Updates on PAD and CLI

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Submitted on Fri, 07/21/2017 - 11:21

by Frank J. Criado, MD, FACS, FSVM

Continuing with the VDM Blog Post series on take-home messages and updates from Charing Cross 2017, here is a short summation of comment-worthy presentations on peripheral arterial disease (PAD) and critical limb ischemia (CLI).

The first session addressed the question of “whether to intervene.” In her talk about assessing PAD, Mirjami Laivuori (Helsinki, Finland) commented that the ankle-brachial index (ABI) “was the most important tool” in screening for PAD. She noted that an ABI of <0.9 was associated with an increased risk of cardiovascular disease but added that the tool was “prone to errors.” This is because many patients present with mediasclerosis of the ankle arteries, whereby the ABI can be falsely high making the ABI measurement unreliable. Toe pressures can be measured alongside the ABI non-invasively. Mediasclerosis is minimal in the digital arteries and, therefore, falsely high results are distinctly unusual.

Fabrizio Fanelli (Rome, Italy) looked at patients with established PAD in his presentation “Algorithm of Care: How Evidence Has Changed My Current Treatment Practices.” He commented that treatment has become “more and more complicated” because of the number of devices now available. He explained that physicians had to determine the most suitable treatment for a lesion, adding that drug-coated balloons (DCB) had “great efficacy” for some lesions but were less effective for others (such as in heavily calcified lesions).

Focusing on patients with CLI, Barry Katzen (Miami, USA) noted that there were “patients in whom multiple procedures and technologies fail.” He added, “It was important for operators to understand when a cycle of failure is developing and when, perhaps, amputation may be the best solution for a patient.”

The following session specifically looked at CLI and diabetes, with Gunnar Tepe (Rosenheim, Germany) reviewing the available evidence for the use of DCB angioplasty in diabetic patients and in women. He noted that beneficial DCB treatment has been demonstrated in these historically challenging subgroups, but he cautioned that each DCB must be evaluated on the merits of its own evidence.

In a subsequent session on managing below-the-knee lesions, Eugenio Stabile (Salerno, Italy) presented data from two registry studies for a next-generation DCB (Safepax, Cardionovum) in the superficial femoral artery (SFA) and in below-the-knee lesions. He shared that the SFA data were comparable with those from similar registries, even in the presence of increasing clinical and anatomical complexity. The registry results for Safepax in below-the-knee lesions have shown the device to be safe and effective, but these are early and somewhat preliminary results and further evidence must be awaited.

Klaus Amendt (from Mannheim, Germany), in a session on stenting, spoke about the LOCOMOTIVE registry. This registry explored the use of a multiple stent delivery system (VascuFlex Multi-LOC; B. Braun) to treat de novo and restenotic lesions. According to Amendt, the first clinical experience (at 6 months) suggests that the system is safe and effective in patients with PAD in the femoropopliteal arteries.

In the final session of the day, which reviewed the role of bypass grafting, Yann Goueffic (Nantes, France) gave the presentation “Follow-up of Patients Treated By Prosthetic Bypass of the Lower Limb: Cost Model Evaluation.” He said that registry data for the GORE PROPATEN vascular graft in below-the-knee lesions showed that the graft was associated with a high patency rate at 2 years. However, he added, “Level-1 clinical evidence is still lacking for below-the-knee PROPATEN bypasses in critical limb ischemia patients.”