Low-Profile Peripheral Balloons in Infrainguinal Disease

Equipment images courtesy of Dr. J.A. Mustapha and colleagues.

Disclosure: Dr. Mustapha reports he is a consultant for Bard, Covidien, Cordis, CSI, Spectranetics, Boston Scientific, Cook, and Terumo. Dr. Davis reports he is a consultant for Bard, Boston Scientific, Volcano, Avinger, and Cordis.

The authors can be contacted via Dr. J.A. Mustapha at jihadmustapha@aol.com.

The constant evolution of technology has made a difference in medicine for many years, and we have become accustomed to expect improvements in the devices we use in our day-to-day practice. However, the extent of innovation and progress we have seen in peripheral vascular devices in the last 10 years far exceeds any expectations. Today we are able to perform revascularization procedures with excellent results thanks to new low-profile tools, despite the increasing complexity of vascular disease our patients present with. Dr. Davis has pioneered many of the currently available endovascular procedures and will take us through the value of the technological evolution for the critical limb ischemia (CLI) patient. Current low-profile devices provide safe approaches to risky procedures, from crossing chronic total occlusions to performing atherectomy, balloon angioplasty, and even stenting procedures.

J. A. Mustapha, MD: What do you like about today’s low-profile peripheral balloons?

Thomas P. Davis, MD: First, I like how low-profile balloons have evolved and improved over the last decade. Additionally, I like the positive change in the shaft, which has improved our ability to have more pushability and trackability, especially during pedal loop revascularizations.

J. Mustapha: If you had the current low-profile balloons 10 years ago, would that have increased your procedural success rate?

T. Davis: Absolutely. Ten years ago, the primary failure cause was the lack of low-profile tools.

J. Mustapha: You showed us the way with pedal loop balloon angioplasty. Before we get into more details, what should we NOT do during pedal loop percutaneous transluminal angioplasty (PTA)? Are there different pedal loops?

T. Davis: There is always a main pedal loop, which should always be the first one to attempt to open. Also, there are multiple other anterior and posterior pedal loops that also can be used for pedal revascularization, but of course, not to the extent of the primary pedal loop.

J. Mustapha: Can you always find the pedal loop?

T. Davis: Most of the time; however, there will be rare times when one can’t find the loop.

J. Mustapha: Do you have a go-to balloon for pedal loop PTA? If so, why? 

T. Davis: It always depends on the size and the length of the balloon I need, and whether that balloon is present. Otherwise, the majority of the current low-profile balloons are more than sufficient for the job.

J. Mustapha: Do you recommend transcollateral balloon angioplasty for limb salvage procedures?

T. Davis: Of course, but it depends on the size and location of the collaterals. Never balloon through the last standing collateral in patients with rest pain (Rutherford IV). Rutherford V candidates may be acceptable if you think you have a great chance of successful revascularization.

J. Mustapha: Do you recommend specialty balloons in transcollateral and pedal loop PTA?

T. Davis: No, I do not.

J. Mustapha: When do you use specialty balloons in the infragenicular arteries?

T. Davis: I always start with a non-specialty balloon and move toward specialty balloons after the conventional balloons, including high-pressure balloons, fail to yield the target lesion.

J. Mustapha: In your experience, what is the average size of the proximal, mid and distal anterior and posterior tibial arteries?

T. Davis: It depends on the demographics of the patients. For example, elderly women are sized different from young women and the same for men. Same for whether the patients have additional comorbidities such as severe calcification. Overall, I size the arteries based on the patient at the time of the procedure.

J. Mustapha: Do you have a go-to balloon for complex calcified superficial femoral artery (SFA)/popliteal lesions?

T. Davis: I tend to always start with a standard non-specialty balloon. Most of the time, they do the trick.

J. Mustapha: How do you decide when to use the Chocolate balloon (Cordis) vs the AngioSculpt balloon (Spectranetics)?

T. Davis: Lately and especially with the availability of atherectomy, scoring balloons are becoming less needed. But if I have to choose it will be based on profile, which tends to favor the Chocolate balloon. Based on getting a good scoring of a resistant lesion, I choose the Angiosculpt balloon.

J. Mustapha: Do you have a specialty balloon that you use for in-stent restenosis (ISR)?

T. Davis: Again, it depends. I tend to use AngioSculpt more for ISR, followed with Vascutrak (Bard PV), then Chocolate.

J. Mustapha: Are there any tips you can give us on how to use specialty balloons?

T. Davis: Specialty balloons should be inflated slowly and kept inflated for a minimum of two minutes to get the maximum benefits. Also, deflate slowly and don’t retract the balloon until it is completely deflated.

J. Mustapha: Does the Cutting Balloon (Boston Scientific) still have a role in the infrainguinal angioplasty arena?

T. Davis: Yes, mostly in resistant focal lesions.

J. Mustapha: Does the balloon profile matter to you for supragenicular procedures?

T. Davis: Not as much as it does for below-the-knee.

J. Mustapha: Are there any new specialty balloon on the horizon?

T. Davis: There is always something new cooking, but I am not able to discuss anything at this time.