INFRAINGUINAL

DISEASE
ENDOVASCULAR
THERAPY
DR MUHAMMAD RAHEEM
FELLOW VASCULAR SURGERY
SMBB INSTITUTE OF TRAUMA
 INTRODUCTION
• Endovascular therapy :- A key component of the multimodal
approach to manage P.A.D.
• Endovascular first depends on:-
• Clinical presentation,lesion anatomy,patient
comorbidities,autologous conduit availability.
Medical management:
• Supervised exercise .
• Impact of smoking cessation.
• Statin impact .
• ACE inbibitor impact.
• Antiplatelet therapy impact.
• Anticoagulation therapy impact.
 INTERMITENT
CLAUDICATION
Medical management:- 1-3% wit IC will progress to require amputation within 5
years.
Failure of medical management ; 1) can not modify life style.
2) No access to supervised walking programs.
3) Aggressive approach to intervention.
 Femoropopliteal segment

• It is the most common affected infrainguinal area for patients of I.C.

• Lesions of C.F.A are well served with femoral end artrectomy with patch
angioplasty.
• Endovascular therapy has become first line therapy for managing occlusions of
S.F.A extending to popliteal segment especially with segment <4cm.
• There is a sheer number of treatments availble including:
• Plain balloon angioplasty
• Bare metal stent
• Atherectomy
• Stent graft placement
• Drug coated balloons
• Drug eluting stents
 Balloon angioplasty
• In early 90s it used to be primary tool of management for the lesion in F.P.S.

• It functions to disrupt the atherosclerotic plaque by increasing the lumen

diameter.

• Dissection is key factor limiting the effectivess and durability of P.B.A and as a bail
out stenting is usually required.

• Its greatest usefulness is in patients with short segment disease with aggressive
post interventional medical management.
 Stents (balloon expandable vs self
expandable)

• Stenting since it has originated, it has evolved to be the preferred initial approach
for medium to long segment occlusions in the superficial femoral and popliteal
artery.

• Vast majority of peripheral stenting is now done with self expandable stent rather
than balloon expandable stent because B.E.Ss have tendency to recoil during
ambulation.
• Self expandable stents are nickel titanium alloys are among the most common
stents used today.

• These exert radial force and are highly resistent to compression.

• They have a spun coil that would expand to a set diameter upon warming in
heated saline.

• DURABILITY II TRIAL-self expandable stents reported primary patency in 77% of

the patients at 1 year. Most patients (83%)reported improvement in their
Rutherford classification and 55% being totally asymptomatic.
• Complete se trial- showed long term follow up of patients as low rate of
intervention at 36 months(18%) and high rate of primary patency at 72 months
(63%).

• In the vibrant trial- stent grafts were compared with B.M.S.

• Both groups had same patency but stent graft appears to affect the collaterals
more paticularly if covered at the time of placement and has higher rate of
ischemia and device failure.
• The use of self expanding stents in F.P.S should be considered first line
endovascular intervention for patients with claudication, who failed medical
therapy , and have lesions mid to long (>4cm).

• It is reasonable to consider E.V .T first but only in patients in whom distal targets
for bypass are not compromised or there is no suitable autogenous graft.
 Drug eluting stents and drug coated
balloons
• Sirocco trial: the study failed to demonstrate any difference compared with
B.M.S.

• Zilver ptx trial: it was designed to compare D.E.S with P.B.A and was found to
have higher rates of primary patency even at 5 years when compared with
P.B.A(72% vs 53%).

• Freedom from pain ulceration worsening claudication occured in nearly 90%

(D.E.S) vs 75% (P.B.A).
• D.C.Bs is based solely on use of balloons and stents coated with paclitaxel. D.C.Bs
were compared with P.B.A alone and trials showed lower rates of loss of patency
with D.C.Bs.

• Widespread use of both D.E.S and D.C.B is controversial because of increased risk
of mortality so there should be frank conversation with patient regarding the
mortality risk known balanced with patency benefits.
 Behind the knee segment
• Due to increased mechanical forces and reduced artery size it is not
recommended to place stents in this area. In addition to this, there is increased
risk of stent fracture resulting in restenosis and occlusion.
 Infrapopliteal segment
• It is unknown if claudication symptoms are durably releived by treating isolated
I.P segment. However, the risk of dissection, thrombosis of later outflow target
are tangible.
 Athrectomy
• It is meant to disrupt and debulk the plaque to improve lumen diameter.

• Directional, rotational and laser.

• It is associated with high risk of embolization reintervention and amputation.

 Chronic limb threatening ischemia
• In such patients presenting with Rutherford (4 - 6) aggressive and timely
intervention is necessary to preserve limb and functionality.

• The results of best C.L.I in conjunction with expected results of BASIL 2 (best E.V
vs vein bypass graft) and BASIL 3 (P.B.A vs stenting) 2023 should help to identify
patients best served by either open or endovascular strategies.
 Femoropopliteal segment
• Patients with C.L.T.I often have multi level disease involving both the F.P.S and below
knee segments.

• Patients undergoing femoral intervention in C.L.T.I appear to have worse outcomes even
after successful intervention.

• There is higher risk of technical failure with P.B.A in C.L.T.I patients compared with IC due
to its inability to cross S.F.A lesion or inability to re enter the lumen .

• A failed P.B.A followed by succesful bypass is associated with worse overall outcomes.

• Even with stenting 2/3 showed re stenosis.

 Drug Coated Balloons
• DEBATE- SFA TRIAL: Compared the results of DCB +Stenting vs PBA + Stenting in two
groups.

• At 12 months follow up no one undergone amputation and in 83% of DCB group

had restenosis of treated segment.

• DEBELLUM TRIAL: Restenosis at 6 month and 1 year were lower in DCB group vs
PBA but amputation and mortality were equal.

• DCBs may be suited best to improve outcomes in patients who are high risk for peri
operative events and who are relegated to E.V only approaches because of this.
 Infrapopliteal Disease
• P.B.A alone has been studied to treat I.P disease and compared with bypass.

• Showed similar results in terms of survival , amputation free survival and limb
salvage when compared with limb salvage.

• COCHRANE REVIEW: It reviewd studies thar examined PBA vs Stent.

• Initial high er patency was seen in stent group but limb salvage and amputation
rates were similar.
• Most of the tibial disease are long segment and there are no long segment stents
are available.
 Drug Coated Balloons
• In multiple studies, the results were almost same between DCBs and PBA.

• Like DES , there are technical limitations of DCBs for tibial disease as there are no
commercially available balloons in 2mm to 3mm range for tibial vessels.
 Hybrid Considerations
• Combination of both open revascularization and and endovascular techniques .

• Iliac stenting with femoral end artrectomy , femoro-femoral bypass, femoro-distal

bypass.
• Femoral endartectomy with retrograde iliac stenting.

• Fem-pop stenting can be used to move proximal anastomosis site distally for
shorter vein segment for bypass.
 SAFARI
• Subintimal arterial flossing with antegrade-retrograde intervention for the
treatment of occlusive disease that cannot be crossed with antegrade techniques
has become increasing attractive option who lack surgical option.
• Retrograde revacularization is a viable strategy for limb salvage in complex tibial
disease.