HHE Cardiovascular 2019 | Page 8

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