Tools of the Trade: Adjunctive Tools for Lesion Crossing in Critical Limb Ischemia

Critical limb ischemia (CLI) due to obstructive atherosclerosis causes pain and tissue damage and may result in amputation and death. Revascularization saves the limbs and lives of patients with CLI. This review addresses adjunctive tools for lesion crossing, including mechanical atherectomy, laser atherectomy, crossing devices, and luminal reentry devices. Mechanical atherectomy devices are designed to excise atheroma, often heavily calcified, thereby preparing a channel for further intervention. Mechanisms (and devices) include directional (SilverHawk™, TurboHawk™, RockHawk™), rotational (Jetstream™, Pheonix™), and orbital (Diamondback 360°™, Predator 360°™, Stealth 360°™) atherectomy. A laser atherectomy device (Turbo Elite™) vaporizes atheroma by heating tissues with ultraviolet light. Crossing devices specifically designed for chronic total occlusions either navigate a vessel's true lumen or guide a controlled subintimal course with reentry into the distal true lumen. Crossing devices include Crosser® Catheter, Wildcat™, Ocelot™, Kittycat™, TruePath™, Viance™, Frontrunner™, TOTAL across™, and PowerWire™. When a guidewire or crossing device traverses a lesion via a subintimal course, a luminal reentry device may facilitate deployment of the guidewire in the distal vessel lumen. Reentry devices include Outback LTD™, Offroad™, Pioneer Plus™, and Enteer™.

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Bailout directional atherectomy for side branch salvage following subintimal recanalization of infragenicular arteries

VASA ◽

10.1024/0301-1526/a000206 ◽

2012 ◽

Vol 41 (4) ◽

pp. 292-294

Author(s):

Airoldi ◽

Faglia ◽

Clerici ◽

Latib

Keyword(s):

Critical Limb Ischemia ◽

Popliteal Artery ◽

False Lumen ◽

Limb Ischemia ◽

Side Branch ◽

Percutaneous Angioplasty ◽

True Lumen ◽

Subintimal Angioplasty ◽

Directional Atherectomy ◽

Large Side

A 64-year old diabetic male presenting with critical limb ischemia was treated with percutaneous angioplasty for occlusion of the infragenicular popliteal artery and crural vessels. Directional atherectomy was uncommonly used in the false lumen created by following subintimal angioplasty of the infrapopliteal vessels for re-access into the true lumen. The positive clinical and angiographic results indicate that atherectomy can be considered a useful tool for rescue interventions to reopen large side branches unintentionally occluded during subintimal angioplasty.

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Endovascular Recanalization of Chronic Total Occlusions of the Native Superficial Femoral Artery After Failed Femoropopliteal Bypass in Patients with Critical Limb Ischemia.

10.21203/rs.3.rs-511684/v1 ◽

2021 ◽

Author(s):

Roberto Minici ◽

Michele Ammendola ◽

Marisa Talarico ◽

Maria Luposella ◽

Marco Minici ◽

...

Keyword(s):

Femoral Artery ◽

Critical Limb Ischemia ◽

Superficial Femoral Artery ◽

Limb Ischemia ◽

Secondary Patency ◽

Femoropopliteal Bypass ◽

Technical Success ◽

Clinical Prognosis ◽

Chronic Total Occlusions ◽

Endovascular Recanalization

Abstract Background: The femoropopliteal bypass occlusion in patients with critical limb ischemia and chronic total occlusion of the native superficial femoral artery remains a significant problem, that hardly challenges vascular surgeons and interventional radiologists. Performing a secondary femoropopliteal bypass is still considered the standard of care, although it is associated with a higher complication rate and lower patency rate in comparison with primary bypass. Advanced age, lack of a good great saphenous vein, anastomosis’ pseudoaneurysms and high surgical risks make surgical approach not always suitable. Over the past few years, angioplasty has been commonly used, with the development in endovascular technologies, to treat chronic total occlusions of the native SFA, with a good technical success rate and clinical prognosis. Hence, the idea to recanalize the native SFA chronic total occlusions, in patients with critical limb ischemia (CLI) and femoro-popliteal bypass failure, has been born, limited to those patients unfit for surgery or refusing surgical reconstruction. Data regarding long-term outcomes of this approach in femoro-popliteal bypass failure are limited to few case-series studies.Results: Technical success was achieved in 51 (94.4%) of 54 limbs. Angiographically, 77.8% of the lesions were TASC II category D, while 22.2% TASC II category C. The average length of the native SFA lesions was 26.8 cm. Clinical success, with improved Rutherford classification staging, followed each case of technical success. The median follow-up value was 5.75 years (IQR, 1.5 – 7). By Kaplan-Meier survival analysis, primary patency rates were 61% (±0.07 SE) at 1 year and 46% (±0.07 SE) at 5 years. Secondary patency rates were 93% (±0.04 SE) at 1 year and 61% (±0.07 SE) at 5 years. Limb salvage rates were 94% (±0.03 SE) at 1 year and 88% (±0.05 SE) at 5 years.Conclusions: The endovascular recanalization of chronic total occlusions (CTO) of the native superficial femoral artery (SFA) after failed femoropopliteal bypass is a safe and effective therapeutic option in patients unfit for surgery with critical limb ischemia.

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CRT-200.05 Laser Atherectomy for infrapopliteal Lesions in Patients With Critical Limb Ischemia

JACC Cardiovascular Interventions ◽

10.1016/j.jcin.2020.01.092 ◽

2020 ◽

Vol 13 (4) ◽

pp. S30-S31

Author(s):

Stefanos Giannopoulos ◽

Damianos Kokkinidis ◽

Omar Jawaid ◽

David Cantu ◽

Gagan D. Singh ◽

...

Keyword(s):

Critical Limb Ischemia ◽

Limb Ischemia ◽

Laser Atherectomy

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Magnetic Resonance Imaging Allows the Evaluation of Tissue Damage and Regeneration in a Mouse Model of Critical Limb Ischemia

PLoS ONE ◽

10.1371/journal.pone.0142111 ◽

2015 ◽

Vol 10 (11) ◽

pp. e0142111 ◽

Cited By ~ 20

Author(s):

Germana Zaccagnini ◽

Anna Palmisano ◽

Tamara Canu ◽

Biagina Maimone ◽

Francesco M. Lo Russo ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Mouse Model ◽

Critical Limb Ischemia ◽

Tissue Damage ◽

Limb Ischemia ◽

Resonance Imaging

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Endovascular recanalization of chronic total occlusions of the native superficial femoral artery after failed femoropopliteal bypass in patients with critical limb ischemia

CVIR Endovascular ◽

10.1186/s42155-021-00256-0 ◽

2021 ◽

Vol 4 (1) ◽

Author(s):

Roberto Minici ◽

Michele Ammendola ◽

Marisa Talarico ◽

Maria Luposella ◽

Marco Minici ◽

...

Keyword(s):

Femoral Artery ◽

Critical Limb Ischemia ◽

Superficial Femoral Artery ◽

Limb Ischemia ◽

Secondary Patency ◽

Femoropopliteal Bypass ◽

Technical Success ◽

Clinical Prognosis ◽

Chronic Total Occlusions ◽

Endovascular Recanalization

Abstract Background Femoropopliteal bypass occlusions are a significant issue in patients with critical limb ischemia and chronic total occlusion of the native superficial femoral artery, which challenges vascular surgeons and interventional radiologists. Performing a secondary femoropopliteal bypass is still considered the standard of care, although it is associated with a higher complication rate and lower patency rate in comparison with primary bypass. Over the past few years, angioplasty has been commonly used, with the development in endovascular technologies, to treat chronic total occlusions of the native superficial femoral artery, with a good technical success rate and clinical prognosis. The purpose of the study is to assess the outcome of endovascular recanalization of chronic total occlusions of the native superficial femoral artery, in patients unfit for surgery with critical limb ischemia after failed femoropopliteal bypass. Results A total of 54 patients were treated. 77.8 % of the conduits were PTFE grafts; the remainder were single-segment great saphenous veins. The most common clinical presentation was rest pain. Technical success was achieved in 51 (94.4 %) of 54 limbs. Angiographically, 77.8 % of the lesions were TASC II category D, while 22.2 % were TASC II category C. The average length of the native SFA lesions was 26.8 cm. Clinical success, with improved Rutherford classification staging, followed each case of technical success. The median follow-up value was 5.75 years (IQR, 1.5–7). By Kaplan-Meier survival analysis, primary patency rates were 61 % (± 0.07 SE) at 1 year and 46 % (± 0.07 SE) at 5 years. Secondary patency rates were 93 % (± 0.04 SE) at 1 year and 61 % (± 0.07 SE) at 5 years. Limb salvage rates were 94 % (± 0.03 SE) at 1 year and 88 % (± 0.05 SE) at 5 years. Conclusions The endovascular recanalization of chronic total occlusions (CTO) of the native superficial femoral artery (SFA) after a failed femoropopliteal bypass is a safe and effective therapeutic option in patients unfit for surgery with critical limb ischemia.

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l-Alanyl-Glutamine Preoperative Infusion in Patients with Critical Limb Ischemia Subjected to Distal Revascularization Reduces Tissue Damage and Protects from Oxidative Stress

Annals of Vascular Surgery ◽

10.1016/j.avsg.2010.01.005 ◽

2010 ◽

Vol 24 (4) ◽

pp. 461-467 ◽

Cited By ~ 26

Author(s):

Wellington Forte Alves ◽

Erika Elisa Aguiar ◽

Sergio Botelho Guimarães ◽

Antonio Ribeiro da Silva Filho ◽

Petrúcia Maria Antero Pinheiro ◽

...

Keyword(s):

Oxidative Stress ◽

Critical Limb Ischemia ◽

Tissue Damage ◽

Limb Ischemia

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REDUCED AMPUTATION WITH SUCCESSFUL RECANALIZATION OF INFRAPOPLITEAL CHRONIC TOTAL OCCLUSIONS IN CRITICAL LIMB ISCHEMIA

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(13)62080-x ◽

2013 ◽

Vol 61 (10) ◽

pp. E2080

Author(s):

Gagan Deep Singh ◽

Ehrin Armstrong ◽

Usman Javed ◽

Khung Yeo ◽

Satinder Singh ◽

...

Keyword(s):

Critical Limb Ischemia ◽

Limb Ischemia ◽

Chronic Total Occlusions

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Midterm Outcomes After Infrapopliteal Interventions in Patients With Critical Limb Ischemia Based on the TASC II Classification of Below-the-Knee Arteries

Journal of Endovascular Therapy ◽

10.1177/1526602817704643 ◽

2017 ◽

Vol 24 (3) ◽

pp. 321-330 ◽

Cited By ~ 11

Author(s):

Gagan D. Singh ◽

Ellen K. Brinza ◽

Justin Hildebrand ◽

Stephen W. Waldo ◽

T. Raymond Foley ◽

...

Keyword(s):

Critical Limb Ischemia ◽

Velocity Ratio ◽

Peak Systolic Velocity ◽

Duplex Ultrasound ◽

Limb Ischemia ◽

Vessel Diameter ◽

Primary Patency ◽

Tissue Loss ◽

Success Rates ◽

Chronic Total Occlusions

Purpose: To analyze the relationship between the new TransAtlantic Inter-Society Consensus (TASC II) infrapopliteal classification and limb outcomes among patients with critical limb ischemia (CLI). Methods: A single-center retrospective study was performed on 166 consecutive CLI patients (mean age 71 years; 113 men) undergoing endovascular treatment of 244 infrapopliteal lesions from 2006 to 2013. Patient, procedural, angiographic, and limb outcomes were compared for the new TASC A/B vs C/D classification for infrapopliteal lesions. Binary restenosis was determined by a peak systolic velocity ratio >2.0 by duplex ultrasound on follow-up at 1, 3, 6, and 12 months. Results: Seventy-two (43.4%) patients had TASC A/B lesions, while 94 (56.6%) had TASC C/D patterns of infrapopliteal disease. Baseline demographics and tissue loss (93% vs 94%, p=0.59) were similar between the groups. TASC A/B lesions were shorter (53±35 vs 170±83 mm, p<0.001), less severely stenosed (77%±24% vs 93%±14%, p<0.001), had a larger target vessel diameter (2.9±0.5 vs 2.6±0.5 mm, p<0.001), and were less frequently chronic total occlusions (24% vs 64%, p<0.001) compared with the TASC C/D group. Three-year freedom from both amputation (85% vs 67%, p=0.02) and major adverse limb events (79% vs 61%, p=0.02) were significantly higher in the TASC A/B group. Technical success rates (95% vs 80%, p<0.001) and 1-year primary patency (58% vs 51%, p=0.04) were higher in the A/B group. Overall 3-year survival was similar between the groups (96% A/B vs 88% C/D, p=0.2). Conclusion: TASC C/D infrapopliteal lesions are associated with higher amputation and major adverse limb events rates and lower primary patency compared with TASC A/B infrapopliteal lesions. Further studies are needed to assess the association between TASC C/D infrapopliteal lesions and clinical outcomes in patients with CLI.

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