Cath Lab Digest

To continue on the SFA trail, I would like to ask: How many of us would be willing to randomize a patient to “optimal” balloon angioplasty in a head-to-head comparison with other devices for a lesion length of up to 20 cm? Although the answer for many is unequivocally, “never”, many others may suggest that a “coin-flip” approach with an endoprosthesis (stent) is not much better. I don’t know the answer to the question, but I need to get an idea about where we as “plumbers” with the “best” interest of our patients at heart fall on the issue.

Clearly, the 1-year, and many times, 2-year data, are less than robust for our patients, thereby requiring a second, and often multiple, subsequent procedures. I know this from my own practice, but also because we all have seen many patients from other operators come for a second opinion who should have had surgery in lieu of “another” procedure to make the leg better and for it to be “cured”. That argument is very short-sighted in this current market of limited resources. To be sure, an opportunity to avoid any surgical intervention and allow that “trump” card to be played at a later date is still my preferred approach to many, if not all, patients initially. However, there does come a time when, faced with the reality of the problem, an alternative approach — whether surgical or other — must be addressed.

I am sure this will engender some real feelings and arguments, but if we look at the data pragmatically, we cannot in good conscience state that the endovascular approach is currently at such a strong level of evidence to state that we “know” the answer unequivocally. Thus, my initial question. Without a doubt, new stent designs may change the landscape, and many of us look forward to the presentation of these data as game-changers. I hope that future trials will be “head-to-head” in a “real-world” population so that we can fully discuss with our patients the best approach, benefits and risks with any lower-extremity revascularization procedure. However, in the short term, how many of us would be willing to randomize real patients to these lengthy lesions and only afford an angioplasty result?

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Dr. Garcia received his B.A. and M.D. degrees from the University of Arizona. He was an Intern and Resident at Parkland Memorial Hospital, University of Texas at Southwestern in Dallas, Texas. He received his training in Cardiology at the University of Iowa Hospitals and Clinics in Iowa City, Iowa, and as an interventional cardiologist at the Beth Israel Deaconess Medical Center, Harvard Medical School. Further, he received his peripheral vascular training at St. Elizabeth’s Medical Center, Tuft’s University, Boston, Massachusetts. He then served as the Chief of Vascular Medicine and Peripheral Vascular Interventions for the Florida Heart Group in Orlando, Florida. Dr. Garcia returned to Harvard’s Beth Israel Hospital as a full-time interventional cardiologist and Director of the Peripheral Cardiovascular Program and Peripheral Interventions at the Beth Israel Deaconess Medical Center as well as the Director of the Interventional Fellowship Program. This program developed into one of the busiest in the city of Boston, performing over 600 peripheral procedures per year.

Dr. Garcia has now returned to St. Elizabeth’s Medical Center as Chief of the Section of Interventional Cardiology and as Associate Director of the Vascular Medicine Program. Dr. Garcia’s work has largely focused on arterial occlusion-reperfusion models and the efficacy of therapeutic modalities or interventions with regard to free radical generation or endovascular stenting outcomes. Dr. Garcia continues his research interests in a wide variety of studies including acute MI studies, unstable angina studies, interventional trials, peripheral interventional trials, angiogenesis trials, imaging modality studies, and numerous device trials for both the coronary and peripheral circulations. His work has been presented in numerous manuscripts, abstracts, textbooks and textbook chapters.