1) Endovascular treatment is the preferred strategy for revascularization below-the-knee (BTK) due to involvement of multiple lesions, but requires a thorough toolbox of devices. 2) Access selection and catheter positioning are critical, with ultrasound guidance recommended for pedal access. Wires are the most important devices, with specialty wires needed for different lesion types. 3) Other key devices include balloons matched to lesion length, stents for suboptimal angioplasty, and debulking devices to modify complex plaques, all of which require understanding their performance characteristics.

1. Mahmood Razavi, MD, FSIR
Director
Center for Clinical Trials
Vasc Interv Specialists of Orange
Planning BTK Interventions for CLI:
Approach & Toolbox Options

2. Disclosures
♦ Scientific Advisory Board
• 480 Biomedical, Abbott Vascular, Bard, Boston
Scientific, Covidien, EmboMedix, Javlin, Mercator,
Neuravi, Reflow Medical, Trivascular, Veneti, Walk
Vascular
♦ Consultant
• Cordis
♦ Grants
• NIH, WL Gore

3. Limb-Specific Treatments of CLI
♦ Pain control
♦ Management of ulcer and gangrene
• Infection control
• Local tx & pressure relief
♦ Revascularization
♦ Amputation

4. Endovascular Treatment of CLI
♦ Complex problem!
• Frequent involvement of multiple segment
♦ Typical scenario:
• Treatment of more than one vascular beds
• Application of multiple tools and technologies
♦ Outcome related to multiple anatomic &
physiologic parameters

5. Claudication
Rest pain
Tissue loss
Survival
Limb salvage
Recurrence of sx
Progression of sx
1º or 2 º Patency
Re-intervention rate
Maintenance of independence
Indication vs. Outcome
Taylor et al. J Am Col Surg. 2009;208:770
• RB-4
(5%-15%)
• RB-5
(50%-70%)
• RB-6
(10%-20%)

6. All seg
5%
3%
A/I
1%
A/I+ fem
4%
fem
30%
Fem+pop/tib
Pop/tib
55% Rueda CA et al. JVS 2008;47:995

7. Endovascular Strategy
• To the extent possible, all treatable lesions
should be treated to obtain in-line flow to
the foot & affected area
• Choice of tibial revascularization depends
on patients’ anatomy and symptoms
(angiosome concept)

8. Toolbox
Critical to Outcome
• Access
• Support catheters
• Wires
• Balloons
• Other adjunctive devices/techniques
– Atherectomy, stenting, thrombectomy, etc.

9. Access
• Antegrade vs retrograde CFA
– Pts body habitus & status of SFA in sx limb
• Pedal (when antegrade crossing fails)
– Always use ultrasound
– AT vs PT, vs high DP (peroneal not desirable)
– Rule of thumb: entry close to ankle
• Pedal loop/ transcollateral
– Alternative to above but not always possible

10. Ultrasound image of dorsalis pedis during pedal access

11. Access
• Tip of sheath/guidecath as close to knee as
possible
– Improves pushability
– Decreases contrast dose while improving image
quality
– Makes wire/cath exchanges easier/faster

13. Support Catheters
• May use balloons as
support catheter to
advance wire
• Support catheters
useful in crossing
lesions or for
exchanging wires
• Trackability, torque
control, pushability,
visibility

14. Wires: Critical to Success
• Popliteal artery: 0.035"; 0.018"; 0.014"
– True lumen passage preferred in CTOs (choose
carefully) – limited re-entry opportunity
• Tibial vessels:
– 0.014” advantageous- more options available on
this platform: balloons, atherectomy, stents,
support catheters, aspiration devices, EPDs, etc.

15. Specialty Wires
• CTO wires
– Heavier tip loads
• Finesse wires (multiple tandem lesions)
– Torque control & crossability
• Support (workhorse wires)
• Atherectomy compatible wires

16. Robust tip (hydrophylic), good torque control, good support

19. 73-Y-O male with
DM, s/p resection of
2nd
& 3rd
distal
phalanges. Now has
1st
toe osteomyelitis
Toe press= 22 mmHg

22. Balloons
• OTW preferred
– Better trackability & pushability
– Ability to change wire if needed
• Match balloon length to lesion
– Length up to 220 mm available
• Tapered balloons could be useful
Do not undersize balloons. Higher risk of failure!

26. Undersized
balloon?

29. Stents
♦ Bare stents (for suboptimal
PTA results)
♦ DES (better patency than
PTA alone)
• Longest device in U.S. 38
mm
• Limited by cost

30. Early Failures BTK
Razavi M et al J Vasc Surg in press

31. Results of Meta-Analysis
Razavi et al J Vasc Surg in press

32. Debulking Devices
• MiniHawk & RockHawk (ev3/Covedien)
• JetStream (Pathway Medical)
• DiamondBack 360 (CSI)
• Turbo Elite excimer laser (Spectranetics)
• Phoenix (Atheromed)
Enabling devices

33. • 74-year-old female with DM & right 1st toe
non-healing ulceration

39. Conclusion
• “Endo first” is the strategy of choice for
BTK revascularization
• Toolbox critical to both acute success and
improved clinical outcome
• Devices for endo-tx of CLI improving
• Thorough familiarity with their
performance characteristics necessary