Advanced age,
diabetes mellitus
and renal
disease have all
been associated
with an
increased need
for advanced
endovascular
techniques
beyond balloon
angioplasty and
stent placement
in such patients
tomography revealed multiple calcium fractures,
enabling area gain for the delivery and expansion
of DES as the mechanism of action. This
technique is available for both coronary and
peripheral vessels.
Complex and calcified peripheral lesions
Due to recent technological advances a minimally
invasive endovascular approach is in the
meanwhiles widely accepted for the treatment of
symptomatic patients with PAD. Commonly used
techniques include plain balloon angioplasty, DCB
angioplasty, bare metal stents and drug-eluting
stents. All these devices have been successfully
used to treat claudication symptoms and have
achieved limb salvage in CLI patients. 6,7
Endovascular approaches, however, may be
compromised by severe calcification. Calcification
may be the reason for a poor primary outcome
due to early recoil or extensive flow-limiting
dissections after high-pressure angioplasty. 8 Such
mechanical effects increase the probability of the
need for bailout stent placement, which even
with modern dedicated stent devices is associated
suboptimal long-term patency, especially in
moving vessel zones. 9 With the use of
percutaneous plaque modification and debulking
techniques based on atherectomy however, such
calcified lesions can be tackled more easily after
removal or fragmentation of atherosclerotic
plaque. More homogeneous balloon expansion at
lower pressures can be achieved in this way,
which reduces barotrauma while facilitating
better drug delivery to the vessel wall during DCB
angioplasty, and in many cases obviating the need
for stent placement. Some of the techniques
available for wire passage with CTO lesions, as
well as devices available for debulking and lesion
8
HHE 2019 | hospitalhealthcare.com
preparation in heavily calcified peripheral
arteries, are described below.
Techniques for lesion crossing
Similar to coronary CTO, methods for facilitating
crossing of peripheral CTO, include the use of
support catheters and the puncture of the distal
superficial artery, crural or pedal arteries. Such
distal puncture techniques may more easily
facilitate passage of the occlusive lesion, because
like with coronary CTO the distal cap is usually
less calcified and therefor easier to penetrate
compared to the proximal cap of the occlusive
lesion. 10
Scoring balloons
Like in coronary arteries, scoring balloons can be
used in moderately to heavily calcified peripheral
lesions, facilitating improved lesion preparation.
In this regard, data from the Heidelberg PANTHER
registry indicate that treatment of calcified
femoropopliteal lesions with the AngioSculpt TM
scoring balloon is safe and is associated with a
high technical success rate and a primary patency
rate of 81.2% at 12 months of follow-up. 11
Directional atherectomy
With directional atherectomy, carbide rotating
cutter blades are used to cut and remove
atherosclerotic tissue. As implied by the name
of this technique, the atherectomy device can be
guided to the target lesion and rotated in the
preferred direction. Thus, directional atherectomy
is an optimal technique for the treatment of
eccentric lesions. The resected tissue is collected
in a nose cone, which must be repeatedly emptied
when several passages are necessary. Because no
aspiration mechanism is involved, the use of