Curtiss T. Stinis, M.D., F.A.C.C., F.S.C.A.I.Director, Peripheral Interventions

Director, Interventional Cardiology Fellowship Program

Scripps Clinic

La Jolla, CA

Overview of PAD:Overview of PAD: Anatomy, ConsiderationsAnatomy, Considerationsfor Treating CLI, and Case Examplesfor Treating CLI, and Case Examples

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Arteriosclerosis is a Systemic Disease

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Scope of the Problem:Polyvascular Disease

Coronaryartery

14.2%

63% of PAD patientshad polyvascular disease

N = 7013

Cerebro-vascular

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Bhatt DL, et al. Presented at: ACC Scientific Session; March 6-9, 2005; Orlando, Fla.

Peripheralartery

39.4%

Polyvasculardisease

Normal subjects

Asymptomatic PAD

100

75

Su

rviv

al

(%)

PAD: Long Term Survival

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Criqui MH et al. N Engl J Med. 1992;326:381-386.

Asymptomatic PAD

Symptomatic PAD

Severe symptomatic PAD

50

25

0 2 4 6 8 10 12

Su

rviv

al

(%)

Year

PAD is alive and well….

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Clinical Presentations of PAD

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Classification of PAD

FONTAINEStage Clinical Grade Category Clinical

I Asymptomatic 0 0 Asymptomatic

IIa Mild claudication I 1 Mild claudication

RUTHERFORD

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IIb Moderate–severe claudication I 2 Moderate claudication

I 3 Severe claudication

III Ischemic rest pain II 4 Ischemic rest pain

IV Ulceration or gangrene III 5 Minor tissue loss

IV 6 Ulceration or gangrene

Dormandy JA, Rutherfors RB J Vasc Surg 2000; 31(1): S1-S296

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Revascularization Therapy forPeripheral Arterial Disease

Intermittent Claudication

Analogy: Angina

Timing: Elective

Revascularization is only considered forsymptomatic patients who have failed

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Critical Limb Ischemia

Analogy: Acute Coronary Syndrome

Timing: Urgent!

symptomatic patients who have failedguideline-directed medical therapy(including a supervised exercise program)

Critical Limb Ischemia:A Unique and Difficult Patient Subset

•15-20% of patients with intermittent

claudication deteriorate to ischemic

rest pain/ulceration/gangrene

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rest pain/ulceration/gangrene

•Therefore, 20 million Americans

will present with critical limb

ischemia annually

J CardiovascSurg(Torino)..1989;30:50-57

Critical Limb Ischemia:Current Reality

•Shockingly primary amputations are still the mostcommon treatment for critical limb ischemia

•In 2010-2011 67% of American CLI pts had primaryamputation as initial treatment

•More shockingly 50% of primary amputations are

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•More shockingly 50% of primary amputations areperformed without angiography or even a simple ABI!!

•40% of amputees die within 2 years of amputation

•The professional nursing home care costs in the US afteran amputation have been estimated at $100,000 per year

Allie et al, Eurointerventions, May 2013

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Survival After Limb Amputation

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Revascularization for CLI:Key Requirements

• Knowledge of lower extremity arterialanatomy

• Knowledge and skill set with advanced

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• Knowledge and skill set with advancedendovascular techniques

• Prompt and effective revascularization

Key Anatomy of the Abdominal Aorta

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Key Arterial Anatomy of the Pelvis

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Key Arterial Anatomy of the Pelvis

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Internal Iliac, Lumbar,Inferior Epigastric areall Important Sourcesof Collaterals

Key Anatomy of the Femoral Region:Critical to Good Access and Closure

Anatomic

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Functional

Key Anatomy of the Femoral Region:Important to Think in 3D!

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The Pubis: a Key Structure inFemoral Access Management

PUBIS

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Access Above or Below the Pubis isAssociated with Significant Complications

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ProfundaFemorisHunter’s Canal

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SFA

The Profunda is an ImportantSource of Collaterals

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SFA Passes Posteriorly through Hunter’sCanal to become the Popliteal Artery

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The SFA & Popliteal Artery AreSubjected to Multiple Stressors

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The SFA & Popliteal ArteryExhibits Complex 3D Anatomy

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Popliteal

Anterior tibial

Posterior tibial

Geniculate popliteal

Anterior tibial artery

Hunter’s Canal

Suprageniculate popliteal

Infrageniculate popliteal

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Posterior tibial

Peroneal

Posterior tibial artery

Peroneal artery

Tibioperoneal trunk

Geniculate Branches are anImportant Source of Collaterals

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Anterior Tibial

Peroneal

To resolve ischemicrest pain or heal an

Lateral View of the Foot is Key forDefining Distal Target Vessels

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Dorsalis Pedis

Anterior Tibial

Posterior Tibial

rest pain or heal anulcer, one continuouslypatent infrapoplitealvessel to the foot isnecessary

Medial & LateralPlantar Arteries

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Surgical Treatment for CLI:Bypass Surgery

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Fundamental Principles of LowerExtremity Bypass Surgery

Requires an Adequate Conduit

Often UNAVAILABLE due to priorlower extremity bypass or previousCABG

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CABG

Requires adequate distal targetand outflow

Often UNAVAILABLE in ESRD andDiabetes

2 weeks post-op from

Femoral-Popliteal Bypass….

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Downsides of Vascular Surgery forthe Treatment of CLI

•Higher risk

•More invasive

•Cannot address runoff disease

Mismatch issues between conduit and target

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•Mismatch issues between conduit and targetvessels

•Complications of seroma, infection, chronicpain, scars, chronic edema

Endovascular Therapy:The Dominant Revascularization Strategy

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DiffuselyDiffuselyDiseasedDiseasedFemoralFemoralArteriesArteries

TotallyTotallyOccludedOccludedSegmentsSegments

2893 Lesions in 417 patients with DMand foot ulcer

The Challenge: PAD patients oftenpresent with complex multi-level

disease and long occlusions

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Scripps Clinic CLI Program:Latest Techniques and Technologies

Standard Retrograde Approach

Access to distal cap via donor vessel

Retrograde Transcollateral Approach

Access to distal cap via retrograde collaterals

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Access to distal cap via retrograde collaterals

Antegrade Transcollateral Approach

Access to distal cap through antegrade collaterals

Combined with Latest Lesion Treatment Technologies:• Drug-coated balloons• Drug-eluting stents

CART Technique:Combined Anterograde and Retrograde Tracking

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• 0.014 supportcatheter acts as asheath and supportdevice for wire

• Allows muchsmaller hole in

Pedal Access

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smaller hole inartery and allowsflow around it intofoot

• Analogous to radialaccess forcoronaryprocedures

76yo male with DMII,BKA of left leg, openand non-healingwound on bottom ofright foot for 6 months

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DSA image of the foottaken after intra-arterial verapamil

DP suitable target forretrograde access

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Direct dorsalis pedisaccess obtained ontop of foot

Pilot 200 initiallypassed retrogradeand Quickcrossadvanced

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Pilot swapped forConfienza Pro 12which successfullyadvances further intoAT

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Confienza Pro 12successfullyadvanced further intoAT

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Confienza Pro 12advanced to poplitealartery

Corsair with Fielderwire advancedantegrade into

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antegrade intopopliteal arteryocclusion

Retrograde ConfienzaPro 12 maneuveredinto vicinity of inflatedballoon

Balloon deflated andwire successfully

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wire successfullypassed into spacecreated by balloonand passedretrograde up leg intotrue lumen of SFA

Wire snared fromantegrade sheath andpulled into antegradesheath whilesimultaneouslyfeeding wire intoQuickcross at pedal

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Quickcross at pedalaccess point

Snared wireexternalized viaantegrade sheath andCorsair advancedover wire whileQuickcrosssimultaneously

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simultaneouslyretracted from pedalaccess point

Once antegradecatheter passed distalto original occlusion,retrograde wire andcatheter removed

Point pressure overDP access done for 5

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DP access done for 5minutes to achievehemostasis

New wire passed viaOTW catheter andOTW catheterexchanged for ballooncatheter and inflationperformed

Entire occludedsegmentangioplastied

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Coronary DESdeployed in proximalAT

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Popliteal arteryundergoes additionalangioplasty with DCB

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Final Results

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Wound completely healed in 6 weeks

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68yo male with DMII,previous heavysmoker, large openwound on the rightforefoot for 2 months

Total occlusion of the

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Total occlusion of thepopliteal artery, AT,and PT

AT reconstitutes atankle, but diffuselydiseased in foot

Plan for antegradetranscollateralapproach to avoidgoing through area ofopen wound on foot

Asahi Scion wire with

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Asahi Scion wire withCorsair catheter

Collateral traversedwith Scion andCorsair

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Collateral traversedwith Scion andCorsair

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Second Corsair andwire advanced fromabove into subintimalspace

Both wires are withinvessel architecture,

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vessel architecture,but neither is in truelumen

Balloon passed overantegrade wire andinflated to createlarger subintimalspace

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Balloon passed overantegrade wire andinflated to createlarger subintimalspace

Retrograde wire andCorsair successfully

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Corsair successfullypassed into newspace and up intotrue lumen of SFA

Wire snared andexternalized, OTWcatheter advancedpast occlusion andnew wire inserted

Angioplastyperformed ofoccluded poplitealartery

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Coronary DES placedat origin of peronealartery

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Zilver PTX self-expanding DESplaced acrosspopliteal occlusiondue to continuedvessel recoil despiterepeated angioplasty

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repeated angioplasty

Final Results

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Final Results

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Final Results

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Wounds healed after skin grafting and 12 weeks

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Success in CLI Treatment:It Takes a Village!

Vascular Specialists

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Wound CareSpecialists

Endocrinology

Infectious Disease Specialists

PATIENT

Thank You

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