Infrapopliteal Intervention

By John R. Laird, Jr, MD, Chief Medical Editor

In recent years, there has been increasing enthusiasm for endovascular approaches to the treatment of infrapopliteal arterial disease. There are many reasons for this paradigm shift. As more vascular surgeons embrace endovascular interventions, distal bypass procedures are often relegated to second-line therapy. Recent publications, such as the BASIL trial, support the use of endovascular treatments as the initial approach for patients with critical limb ischemia (CLI). Angioplasty equipment has improved greatly, and the techniques of infrapopliteal intervention have become more refined. Low-profile angioplasty balloons in longer lengths have become available, along with specialty balloon catheters, such as the Cutting Balloon and PolarCath balloon. Debulking devices have been used successfully for infrapopliteal disease, and there is growing enthusiasm for stents (bare-metal and drug-eluting) in this vascular territory. The challenge for the practicing interventionist is to know what device is most appropriate in a particular setting and to understand the data supporting the use of a particular device. In this issue of Endovascular Today, we will attempt to make some sense of things and provide you with the latest information on innovative treatment strategies for infrapopliteal arterial disease.

Aravinda Nanjundappa, MD, and I will start by providing an overview of the clinical problem of CLI and share some general principles regarding its management. Ali Morshedi-Meibodi, MD, and Robert S. Dieter, MD, provide an excellent overview of endovascular alternatives to the surgical gold standard in treating infrapopliteal arterial disease, offering a summary of many of the options currently available. Based on the success we have seen in many other vascular beds, there is increasing interest in the potential that stenting holds for treating infrapopliteal disease. In his contribution to this issue, Thomas Rand, MD, advocates the development of stents for below-the-knee placement to combat amputation in patients with CLI and points to encouraging results from recent studies with novel stent designs.

Similarly, Dierk Scheinert, MD, and colleagues present an article describing the use of sirolimus-eluting stents in focal infrapopliteal obstructions. The authors note lower restenosis rates and a reduced need for target lesion revascularization and amputation with sirolimus-eluting stents compared to bare-metal stents. Given the inherent drawbacks to the use of a drug-eluting stent or other permanent metal implant in the infrapopliteal arteries, there continues to be great enthusiasm for bioabsorbable stents for this application. Marc Bosiers, MD, et al discuss the benefits of an absorbable metal stent for peripheral arterial use and update us on the progress of studies investigating the use of absorbable metal stents in the coronary and peripheral arteries.

Acknowledging the changing landscape of CLI management and the number of treatment options available, Neal C. Hadro, MD, focuses on the variety of angioplasty technologies designed to achieve successful infrapopliteal revascularization in CLI patients.

We are also fortunate to have Dr. Alan Lumsden's Coding and Reimbursement contribution, which covers a variety of endovascular lower-extremity procedures in a case study format.

This month's Today's Practice article highlights the recent free screening event held by my fellow Chief Medical Editor, Barry T. Katzen, MD, in conjunction with Baptist Cardiac & Vascular Institute and Cook Incorporated. The program screened 199 men and women aged 60 years and older for abdominal aortic aneurysms, carotid artery disease, and peripheral arterial disease, and serves as an excellent example of the public outreach necessary to combat this disease.

Manish Mehta, MD, et al present their work using a multidisciplinary endovascular treatment algorithm for treating ruptured abdominal aortic aneurysms, which has produced encouraging survival rates in this troubling patient population. Finally, we are pleased to have Mark Mewissen, MD, featured in our monthly interview. Mark is a good friend and internationally renowned interventional radiologist who has made very important contributions to our field. I am sure that you will enjoy his insightful comments.

As always, I hope you enjoy this issue of Endovascular Today and that you find it both educational and relevant. I welcome any comments that you may have regarding ways to improve our message.


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About Endovascular Today

Endovascular Today is a publication dedicated to bringing you comprehensive coverage of all the latest technology, techniques, and developments in the endovascular field. Our Editorial Advisory Board is composed of the top endovascular specialists, including interventional cardiologists, interventional radiologists, vascular surgeons, neurologists, and vascular medicine practitioners, and our publication is read by an audience of more than 22,000 members of the endovascular community.