Strategies to Reduce Embolization in Endovascular Revascularization

I just finished an intervention on a subtotally, heavily calcified superficial femoral artery (SFA), with the use of an embolic protection device. The SFA was had the appearance of “popcorn” calcifications — densely calcified, with an eccentric true lumen. I performed the intervention in a lab that has previously not done any significant amount of peripheral work and definitely not any complex SFA interventions. After the diagnostic angiogram, I thought that the embolic risk was high and such an event would not be well tolerated by the patient nor by this lab. Fortunately, an embolic protection filter was available. At the end of the case, there was a moderate amount of debris captured by the filter and I was happy to have used the device.

We now have available balloons that are specifically designed to prevent distal embolization ( as well as a variety of embolic protection devices. Although the incidence of clinically significant peripheral embolization during endovascular revascularization is thought to be low, it can be devastating. It has become my practice — for virtually all cases — to utilize devices to reduce embolization. Although there is much to be learned about which cases are the highest risk for embolization, I would like to hear from other endovascular specialists about their experience with strategies to reduce embolization during endovascular revascularization.

Robert S. Dieter, MD RVT


Dr. Dieter is an interventional cardiologist and vascular medicine specialist. He has completed advanced fellowship in Vascular Medicine and Peripheral Vascular Interventions at Georgetown University/Washington Hospital Center in Washington, D.C.

With a patient care emphasis in Vascular Medicine, he specializes in the management of patients with complex vascular diseases. He manages patients with stroke, TIA, and those at risk for stroke, particularly those with carotid artery blockages requiring angioplasty/stenting or those with PFO. He also specializes in renal artery stenosis. In fact, Dr. Dieter has published on new and potentially safer methods to treat blockages in the renal arteries. Dr. Dieter performs minimally invasive abdominal aortic aneurysm repair (endograft). Dr. Dieter has extensive training in the management of patients with claudication, as well as those with critical limb ischemia and non-healing ulcers — particularly in patients with diabetes. Furthermore, Dr. Dieter is board-certified in interventional cardiology and specializes in angioplasty, stenting and myocardial infarction treatment. Although Dr. Dieter is a vascular medicine specialist and interventional cardiologist, his underlying philosophy is the prevention of disease. He completed an advanced fellowship with renowned experts in Preventive Cardiology. Dr. Dieter actively treats patients with complex dyslipidemias.

Dr. Dieter graduated Alpha Omega Alpha from medical school. He has written over 100 journal articles, eight book chapters, is on the editorial board of several medical journals, and lectures internationally on cardiovascular diseases. He is the editor of two textbooks on vascular disease.

Dr. Nanjundappa completed medical graduation in Adichunchanagiri Institute of Medical Sciences, India. He is specialist in Internal Medicine and Cardiology. He has certification in Cardiovascular Disease, Internal Medicine and Interventional Cardiology. He has been resident and fellow at Seton Hall University, Shands Hospital, Washington Hospital Center. He has also served as Director of Vascular Medicine and Peripheral Interventions at Pitt County Memorial Hospital, Greenville, North Carolina. At present, he is working as an Associate Professor of Medicine and General Surgery at West Virginia University School of Medicine, Charleston, West Virginia. He is a Board-Certified Cardiologist and Interventionalist.

Recipient of numerous teaching, research awards and grants, Dr. Nanjundappa is author of more than 60 peer-review journal articles and text book chapters. A frequent national and international guest lecturer, he serves on the editorial boards of eight journals including: Angiology; Interventional Cardiology (Associate Editor); and The Internet Journal of Endovascular Medicine (Chief Medical Editor). Dr. Nanjundappa has participated in several important Clinical Trials including: CLEVER, CORAL, CAPTURE, CREST, HERCULES, MOBILITY, and CHOICES.

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