Tools and options for recanalisation of long-femoro-popliteal segments Pr E Ducasse Unit of Vascular Surgery University of Bordeaux ESVB 2011-may 14th E Ducasse, G Sassoust, D Midy
THE ACCESS!! Retrograde / antegrade!! We consider only percut. approach
STRATEGIE!! 1 the importance to stent the SFA!! 2 to improve the ostium!! 3 to improve the technical success
1 / SFA long-segment Yoshio Sasaki et al.heart Vessels (2008)
2 / SFA Failure!! Primary stenting Versus PTA +/- stent!! Not yet disputed!! Decrease of immediate failure!! increase effectiveness in FU!! Since SIROCCO 2 Mean Lesion Length (cm) 0 5 10 15 4.5 6.5 8.4 10.0 12.0 FAST RESILIENT ASTRON ZILVER ABSOLUTE
FAST Trial Baseline Characteristics 0 5 10 15 FAST Trial Baseline Characteristics Mean Lesion Length (cm) "! n=244, 11 centers, primary endpoint : restenosis @ 12 M. "! PTA (n=121) vs. primary stenting (n=123) "! Rutherford stages 2 to 5 "! de-novo lesions "! mean lesion length 4.5 cm (range 1 to 10cm) "! 1/4 chronic total occlusions "! Luminexx nitinol stent (Bard) Krankenberg H et al. Circulation. 2007;116:285-292
FAST Trial Baseline Characteristics No significant differences for any patient / lesion subgroups.
RESILIENT Trial Baseline characteristics 0 5 10 15 Mean Lesion Length (cm)!! n=206, 24 centers, endpoints TLR and TVR @ 6 and 12 M.!! PTA (n=72) vs. primary stenting (n=134)!! Rutherford stages 1 to 3!! mean lesion length 6.5 cm (range <15cm)!! 1/5 chronic total occlusions!! Life Stent (Edwards - Bard) Katzen B et al. ISET 2008
RESILIENT Trial Baseline characteristics
ASTRON Trial Baseline characteristics 0 5 10 15 Mean Lesion Length (cm)!! n=73, restenosis @ 12 M.!! PTA / optional stenting (n=39) vs. primary stenting (n=34)!! Rutherford stages 2 to 5!! de-novo and restenotic lesions!! mean treated length 8.4 cm (range 3 to 25cm)!! 1/3 chronic total occlusions!! Devices: Astron Stent (Biotronik) Schillinger M et al., EuroPCR 2008
ASTRON Trial Baseline characteristics Binary Restenosis (%) 100 80 60 40 20 0 P=0.033 P=0.005 P=0.006 P=0.028 18.9% 2.9% 55.6% 21.9% 50.0% 18.2% 61.1% 34.4% 7/37 1/34 20/36 7/32 18/36 6/33 22/36 11/32 3 Months 6 Months 6 Months 12 Months DUS DUS CTA DUS PTA plus optional stenting Primary stenting
ASTRON Trial Baseline characteristics In patients with a mean treated length around 8 cm, primary stenting using the Astron Nitinol Stent improved morphological outcome compared to PTA with optional stenting.
ABSOLUTE Trial Baseline Characteristics 0 5 10 15 Mean Lesion Length (cm)!! n=104, 1 center (vienna Study), endpooint : restenosis @ 6 M.!! PTA plus optional stenting (n=53) vs. primary stenting (n=51)!! Rutherford stages 2 to 5!! de-novo and restenotic lesions!! mean treated length 12.0 cm (range 3 to 33cm)!! 1/3 chronic total occlusions!! Devices: Dynalink / Absolute Stents (Abbott Vascular) Schillinger M et al. N Engl J Med. 2006;354:1879-1888
ABSOLUTE Trial Baseline Characteristics 55% 31%
ABSOLUTE Trial Baseline Characteristics!! Patients in the primary stent group showed a trend toward better walking capacity on the treadmill [302 m (IQR, 99 to 700) versus 196 m (IQR, 77 to 355); P=0.12] and better ankle brachial index values [0.88 (SD, 0.18) versus 0.78 (SD, 0.17); P=0.09].
ABSOLUTE Trial Baseline Characteristics!! At 2 years, primary stenting with self-expanding nitinol stents for the treatment of SFA obstructions yields a sustained morphological benefit and a trend toward clinical benefit compared with balloon angioplasty with optional stenting.
In more!! ZILVER PTX study..!!251 patients PTA Vs 247 Pt. ZILVER PTX!!86.6% event-free survival Vs 77.6% @ 24 M!!74.8% primary patency Vs 57.8% @ 24 M!! Many others, ex: Dick P, Schillinger M et al. Balloon angioplasty versus stenting with nitinol stents in intermediate length superficial femoral artery lesions. Cath Cardio Int 74; 2009: 1090-5.
SFA STENT Failure!! Failure of implanted material??!! Clinical implication?
SFA STENT Failure SFA stent fracture rates Data from randomised trials SIROCCO I SIROCCO II ABSOLUTE FAST RESILIENT 6 months 19% 9% 1.5% 2.2% 12 months 31% 11% 1.5% 12% 2.9% Length 85 mm 82 mm 124 mm 45mm 65mm Factors that determine fracture rates: Length of the lesion Type of stent
In vitro fatigue testing of SFA stents Explanation for outcomes of randomized trials? STENT THE SFA, BUT USE THE DEDICATED STENT Commercially available stents exhibit a variable ability to withstand chronic deformation in vitro, and their response is highly dependent on the type of deformation applied. Nikanorov A, et al. J Vasc Surg 2008
Ostium management After recanalisation and/or dilatation of the ostium:!! Systematic stenting using BES (very short!!)!!
SFA technical failure!! In most cases, no problem for the recanalisation,!! The most difficult (and also dangerous (for the patient )) moment is the reentry In case of difficulties use all techniques
SFA technical failure!! SFA RETROGRADE!! Direct popliteal puncture!!but patient in ventral position!!puncture most often requires US support!! Direct SFA puncture!!very easy in the distal part
SFA retrograde!! Direct puncture!! Retrograde recanalisation!!iliac angioplasty + stent!!direct antegrade CFA puncture wire capture!!on catheter wire reverse!!distal recanalisation / reentry
SFA technical failure Retrograde + antegrade inflation : Intimal breakage = the «!rendez-vous!» technique
SFA technical failure!!retrograde inflation + antegrade perforation
SFA technical failure!! Example, 72 Y. male CLI status
Push the limits
Push the limits
Push the limits
Push the limits
Push the limits
Push the limits
Push the limits
Push the limits
Push the limits
SFA Failure!! with a good technique.and dedicated material : everything is possible