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Extreme Intervention in the OIS:
Below the Ankle
Eric J Dippel, MD FACC
Davenport, IA USA
April 6, 2019
Conflict of Interest
Consultant
– Abbott Vascular
– Becton Dickinson/CR Bard
– Medtronic/Covidien
– Philips/Spectranetics
– WL Gore
Physicians Initial Response to
Interventional Therapy (at least to me)
1st- “It doesn’t work and it is always dangerous. Clearly those performing it don’t understand plaque.”
2nd- “It seems PTA of stenotic iliacs may occasionally work (never occluded iliacs) – an iliac stent trial would be “UNETHICAL.”
3rd- “It is malpractice to intervene below the inguinal ligament”.
4th – “There may be an occasional role for PTA of short SFA stenosis but one should never intervene below the knee or long segment disease.”
5th- “Stents in the SFA are malpractice”.
6th- “You can’t stick the popliteal artery.” “Can’t cross a CTO”
7th- “ Atherectomy is just inferior endarterectomy”
8th- “You should never intervene on IP vessels”.
9th- “It would be malpractice to access the IP vessels as you may injure targets”. “But didn’t you just advise a BKA”?
10th- “Intervention just doesn’t last”
11th- “You can’t intervene below the ankle”
12th- “How can I do this?”Craig Walker, NCVH 2017
Vascular Anatomy of the Foot
Angiosomes of the Foot
Incidence of Wound Healing
Neville RF, CRT 2016
Importance of Angiosome directed revascularization
Pedal Arch Classification
Kawarada, O, et al. CCI. 2012(80):861-871
Complete Incomplete Incomplete Absent
Predictors of Wound Healing
Kawarada, O, et al. CCI. 2012(80):861-871
Directional Atherectomy
Hawk One-S
– 12,000 rpm
6 Fr
Vessel diam: 2-4mm
Crossing profile: 2.2mm
Effective length: 145cm
Tip length: 5.9cm
DA
Soft/Fibrotic Plaque ++++
Calcified Plaque ++
Thrombus -
Embolization ++++
Forward cutting -
Cost ++++
Laser Atherectomy
Turbo Elite
4-6 Fr
Catheter size: 0.9, 1.4, 1.7, 2.0mm
Vessel size: 1.3-3.0 mm
Shaft length: 150cm
LA
Soft/Fibrotic Plaque ++++
Calcified Plaque ++
Thrombus ++++
Embolization +
Forward cutting +
Cost ++
Case Report
65 yo male
IDDM, Neuropathy, Retinopathy, HTN,
CAD, ↑Chol
R ankle fracture
– ORIF with external fixation (x 3 months)
– Developed ischemic ulcers on all toes and
distal forefoot
Case Study
• Normal Aorto-iliac segment
• Normal Femoro-popliteal
segment
Case Study
Severe distal tibial disease
• Grand slam wire
• 1.4mm Turbo Elite laser
• PT 2.0x200mm
3.0x300mm
• AT 3.0x100mm
Tibial Critical Limb Ischemia
Case Study
Before After
Phoenix Atherectomy
Atherectomy and extraction
– 10,000-12,000 rpm
5-7 Fr
Tracking
– 1.8 mm x 149cm (5 Fr)
– 2.2 mm x 149 cm (6 Fr)
Deflecting
– 2.4 mm x 127 cm(7 Fr)
PA
Soft/Fibrotic Plaque ++++
Calcified Plaque +++
Thrombus ++++
Embolization +
Forward cutting +
Cost +++
Phoenix
Continue Treatment with 1.8mm Phoenix Catheter into Mid-Foot Post-Dilatation with Lutonix
DCB
Case performed by Prof. Zeller
Distal Posterior Tibial Case Study62 yo male, Non-healing foot ulcer
Final result after nitro and
post-dilatation with DEB.
1.8mm Phoenix catheter
being advanced into foot.
Case performed by Dr. Aljoscha Rastan
Bad Krozingen, Germany
Unsubtracted image showing
guidewire in posiiton
Distal Posterior Tibial Case Study
Orbital Atherectomy
Diamondback 360
– 60k, 90k, 140k rpm
– 30-70micron
4-6 Fr
Crown size: 1.25, 1.5mm
Vessel diam: 1.6-3.9 mm
Shaft length: 145cm
Tip length: 7mm
OA
Soft/Fibrotic Plaque ++
Calcified Plaque ++++
Thrombus -
Embolization ++++
Forward cutting -
Cost ++
58YO MALEDIABETES, CAD
NECROTIZING FOOT INFECTION
Courtesy of Eric Scott, MD
DIAGNOSTIC
ANGIOGRAM
AP FOOT LATERAL FOOT
Courtesy of Eric Scott, MD
DENSE CALCIFICATION AT
PROXIMAL CAP
0.014” PILOT WIRE
UNABLE TO CROSS
0.014” COMMAND
WIRE UNABLE TO CROSS
0.014” APPROACH CTO 25G TIP CROSSED LESION
0.014” BALLOON
UNABLE TO CROSS
LESIONCourtesy of Eric Scott, MD
1.25mm Micro Crown
CSI DiamondBackAtherectomy
Courtesy of Eric Scott, MD
FINAL IMAGES
AP FOOTLATERAL FOOT
Courtesy of Eric Scott, MD
3 MONTHS LATER
Courtesy of Eric Scott, MD
Conclusions
Severe pedal disease is very common in critical limb
ischemia
– Frequently the only resort to limb salvage
Endovascular pedal intervention can be safely performed
with a high degree of technical success (>90%)
– Can recanalize arteries that are non-bypassable
Must use meticulous care to avoid complications
– Careful wire selection
Be familiar with all the tools in the toolbox
ConclusionsDA OA LA PA
Soft/Fibrotic Plaque ++++ ++ ++++ ++++
Calcified Plaque ++ ++++ ++ +++
Thrombus - - ++++ ++++
Embolization ++++ ++++ + +
Forward cutting - - + +
Cost ++++ ++ ++ +++
French 6 4-6 4-6 5-7
Tx Vessel (mm) 2-4 1.6-3.9 1.3-3.0 1.8-4.0
Shaft length (cm) 145 145 150 149, 127
Tip length (cm) 5.9 0.7 - -
DA = Directional Atherectomy
OA = Orbital Atherectomy
LA = Laser Atherectomy
PA – Phoenix Atherectomy
