, who in the audience has, has not touched a Rotorex yet? OK, great. Who in the audience routinely uses IIS during their cases? OK, beautiful. I, I implore you to reconsider those who didn't raise their hands. So the Rotorex is duly indicated for peripheral arterial atherectomy and thrombectomy um via the FDA. The system design is, is very unique. Um, it's, it has your, uh, I don't have a. Never mind, um, it starts with the modified bevel tip, the rotating cylinder at the front with the aspiration window, so this creates the, the best vortex for thrombectomy that's on the market, personal opinion, um, it's very simple to set up and very easy to use. So this is, this is looking at atherectomy and thrombectomy simultaneously, so you're getting that amazing aspiration while still having an a traumatic rotation at the head of the catheter which is really helping to debulk your mixed plaque and break up any clots so that when when it's being siphoned out you're not worried about what's remaining. On top of that, I will say that the vortex created by this very powerful Archimedes screw inside of the catheter. Is preventing you from really needing a digital protection device. Um, before I even get into cases, a couple of, couple of things that I want to share with everybody here. Number one, the wire if you're not used to the wire, uh, do not primarily wire with it exchange, OK, because it's very stiff and, and more likely to be traumatic if you're not used to wiring with it. I would also recommend, especially if you go on prolonged runs with the rotor X, one of the things that we've found is that if I've, if I've used the device for more than 5 minutes on the wire, if I don't exchange the wire out before I start ballooning, uh, there's a higher percentage of times where it's actually melding with the balloon. In which case I'm losing wire position because I have to take the whole system out and then rewire it with a different 014 018 wire, so I highly recommend if you're going on a prolonged run using the rotor X that you, you exchange that wire. Second thing, and this is a learning curve, if you're doing normal, um, contralateral access. Especially in long for long CTOs, the biggest issue with the device is the fact that if it overheats, you're more likely to fracture the, the, the rotating screw inside. So what do we have to do? We have to make sure the classic forward and back, so we're dancing with that catheter. We're making sure we're bathing it in blood because believe it or not, the blood is cooling off the system. One of the things that you can do that I, I learned, uh, from, uh, Miguel Montero Baker, you can hook up, um, to the side arm of your, of your sheath a, a, a saline bag on a pressure bag so that you have some level of continuous flow through your sheath which is helping to cool off your device in a long segment CTF and that's 6 or 8 French, whichever you're gonna use, OK? Our first patient, everybody likes sexy pictures. We should have a couple. 60 year old male, diabetic, hypertensive, of course he's actively smoking, history of prostate cancer, uh, presented with a non-healing ulcer to his left great toe. Uh, he had gangrene, antibiotics. Um, they're saying he was requiring an amputation, referred in for urgent evaluation. ABI measured, um, in my office was 0.4. Um, so it was brought into my OBL. I'm an OBL guy. I don't know everybody, what everybody else does. Um, 90% of my cases are actually transpedal, which is interesting based on the conversation that Tino, uh, was hosting before, and, uh, I actually, this case was done via contralateral common femoral access. Surprise, uh, it's not, not normal for my practice. So what do we see? We've got significant SFA disease. We've got um one partial vessel runoff via, via that AT. And we've got a CTO short segment right there in the digital SFA. So we, we decided to try to pursue opening his perineal from the ostium so that he could have full inline flow down to the foot to improve his healing. We failed crossing with an 014 wire and um and even an 018 crossing catheter. We were successful using a 2-0 balloon and an 018 command wire. Improved our support. We were able to get down and lo and behold, once we were able to get down to the distal calf, we noticed that we were in true lumen and and balloon angioplasty injecting through that balloon. We, we, we found excellent collateralization of all of the plantar arteries. Uh, can you hit play on this? This is our ibis again, I, I prefer ibis. I don't know if. Hopefully we're gonna play it. Survey says. And just click on it. OK, so our iIS showed significant mixed plaque morphology, uh, stenosis throughout the course of the patient's vasculature, and his, um, the size of his vessels were big enough for us to utilize the device. So this is me, this is working. So again, your classic dancing kind of forward and backward with your catheter is very important that you're not just jamming this thing down and then coming back because you're not going to get the efficacy that you want. You're certainly not going to get that vortex and preventing you from distally embolizing anything, and you need to be able to continue to make sure your catheter stays cool. This is, this is our post post balloon angioplasty, so we were successful in revitalizing his perineal. We opened up that distal SFA and popliteal and um inline flow down to that foot and ankle. We did have some concerns over that distal, um, the distal TP trunk, so we had to stent that portion with a 3,528 drug eluting stent. Um, excellent outcome and thankfully the patient did heal. Our second case, and this is more, uh, along the lines of what I prefer, uh, 57-year-old African American female, insulin dependent diabetes, hypertensive, PADs had multiple interventions to the bilateral iliac arteries and lower extremities, presenting with Ruford Class 4 arrest pain. Um, ultrasound showed us we're dealing with a totally occluded, uh, SFA into the proximal popliteal, uh, and in stent. So this is what I prefer. I, I usually will get either DP or PT access at the ankle. Um, if I'm worried about somebody with critical ischemia or we're dealing with non-healing ulcerations, I'll actually go in with a micro catheter and image the pedal loop before putting in a 5-6 linder. But I always put a 56 lender and that's how again 90% of my cases are done transpedally. So we have uh intact 2.5 vessel you could call it 3, runoffs. So I'm, I'm more than happy with what I'm seeing here, but what are we seeing? We've got a total occlusion of the distal SFA, uh, going from the ostium all the way down to the mid popliteal. We're able to cross because again we went through, through a stented portion. Um, these are not my stents. I promise I don't usually, uh, put soup to that stents from, from the osteum all the way down. But this patient needed help, so we go in, we went, we successfully IVs, and following IVs we went in. You want to try to play this? So I will, I will bring an Ibis catheter all the way up into the common fem or the iliacs and then, and then bring it down, um. In the interest of time we're gonna move forward. It's OK. Sorry, I promised the I was showed obviously severe we were in, we were in stent, so we were, we were true women. It had severe prolonged thrombosis with metal morphology inside of the stents, um, and then we, we put a rotor X in. Now I use the 110. Um, which is easiest and quickest coming from a transpedal location. You can use a 135 coming from the contralateral groin. Everything really depends on what you need to, uh, how the length that you're gonna need for the, for the device. We had no problems passing through our AT. That's important. Sometimes, um, if you have a small AT or if you have a diseased, uh, tibial vessel, my recommendation is you can balloon before you balloon the tibial vessel before trying to advance the device because if you have heavily calcified tibial vessels, they're going to give you a bit more of a hard time and if you're in through the AT that angle at the top is going to make your pushability with the device a little stiffer. And the last thing you wanna do is cause damage in your tibial vessel. So if I'm having any issues at all with advancing my device, I'll pull it out. I will balloon the tibial vessel and then go back in with my rotorex, uh, to perform the procedure in the SFA or POPP. So post post uh atherectomy, we have a reconstituted SFA into the pop. We wind up going in with an ultraverse balloon long 300 and we have reconstituted full flow from the SFA through the Papatio. Um, our tibial vessels were always open, so they still look beautiful and everybody's very happy. Uh, uh, other things that I wanna add because uh. I have 1000 cases I could show you and I just wanted to show you what I think is most important as you are gaining your understanding of the rotor X, the best places to use that are always going to be in stent or long CTOs. That's, that's your bread and butter with the device. I use it in, in tibial vessels all the time, but you need to have an iVIS to make sure that your sizing is over 30. If you're if you're gonna treat an AT wherever you're coming from, if it's from uh, uh, a contralateral approach or if you're coming from transpedal, what I've learned and, and what they tell you. You need to stop before you get to the ostium. Right, because the stiffness of the wire with the bulkiness of the device brings you too close to the intima at the osteoma of the AT because of that bend, and when that happens, you are much more likely to dissect or perforate. So, A, making sure that you're over 30, B, stop at the stop before the osteon, advance, and then continue to treat. What I've found, which is interesting, and there are plenty of patients out there with tibial vessels that are 40, believe it or not, um, if you're that big, it doesn't matter. So if I see it on Ibis that my tibial vessels is 40, I'm not stopping at the ossum because I have that much more room to be able to negotiate through, and I think that's very important. Anything else is really just tips and tricks of utilizing this device. I think critically important is making sure you don't overheat. And I run out of time. Wonderful job, Peter. Pete, Pete the Great, thank you very much. Published Created by
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