Best of ISET: Case-Based Discussion Reveals Techniques for PAD Treatment

LOS ANGELES—Cases and clinical takeaways from the International Symposium on Endovascular Therapy (ISET) were highlighted at the annual meeting of the Society for Interventional Radiology (SIR). The “Best of ISET” session focused on current techniques and outcomes for treating peripheral arterial disease and venous disease.

James Benenati, MD, began the session with background on critical limb ischemia (CLI) and how addressing CLI is an unmet need. He offered his personal opinion that all patients deserve an attempt at revascularization before amputation, but he also stated that it’s important to have an endpoint in mind before beginning to treat a patient. Along those lines, he showed a slide of a patient with gangrene and pointed out that existing methods of documentation are not adequate for measuring success. “We need improved methods of describing what CLI is, what the risks are, what the treatment options are, and how to define success,” said Dr. Benenati.

Dr. Benenati emphasized the importance of developing CLI programs. “At our own institution, many of our program directors along with others and vascular surgeons have worked hard to develop a true CLI program, which would include treatment algorithms for acute and chronic limb ischemia for both the emergency department, hospitalists, and others,” he said.

Barry Katzen, MD, next took the stage for a case-based discussion. The case involved a 78-year-old man who presented with a non-healing ulcer on the left extremity. The man had a past history of heart failure and coronary artery bypass surgery, and he was anticoagulated. At another institution, there were two attempts to recanalize the artery. He was not felt to be a candidate for surgical revascularization, and he was referred to Dr. Katzen’s team for further evaluation. The patient had gangrene, but there is not a standardized way of describing the amount of gangrene, which makes establishing and measuring treatment goals difficult, Dr. Katzen noted.

Examination revealed that the foot was salvageable clinically, depending on the anatomy. There was insufficient blood flow at the forefoot to tolerate an amputation, and there were two antegrade attempts already. The case illustrated a dilemma of when to stop and when to move forward and how, with the panel considering factors such as the feasibility of pedal access and whether there was a thrombus brewing. Ultimately, the case proceeded by approaching the dorsalis pedis above the ankle area. Dr. Katzen pointed out that this case is a good example of asking when enough is enough. “The patient had single-vessel runoff down to the ankle, do you think this would be enough for wound healing, and how would you decide?” he said.

After the panel weighed in, Dr. Katzen revealed the decision. “Based on clinical judgement and on the dorsalis pedal puncture and that we didn’t have access to go into the foot further, we stopped.” Although certain toes were not salvageable, there was no further intervention in the patient.

Constantino Peña, MD, came to the podium to discuss tibial interventions and the importance of pinpointing the correct vessel in the angiosome. He referenced a study by Richard Neville, MD, that shows that if you can get direct revascularization to the angiosome, the results are significantly better in terms of achieving complete healing. He said that tibial angioplasty is not perfect but is the tool that is available, and he cited a study that looked at outcomes of angioplasty versus bypass. “The message is, if you can get something to open, you can help limb salvage. You’re going to prevent amputation,” he said.

Dr. Peña mentioned that drug-eluting stents and drug-coated balloons are other tools. Trials of drug-coated balloons are underway in the United States and data will hopefully be available by the end of the year.

Dr. Benenati walked the audience through a case of a 62-year-old man who is a nonsmoker, works as a landscaper, and had worsening claudication over the past year, to the point that he could no longer perform his work adequately. As part of the case, Dr. Benenati emphasized the importance of exercise in making the diagnosis. “All our claudicants exercise. We always check an exercise non-invasive. It’s the single best physiologic monitor to determine if the symptoms are real and if they’re related to the disease,” he said.

The topic then shifted to aorto iliac interventions, with Ripal Gandhi, MD, presenting an overview of data followed by a case. The case involved a 68-year-old man who presented with Rutherford class 3 claudication and had post-exercise imaging showing a drop in the ABI from .53 to .28. “As Dr. Benenati mentioned, we really rely on these exercise exams. If we have a patient who has a very normal-appearing ABI at rest but has classic symptoms of aorto iliac occlusive disease, it’s critical to get the post-exercise exam,” said Dr. Gandhi. He added that the patient also had a CTA, and then he opened up the case to discussion among the panel. The panel emphasized the value of the CTA and debated whether the arm would be a good site for access. After the discussion, Dr. Gandhi said that the case proceeded with an upper extremity approach but that it could have been approached in a number of ways.

The session wrapped up with a lively discussion of approaches to the various cases, as well as post-treatment medical therapy. In particular, there was a question of the circumstances in which dual anti-platelet therapy would be used and what data support its use. Dr. Benenati ended the session by reminding people that next year’s ISET is January 26-30, 2019, and Dr. Gandhi thanked the audience for their participation in the discussion.

—Lauren LeBano

Reference

Benenati J, Katzen B, Peña C, Gandhi R, Samuels S. Best of ISET – PAD. Session at the Society of Interventional Radiology Meeting. March 20, 2018.