Plantar arch and below-the-ankle angioplasty who, when and how? Presentation and case examples Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Cardiovascular Center Miyazaki, Japan
Disclosure Speaker name: Tatsuya Nakama MD.... I have the following potential conflicts of interest to report: Consulting: Boston Scientific Japan, Century Medical Inc. Employment in industry: None Stockholder of a healthcare company: None Owner of a healthcare company: None Other(s): Honoraria recieved from Abbot Vascular, Asahi Intecc., Boston Scientific, COOK, Cordis Cardinal Health, Goodman, KANEKA, Lifeline, Medikit, Medtronic, Orbus Neichi, Terumo,
Our first case of BTA angioplsty
Trans-collateral approach
Final angiogram
Achievement of wound healing Nakama T, et al. EJEVS Extra, 2014; 27: e7-e9
Change Should treat Below-the-ankle our mindset
Single center registry Single-center Retrospective Trial Nakama et al, JEVT 2016; 23: 83-91
improve the rate of wound healing PAA(+) 93% Time to wound-healing PAA(-) 60% P=0.050 PAA(+): 86 days (IQR: 63-155) PAA(-): 152 days (IQR: 80-365) P=0.050 Nakama et al, JEVT 2016; 23: 83-91
Next step Multi-center Trial is necessary!
Japanese Red Cross Kyoto Daini HP, Kyoto Nagoya Kyoritsu HP, Nagoya Tokeidai Memorial HP, Sapporo Miyazaki Medical Association HP, Miyazaki Kasukabe Chuou Genera HP, Kasukabe Nakama T, et al. J Am Coll Cardiol Intv 2017; 10: 79-90
P= 0.003 59.3% 38.1% Higher Rate of wound healing 59% vs 38% Faster Time to wound healing 211days vs 365days Nakama T, et al. J Am Coll Cardiol Intv 2017; 10: 79-90
More distal revascularization is needed Improve the blood supply
problems of BTA intervention
Who? When? How?
Who? Who received the Benefit of BTA angioplasty
From the RENDEZVOUS registry Delayed wound healing score (DH-score) was evaluated Non-ambulatory Depth of wound Daily hemodialysis DH-score 0 Low-risk population (n=28) DH-score 1-2 Moderate-risk population (n=196) DH-score 3 High-risk population (n=33) Nakama T, et al. J Am Coll Cardiol Intv 2017; 10: 79-90
Decision making by DH score Low-risk population Acceptable but controversial Moderate-risk population Good indication High-risk population Too much treatment Nakama T, et al. J Am Coll Cardiol Intv 2017; 10: 79-90
When? Indication of aggressive treatment There is NO evidence about Objective & Quantitative findings
Anatomical variation BTA disease Separate Serial Serial PD (BTK to BTA disease) Separate PD (BTK and BTA disease) isolated Isolated PD (Pure BTA disease)
When BTA intervention needed? 1. Serial disease (BTK to BTA disease) Should be treated in primary session isolated 2. Separate disease (BTK & BTA disease) Staged treatment is better Serial Separate 3. Isolated disease (Pure BTA disease) Should be treated in primary session Care the Indication of intervention
How? technical problem How to guidewire cross How to open (expand) the lesion
How to cross GW Understand the complex BTA anatomy Figure of 8 (eight) shape Set up the Bi-directional approach Distal site puncture (DP) Trans-collateral approach (TCA)
There is No Distal puncture site!! Distal puncture is impossible!
Trans-collateral approach is important technique for BTA CTO revascularization
70s male, CLI (1 st toe ulcer) DM, HD, Ambulatory Previous history of FP bypass DH-score: 2 Moderate risk
Control angiogram
1 st EVT: proximal recanalization
Pedal arch was occluded
Pedal arch recanalization
2.0mm balloon pass the pedal
Whole pedal reconstruction
Final angiogram
Summary Who? Patients with moderate risk (DH score 1 or 2) When? Decided based on Lesion anatomy Objective & Quantitative finding is needed How? Bi-directional approach is important
Conclusion Pedal arch & BTA angioplasty is always challenging and included some risk Accumulation of experiences & evidences is necessary
Systemic review of below-the-ankle, inframalleolar intervention When and how? Last frontier of lower limb intervention Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Cardiovascular Center Miyazaki, Japan