BelowtheKnee Arterial Disease and the Endovascular Toolbox Kyle

Below-the-Knee Arterial Disease and the Endovascular Toolbox Kyle Reynolds, MD Vascular Surgery, PGY-5 Med. Star Washington Hospital Center and Georgetown University Hospital

Kyle Reynolds, MD I have no relevant financial relationships

Below The Knee • Lesions more commonly calcified • Smaller vessels (1. 5 mm-3. 5 mm)

Antegrade • Antegrade Femoral Access • Long 5 F or 6 Fr Sheath – Advance to popliteal artery – Gives increased mechanical advantage

Antegrade • Support Catheter – 0. 018 or 0. 014 Platform – Angled Tip vs Straight Tip • Guidewire – Hydrophillic 0. 018 or 0. 014 wire – Soft and Shapeable Tip

Retrograde • Technical Aspects – 21 gauge needle – 0. 018 wire (V-18 or Command 0. 018) – Support Catheter: CXI or Quickcross – Pass wire from retrograde across the lesion to a patent proximal arterial segment. Externalize the wire and treat from antegrade fashion.

Retrograde • Failure to cross Antegrade: 18% • Success with Retrograde: 86% • Pedal access site occlusion: 2%

Revascularization Therapies • POBA – Gold standard • DCB and DES • BTK atherectomy

Atherectomy • BTK lesions more commonly calcified • Atherectomy can reduce the likelihood of bail out stenting

Atherectomy • • Rotational Orbital Directional Laser

Directional Atherectomy • Usually lesions less than 10 cm • Not severely calcified • Sizes – Hawk. One: 2. 0 mm-7. 0 mm – Turbo. Hawk: 2. 0 mm-7. 0 mm – Silver. Hawk: 1. 5 mm-6. 5 mm

Definitive LE • 70 CLI patients with infrapopliteal disease (96 lesions total) • 1 year results – Primary patency 78% – Limb Salvage 94% – Freedom from TLR 87%

CSI Diamondback Orbital Atherectomy • Longer lesions >10 cm • Extremely Calcified Lesion

Calcium 360 RCT

Tack Endovascular system • Approved for ATK dissections • BTK device for investigational use. –. 014 wire system – Treats vessel diameters 1. 5 -4. 5 mm

Conclusion • Many different techniques and devices in your “endovascular toolbox” to revascularize below -the-knee.