Challenges in Treating Aortic Occlusive Disease

Vascular Disease Management spoke with Daniel Clair, MD, the Chairman of the Department of Surgery for the Palmetto Health-USC Medical Group in Columbia, SC, about challenges in treating aortic occlusive disease, upcoming clinical trials, and a case-based discussion. Dr. Clair presented on these topics at the 2020 International Symposium on Endovascular Therapy (ISET) in Hollywood, Florida.

What are some of the big-picture challenges in treating aortic occlusive disease?

Right now, we have reached the point where endovascular therapy for all aortic occlusive disease ought to be the primary mode of therapy, and aortofemoral grafting should be used in the few circumstances when minimally invasive therapies have failed. That approach is at odds with the beliefs of some surgeons who prefer that we do open bypass for proximal occlusions of the aorta near the renal arteries. 

Can you tell us about any research you have conducted that leads you to choose endovascular approaches for aortic occlusive disease?

About 10 year ago, my group reported a series¹ in which we performed minimally invasive procedures for severe lower extremity ischemia in 30 patients who initially were too sick to undergo aortic femoral grafting. There were no mortalities in that group of patients. While there was some morbidity, the rate was comparable to the morbidity seen in a group of patients receiving an open femoral graft. Based on the results of our research, I have been much more aggressive about choosing endovascular approaches for all aortic occlusive disease. Some patients will still require re-intervention, but that type of re-intervention is much less debilitating than an open aortobifemoral graft. The only time that I will use open aortofemoral grafting is when I have to treat an open aneurysm at the same time that I am treating occlusive disease.

Tell us about any upcoming clinical trials that you are anticipating.

I am excited to be the principal investigator on the LimFlow Percutaneous Deep Vein Arterialization trial, which will examine examine the efficacy of percutaneous deep vein arterialization with a purpose-built set of equipment to provide an alternative revascularization strategy for patients who do not have a standard arterial revascularization option. We have not yet enrolled our first patient, but we do have conditional FDA approval. In terms of other trials, it will be interesting to see the results of the SAVAL trial, which looks at a self-expanding medicated stent used in tibial vessels.

What changes to the field do you anticipate in the next five years?

I think we will continue to see an overall increase in endovascular approaches to aorto-occlusive disease. In terms of lower extremity occlusive disease, we will likely see continued additions to the armamentarium, such as percutaneous deep vein arterialization for patients with severe distal disease.  We need to see an improvement in overall survival in that patient population. Although we are helping those patients in terms of their legs and reducing rates of amputation, we are not reducing mortality rates, which is discouraging.

At ISET, there was a case-based discussion on aortic occlusive disease. What were you excited to share with your colleagues?

The case-based discussion at ISET is very important to attend. Physicians learn best from discussions with experts and colleagues about how to handle particular patients and difficult aspects of cases. We will also be highlighting how to carry out strategies and techniques discussed in the presentations on aortic occlusive disease. From a real-world learning standpoint, the case-based discussion is by far the best way to gain information that will impact clinical practice. Case-based discussion informs how to address specific patient situations as well as how to perform procedures on a daily basis.

The case-based session is especially helpful for learning how to better address proximally aortic occlusions from an interventional standpoint. Many physicians struggle with anxiety about the risks related to those treatments. There are ways to mitigate those risks that we discussed in case-based examples.

Reference

1. Moise MA, Alvarez-Tostado JA, Clair DG, et al. Endovascular management of chronic infrarenal aortic occlusion. J Endovasc Ther. 2009;16(1):84-92.

Complex Aortic Endografting
Business of Healthcare
Friday, January 24, 2020 4:00 PM - 5:52PM
Diplomat 1&2 (2nd Floor)

Aorto-Iliac Disease: Case Based Discussion
Business of Healthcare
Wednesday, January 22, 2020 10:35 AM-11:05 AM
Diplomat 3 (2nd Floor)