PAD Devices
DEVICES
Wire, Catheter, Sheath and Guiding Catheter: Devices and Concepts
Consider ALL points of Arterial Access
-Femoral – antegrade, retrograde
-Radial
-Brachial
-Popliteal
-Tibial
-Other
What is the best sheath for PAD treatment?
Lumen: Small vs. Large
Length: Short vs. Long
Stability: Stiff vs. Flexible
Access: Valved vs. RHV
Dilator: .018″ vs. 0.35″
Sheaths for Radial Access – Thin walled, conventional lumen + 1, low profile taper, varying length. Prone to kinking, and NOT all made with hemostatic valve.
The Perfect Microcatheter
.027″…Progreat
.025″…PX Slim/Lantern…Can use for almost anything, can use Onyx, Particles
.021″…Renegade
.0165″…Excelsior SL-10…Neuro…can NOT use Onyx
.010”…Marathon
Things to Consider for Wire Choice
Core diameter
Core material
Core taper
Core grind
Tip design
Covers/Coatings
Tortuosity
CROSSING CTO TECHNIQUES
-Occlusions are commonplace and crossing these occlusions are critical!
Algorithm
.Can I see the beginning and end of the occlusion?
.What approach am I willing to accept? (Subintimal or Intraluminal)
.When to use device?
.What is my threshold?
.What are my acceptable limits?
-Time
-Dissection
-Contrast
-Complications
-What are points at which to stop
Morphology of Cap!
-Collateral vessel near cap
-Location of distal cap
-Calcification
-Length
-Ambiguous Cap
-Vessel (Femoral vs Tibial)
Why Choose a Crossing Device?
.Increased intraluminal crossing
.More treatment options
.Faster, easier, cooler
.Better results
-Wildcat/Kittycat – Rotating distal tip
-Wingman
-Frontrunner XP
-PowerWire – Uses RF energy
-TruePath
-CenterCross – Opens up scaffold
-Crosser 14 – Uses ultrasound
-Viance – Can spin this catheter
Reentry Device
-Outback (Cordis)
-Pioneer (Volcano/Philips)
-Enteer Device (Covidien/Medtronic)
Atherectomy Devices: When and What to Use
Turbo-Elite – Laser Atherectomy Device – only FDA indicated atherectomy device for in-stent restenosis.
-Turbohawk – Hinge mechanism, NO barotrauma, does not restrict flow…don’t use in carotids or iliacs.
-Pathway
-CSI Diamondback 360 – Dedicated Calcium system; principle goal is reduction in plaque compliance; also uses pulsatile forces.
-Rotoblator
-Jetstream Atherectomy Device – only atherectomy device with active aspiration.
-Phoenix – 5 Fr; designed to ablate and remove plaque; cut, capture, clear….central (no vessel injury).
-Pantheris – Uses optical imaging to you can see the plaque and you don’t cut too deeply; it is more directed and controlled.
Below the Knee Devices: When and Why
Hierarchical Approach to CTO Crossing
-Traditional Antegrade
.Cath/wire followed by specialty CTO devieces
.Re-entry devices
.Balloon-assisted re-entry
-Hydrodynamic boost techniques
-Trans-collateral/plantal-pedal loop
-Bi-directional Approach
.SAFARI
.Trans-pedal (retrograde and antegrade)
Wires
-Command (.014 and .018) and Connect (Abbot Vasc)
-V-14 and V-18 & Transcent .014 (BSC)
-Asahi line of wires: Gladius, Astato, Regalia
Support Catheters (multiple manufacturers)
Current CTO Crossing Devices for Below the Knee
-Wingman (Reflow Medical)
-TruePath CTO (BSC)
Adequate Vessel Preparation [to facilitate drug delivery to media and adventitia]
–Scoring Balloons may reduce the incidence of dissection and residual stenosis and possibly improve drug uptake in the wall.
–Atherectomy no only provides debunking but also increases drug delivery to deeper layers of the vessel wall.
-Cagent Vascular Serranator – may improve dilatation but also improve delivery of drug to media an adventitia.
-Changing compliance of vessels (if patients have VERY calcified vessels) – Intravascular lithotripsy technology using shock-wave device…causes microfragmentation of calcium.
STENT SELECTION
Common Iliac
8-9mm for Men
7-8mm for Women
Ballon-Expandable Stents
Covered-
Atrium: 7 Fr Sheath
VBX: 7 Fr Sheath
Bare Metal-
Express: 6Fr
External Iliac
7-8 +/- 1 mm for Men
7 +/- 1 for Women
Self-Expandable Stents
Viabahn
Smart
SFA
5-6 mm in Men
5 mm in Women
Drug Eluting
Zilver
Eluvia
Bare Metal
LifeStent
S.M.A.R.T. Stent
Popliteal
Supera Stent
BARE METAL, COVERED & INTERWOVEN STENTS
Challenges
Challenging vascular territory, inflammatory response to stress, surrounding musculature creates compression and torsion forces, overlap of stents can create other forces.
Current evidence for BMS (Nitinol – Nickel, Titanium Alloy)- ‘Shape memory’ and super-elasticity! Extremely beneficial properties in making stents.
Current evidence for covered stents -VIBRANT trial (BMS vs. Covered) – at 3 years, no significant difference in primary patency…..VIASTAR trial – at 1 and 2 yrs, primary latency better for covered stents vs. BMS
Current evidence for interwoven stents – SUPERB trial
Pearls-
BMS better PTA for short and intermediate length lesion.
BMS is NOT good for longer lesions.
Coveres Stents patency is better than BMS in longer lesions.
CS patency affected by oversizing.
Interwoven stents have good freedom from CD-TLR at 3 years.
Interwoven patency affected by vessel preparation and elongation.
No direct comparisons between BMS, CS, and interwoven stents.
May be used in specific clinical scenarios.