Atherectomy and DCB for Popliteal Artery Disease Scott

Atherectomy and DCB for Popliteal Artery Disease Scott Kinlay, MBBS, Ph. D Cardiology and Vascular Medicine VA Boston Healthcare System

Scott Kinlay, MBBS, Ph. D I have no relevant financial relationships

Case 1: Popliteal Artery CTO • 66 yr old man with left leg claudication at 50 m • Occasional nocturnal rest pain and numbness in the left foot over the previous month • HL, HT, repaired AAA, ex-smoker • Abnormal SLP/PVR • CTA left popliteal artery CTO & no aneurysm

SLP/ PVRs PVR Above Left Knee PVR Below Left Knee

Angiography • 6 F retrograde access from right CFA

Challenges of the Popliteal Artery • Exposed to extremes of forces • Flexion, rotation, extension…. . Knee Extension Knee Flexion Kinlay S, Bhatt DL. In: Braunwald’s heart disease: 2015. Chapter 60, pp. 1347 -1364.

Popliteal Artery and Stent Kinking • Bailout stenting is not a great option, especially in claudication Edge Dissection Kink • Long-term risks of stent fracture, restenosis and thrombosis Arena FJ. JIC 2005; 17: 482

Angioplasty Alone ? Femoral-Popliteal PTA Bailout Stenting Author Schillinger 2006 Krankenberg 2007 Laird 2010 Dake 2011 Average Lesion Length PTA Group 92 mm 44. 5 mm 64. 4 mm 66. 4 mm Bailout Stenting 17/53 (32%) 12/121 (11%) 29/72 (40%) 120/238 (50%) Schillinger et al. NEJM 2006; 354: 1879 Krankenberg et al. Circulation 2007; 116: 285 Laird et al. Circ CV Interv 2010; 3: 267 Dake et al. Circ CV Interv 2011; 4: 495

Angioplasty Alone ? Femoral Popliteal Restenosis at 12 Months Angioplasty alone around a 40 -50% restenosis rate Schillinger M & Minar E. Circulation 2012; 126: 2433

Atherectomy and PTA vs PTA Alone Lower Balloon Inflation Pressure Ambler GK et al. Atherectomy in PAD. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No. : CD 006680. DOI: 10. 1002/14651858. CD 006680. pub 2

Atherectomy and PTA vs PTA Alone Less Bailout Stenting Ambler GK et al. Atherectomy in PAD. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No. : CD 006680. DOI: 10. 1002/14651858. CD 006680. pub 2

Atherectomy and PTA vs PTA Alone Similar Artery Re-occlusion at 12 Months Ambler GK et al. Atherectomy in PAD. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No. : CD 006680. DOI: 10. 1002/14651858. CD 006680. pub 2

Atherectomy and DCB? • Intuitive to combine…but… • Directional or Rotational? • Upsides – Less bailout stenting? – Less restenosis? • Downsides – Embolism – Dissection – Perforation No trials comparing atherectomy and DCB to PTA or stenting

• 7 F Ansell retrograde from right CFA • 6 g Miracle wire unsuccessful • Crossed with 0. 025” Glidewire • 0. 035” Navicross for support

• Jetstream 2. 1 mm and 3. 0 mm passes • Retrieved filter after using a Twinpass to place another 0. 014” wire

• Dilated with a 5. 0 x 80 mm Sterling balloon • Dilated with a 6. 0 x 120 mm INPACT Admiral DCB

• Popliteal artery post DCB PTA • Angio of the foot with 2 vessel runoff • 18 month follow-up doing well without claudication

Summary • The popliteal artery offers significant treatment challenges • Long-term outcomes with PTA alone or stenting are not great • Atherectomy and DCB offers the potential for better outcomes • Evidence supporting this strategy is limited