International Experience Offers Insights Into CLI Treatment: Sharing the Leipzig Interventional Course (LINC) for the Endovascular Specialist

Disclosures: Dr. Scheinert reports he is on the advisory board or is a consultant for Abbott, Biotronik, Boston Scientific, Cook Medical, Cordis, CR Bard, Gardia Medical, Medtronic/Covidien, TriReme Medical, Trivascular, and Upstream Peripheral Technologies.

Dr. J.A. Mustapha can be contacted at jihad.mustapha@metrogr.org.

LINC is viewed as one of the largest and most comprehensive peripheral meetings in the world. This reputation is rightfully gained, as LINC has provided tremendous value over the years to physicians’ daily practice. It was from LINC that physicians throughout the globe learned many techniques that we use today, such as crossing long chronic total occlusion (CTO) lesions, performing complicated fenestrated abdominal aortic aneurysm (AAA) repairs, and performing carotid stenting. The contribution of knowledge from LINC continues. This year is yet another big year for LINC, where technological advances coupled with new technical skills for the attendees to learn and take back to their practices will be featured. A unique feature of LINC is its amount of education on global peripheral clinical trial data, which gives the attendee a robust knowledge of the past, the present, and a glimpse into the future of peripheral therapies. The founders of LINC have shown great leadership in selecting the most contemporary topics that bring great value to the attendees. I am honored at the chance to interview LINC’s Course Director, Professor Dierk Scheinert, MD. Professor Scheinert is Head of the Department of Medicine, Angiology and Cardiology at Park-Krankenhaus Leipzig and Head of the Department of Angiology at the University of Leipzig, Heart Center, Germany. 

J.A. Mustapha, MD: Do you foresee a new metal technology as an answer for creating stents that can accommodate the hostile tibio-pedal vessel environment?

Professor Dierk Scheinert, MD: The infrapopliteal vascular bed is frequently referred to as a balloon angioplasty area, which is likely to be correct considering the currently available armamentarium. However, this is not because results of angioplasty are so great — in fact, they are not great at all, with a very high restenosis rate. It is rather because this vessel area is frequently affected by long segment disease and specifically in this environment, other technologies such as stents have failed to improve results. The only exceptions at the moment are the drug-eluting stents, but the length of devices is a major limitation. From my perspective it is unlikely that we will see those devices, which are predominantly balloon-expandable stents, become available in longer lengths — so it is likely metallic stents will not be the game changer in critical limb ischemia (CLI) patients with tibial disease.

Dr. Mustapha: Can bioabsorbable stents serve as a bridge for the Rutherford Class 5 and 6 patients who need a high-pressure perfusion for 6-12 months to insure either partial or complete wound healing?

Dr. Scheinert: I think the concept of bioabsorbable stents to provide a temporary scaffold to avoid vessel recoil is very appealing and the coronary data with drug-coated bioabsorbable scaffolds are encouraging. Again, it will be critical to develop scaffolds with longer lengths to make a meaningful contribution to our ability to treat complex below-the-knee (BTK) disease, as it is frequently seen in CLI.

Dr. Mustapha: How important is acute luminal gain? Do you believe we should gear our work toward obtaining a reasonable acute luminal gain that will allow a physiologically functional perfusion for the Rutherford Class 5 and 6 patients?

Dr. Scheinert: Acute and subacute recoil of the vessel wall is a major contributor to the high early re-obstruction rate frequently seen in long-segment BTK disease. Particularly in occlusive lesions with significant plaque load and in calcified lesions, we need improved strategies to increase luminal gain. This is important to guarantee an efficient initial blood flow to the ischemic limb as well as to provide an optimal starting point for the vessel wall to remodel.

Dr. Mustapha: We talk a great deal about tibial disease. Is there any new technology to address and help the pedal circulation, especially the plantar arteries to insure longer patency in critical limb ischemia (CLI)?

Dr. Scheinert: One of the key challenges in BTK interventions is the high percentage of calcified lesions, which makes it difficult to obtain a sufficient luminal gain. While there is no proven technology to deal with this problem, the concept of atherectomy may be of particular value in this vascular bed. In addition, new technologies such as the Shockwave approach (Shockwave Medical, Inc.) to disrupt calcified plaque by ultrasound energy may be of great interest in the future. Personally, I am still convinced that some sort of drug elution is going to be critical to improve long-term durability of BTK procedures. Having said that, I am excitedly waiting to see the results of ongoing randomized clinical trials with dedicated drug-coated balloons (DCB) such as the Lutonix BTK trial. Alternatively, other modes of drug-delivery such as the Mercator microinfusion technology (Mercator MedSystems) may be of great potential interest and we are about to start a pilot study with dexamethasone infusion in BTK arteries.

Dr. Mustapha: In the U.S., we currently see a trend of physicians using atherectomy followed by plain balloon angioplasty, followed with a drug-coated balloon, and occasionally bail-out stenting during revascularization of the superficial femoral artery (SFA)/popliteal segments. Do you have any recommendation that would help get the same functional outcome without such a high-cost approach?

Dr. Scheinert: As mentioned above, the concept of atherectomy followed by DCB may be a great concept to optimize acute luminal gain and limit the need of stenting prior to DCB-based drug delivery to prevent restenosis. Besides the fact that this approach has so far not been validated with appropriate clinical trials, the cost of such combined procedures remains a concern. I believe that stenting with drug-eluting stents or high radial force stents remains a viable option, particularly for lesions that do not respond well to balloon angioplasty, including calcified lesions and long segment occlusions. In these scenarios, stenting provides a straightforward and cost-effective solution. 

Dr. Mustapha: What clinical trial updates are being highlighted at LINC this year?

Dr. Scheinert: I think this year’s focus will be very much on long-term durability of different technologies. This will include 2-year updates on major DCB trials as well as long-term data on drug-eluting and other stents. 

Dr. Mustapha: You feature many new techniques in your live cases at LINC.  What interesting techniques are being highlighted this year?

Dr. Scheinert: The focus at LINC has always been on patient-specific treatment algorithms and pioneering techniques in advanced disease states rather than on isolated new techniques and devices. As such, we are going to continue to highlight the latest techniques in CLI situations such as retrograde CTO crossing in tibial, pedal, and femoropopliteal vessels. However, there is also a huge interest in new areas like venous interventions and we are going to dedicate more than one day of our program to these new, exciting developments. Finally, the latest techniques and controversial issues in endovascular aortic repair remain a traditional focus of interest, particularly for the many vascular surgeons who attend LINC every year.

Dr. Mustapha: The faculty-attendee interaction at LINC has always been reported to be extremely positive. How do you think your faculty maintains this interaction with the incredible growth of the meeting over the years?

Dr. Scheinert: First of all, I think the live case-based format is a very practical way to discuss the latest innovations and different approaches on a patient-specific basis. For everybody in the audience and on the panel, the clinical situation under discussion becomes very clear, which naturally stimulates interaction and an exchange of positions. In addition, we are trying to introduce specific formats and lecture theaters such as the roundtable discussion forums that are dedicated to interactive sessions. This year, we will add another small size theater with very informal seating to enhance interaction during presentations of challenging cases and complications. 

Dr. Mustapha: What can you share with the U.S. physicians about new and exciting events this year at LINC 2016?

Dr. Scheinert: In general, LINC will continue the successful concept of previous years in terms of style and content, with live case-based sessions as a core element of the entire course, covering all aspects of endovascular interventions. With this concept, LINC has evolved as a worldwide leader in endovascular education, with many partnerships and local activities taking place throughout the year in various geographies. For LINC 2016, it is one of our objectives to further enhance global input through live transmissions from centers around the world and by featuring even more international speakers to highlight important developments, special techniques, and talents from around the globe. n