All CLI Patients Have Complex Lesions: Does Complex Mean the Same for All the Operators?

“I hope and I think that complex lesion means the same to all operators,” said Dr. Luis Mariano Palena, MD, director of endovascular surgery at Maria Cecilia Hospital in Cotignola, Italy.

During an AMP Virtual 2020 session, Dr. Palena explained that there are different lesion definition and classification schemes that help facilitate understanding between operators.  

Personally, he “still really likes” the PARC lesion and vessel characteristics and definitions and he uses them in his personal database. But there are also some newer classifications from the Global Limb Anatomic Staging System (GLASS) that help interventionalists categorize the amounts of stenosis, occlusion, calcification, etc, in both the superficial femoral and popliteal arteries, as well as below the ankle (BTA). [see Slide 3]

Complex lesions, he said, can be divided as complex for crossing and complex for treatment. The first refers to long, calcified chronic total occlusions in small arteries, meaning below-the-knee and below-the-ankle. Complex to treat refers mostly to calcification that makes passing a balloon or any device difficult.

“Orbital atherectomy could help in most of these patients, and for sure even when we are able to cross with a balloon, recoiling after subintimal crossing is the most difficult situation to manage,” he told attendees.

Dr. Palena then described a case where he did just that. A 78-year-old male with diabetes, dyslipidemia, hypertension, carotid disease, and bilateral peripheral artery disease (PAD). He had left CLI, Rutherford 6, with wound, ischemia, and foot infection 2,3,1, and gangrene of the 5^th toe.

Subintimal crossing allowed for revascularization of the foot to the arch, but a subsequent full dissection in the popliteal artery necessitated stenting of a long segment. 

“So again, complex means difficult to cross and difficulty to dilate, open, and treat these arteries,” he said, and calcium is the key factor.

The presence of calcium creates the difficulties in crossing and treating, but “new devices support us in this fight against calcium,” said Dr. Palena. But even with advanced technologies—stents, shockwave, and atherectomy—“we know it is really difficult to obtain long-term patency.”