Imaging to Atherectomy: Technologies to Identify and Treat Peripheral Arterial Disease

[Sabeen Dhand]
I feel like when I go to the conferences people talk about having CTAs and MRAs on all their patients, but practically speaking, most of these patients have pretty bad renal failure. And whenever we get a consult for someone with CLI, I'm thinking a couple of things. One, before I even see the patient, I'm looking at what imaging we have. And typically it tends to be either nothing, or maybe an xray of the foot and maybe a Doppler, a duplex study. I've become a huge fan of the duplex studies to learn the anatomy, what might be occluded, where the disease is, and even just looking at access. Before I see the patient I hope to have a duplex study.

[Kumar Madassery]
I agree with pretty much everything you said. I think we're not a very cross-sectional imaging heavy institution when it comes to PAD CLI, unless our physical exam when we see him in clinic or in the hospital suggest that there's going to be an inflow disease at the access area.

Primarily, we'll get a CTA, or maybe an MR, if there's question of weak pulses in the femoral, et cetera. Or there's been extensive aorta bifem, to get a lay of the land. I think cross-sectional comes in handy then, but we primarily rely on our non invasives, to get an idea what we're going to do.

[Kumar Madassery]
There's always talk about should you plaque modify before ballooning, because ultimately most of us will decide, based on the lesion and the characteristics, are we going to just balloon this with some DCB, or are we going to stent it, depending on the patient and their ambulatory status, and all that. Below the knee, drug-coated trials have been tough and haven’t done so well. But there's newer ones coming out, and there's newer devices for tacking the dissections in the tibials and all that.

[Sabeen Dhand]
Typically I believe in remodeling the plaque. I think it gives you less dissection after you do angioplasty. And I will prefer drug eluting angioplasty if I can get away with it. Stenting tends to be something I use as a last resort. Unless the patient's older and especially if I have these kind of flow limiting dissections. But my goal is to get away, just trying to put kind of drug up there. Of course with the tibial, we don't have that yet. But once we do I will end up probably using those too, if the data supports it.

...In addition, the other thing I believe in for below the knee is I do think drug eluting stents, the coronary stents are really useful. I've seen great results with them. In those instances when you have this nasty disease that's not resolving with angioplasty.

[Kumar Madassery]
Yeah, I agree. We rely on the tibial drug eluting stents quite a bit. In a lot of our CLI patients we've had great outcomes with it. I know people are questioning whether or not to use it, but sometimes you get remarkably improved flow. Sometimes we'll kiss the tibial stents too, if you have two vessels that you're preserving. It's something that if you're dealing with a lot CLI, I think it's good to have in your armamentarium.