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Finding Success with the Supera Stent in Femoral Popliteal Disease
Cullins Nwaogu • Updated Feb 27, 2024 • 422 hits
The Supera Stent, with it's compression-resistant woven nitinol design, has become a preferred device for many operators to deploy and treat femoral popliteal disease. The femoral popliteal region has been widely regarded as a challenging area to treat peripheral arterial disease, often requiring unique techniques and specialized devices to achieve durable outcomes. Even with the Supera Stent's advantages in this anatomy, it can require extensive vessel prep ranging from angioplasty to atherectomy to shockwave lithotripsy. Interventional radiologist Dr. John Rundback discusses the design of the Supera Stent on the BackTable Podcast and explains how to increase its effectiveness when treating femoral popliteal disease, including the Supera Stent's deployment. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Brief
• The Supera Stent is used by Dr. Rundback above other stents because its nitinol makeup allows the stent to withstand the various forces in the femoral popliteal area.
• Incorporating atherectomy, focal angioplasty and possibly shockwave treatment to remove dense calcifications in vessels is adequate vessel preparation to prepare for a successful Supera Stent deployment. Dr. Rundback recommends aggressive vessel prep prior to Supera Stent deployment in the femoral popliteal artery.
• Dr. Rundback shares his technical approach to Supera Stent deployment, including tips for precise placement. One tip he emphasizes is to combine forward motion of the front hand with the thumb motion of the backhand to increase deployment success.
Table of Contents
(1) The Role of the Supera Stent in Femoral Popliteal Disease
(2) Supera Stent Deployment: Preparing the Vessel
(3) Techniques to Increase Efficacy with the Supera Stent
The Role of the Supera Stent in Femoral Popliteal Disease
The Supera stent is a woven nitinol stent that can be likened to a spring with a big pen according to Dr. John Rundback. The stent is widely used by Dr.Rundback rather than other stents due to its thermal memory and compression-resistant qualities to address the femoral popliteal area. Because of the various forces that are present in the femoral popliteal area, the compression-resistant quality of the Supera stent is the main selling point, as it is more resistant to breakage. Data and anecdotal experience support the observation that success rates for many other stents have not been as high in the femoral popliteal region because they are more likely to fracture.
[Dr. John Rundback]:
You're probably familiar with the biomechanics of the femoral popliteal artery across the doctor canal. It's unique and we've all seen those really nice pictures with patients with their knees bent and you can get a sense of the torsional and, and the compressive and the elongation of the forces. It's a very dynamic part of the artery, but they've actually done some studies and you get compressive forces right across the adductor down just below that up to 15 to 20% compression of the artery for shortening of the artery. And if you think about it, this has always been my feeling, traditional slotted nitinol tubes are rigid stents. They can't shorten. They can't rotate in response to those physiologic stresses and therefore they're inherently. It can never endothelialize as well. And it is always leading to this activation of the recent, not a cascade.
[Dr. Sabeen Dhand]:
…So more metal, heavy scaffolds. Really the two stents that come to mind in the distal fem pop are Supera, which has been around quite a while, and a newly developed stent that's available now, which is bio mimics. Other than those two, I personally don't use via bonds that much, in the end for the inguinal segment for just your typical CLI patients, but are you using stent grafts?
[Dr. John Rundback]:
Yeah. I mean, again, like you, we don't use them as much as we used to, but now we'll use them. And sometimes you get patients who you want to avoid a lytic aspiration doesn't work. You need to relined strategy, you know, something like that. sometimes you get patients at other things that will fail, so try something different, but it's certainly not our go-to. I think you're right. We're pretty much 50% now probably supera and biomimics. And we found that biomimic stent to be a really, really great stent. Obviously there's a lot of precision in Supera Stent deployment, and although we like to think we're perfect with the supera, there are definitely more challenges in it, you know?
[Dr. Sabeen Dhand]:
Totally. Oh, good, good. So you're 50, 50 the supera. I mean, these stents, the supera and bio mimics are different. We were talking about rigid nitinol tubes in this area that just don't work. I mean, we had FDA indicated life stent, that I used a couple of times and each time it fractured. I will not use those in that segment. But the supera we've used for a long time and I have yet to see a fracture, but it's hard to deploy. I mean, what's the design of the Supera. And how is it delivered for our listeners?
[Dr. John Rundback]:
Yeah. So the design of supera, as you know, it's a woven nitinol stent. So it's like a spring and a big pen. Right. and you know, obviously since its nitinol it's got thermal memory…
You're probably familiar with the biomechanics of the femoral popliteal artery across the doctor canal. It's unique and we've all seen those really nice pictures with patients with their knees bent and you can get a sense of the torsional and, and the compressive and the elongation of the forces. It's a very dynamic part of the artery, but they've actually done some studies and you get compressive forces right across the adductor down just below that up to 15 to 20% compression of the artery for shortening of the artery. And if you think about it, this has always been my feeling, traditional slotted nitinol tubes are rigid stents. They can't shorten. They can't rotate in response to those physiologic stresses and therefore they're inherently. It can never endothelialize as well. And it is always leading to this activation of the recent, not a cascade.
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Supera Stent Deployment: Preparing the Vessel
Dr. Rundback recommends aggressive vessel preparation and plaque modification prior to Supera Stent deployment, utilizing the full armamentarium of revascularization tools: atherectomy, angioplasty, and even shockwave lithotripsy if calcification is an issue. According to Dr. Rundback, dilating the artery to where it is slightly larger than the stent will ensure that the Supera stent deployment is done properly. Lastly Dr. Rundback emphasizes the importance of removing residual waste on the balloon.
[Dr. John Rundback]:
The big thing about Supera is you need to be extraordinarily aggressive about vessel prep. I remember seeing Andre Schmidt spend 45 minutes on doing focal force angioplasty to kind of fully dilate an area before he went ahead and deployed a supera and we try to be almost as rigorous as that. I mean, you really have to go down there, you have to do some plaque modification…
[Dr. John Rundback]:
…You can do that, however you want, we can use atherectomy, and then you have to go ahead and dilate and they say one-to-one, but often we’re 1.1 or one millimeter bigger, which is interesting because when we use these in the popliteal, we find we're using balloons that we would not normally have used, because we were able to be causing injury,
…You're already committed. You're down that road. And you have to make sure that you don't have any residual waist on the balloon as best as you can – it's very important. And I think, there may be a role here for shockwave to get these very, very dense calcifications so you get now, as you said, a more lasting vessel.
Techniques to Increase Efficacy with the Supera Stent
Additional tips that Dr. Rundback suggests for maximizing the efficacy of the Supera stent involves utilizing the stent margins that are present in pictures. He also shares certain handling maneuvers for the Supera stent, like compressing rather than elongation, and combining the forward force of the front hand alongside the thumb motion of the backhand to increase Supera Stent deployment success.
[Dr. John Rundback]:
…And once you get that vessel prep, well, then these deployments are much better, but it's a combination of forward force on your front hand. and then of course, the thumb motion on your backhand, and if you're going to cheat, you want to compress rather than elongate. And, they have very nice pictures, where you can sort of see the stent margins lining up like little soldiers. That's optimal. And it's a lot of work. We really liked them, but it's definitely more work. On the other hand, it is very gratifying when you get a great result. And, you know, I know, from the Viva OPC and the popliteal segment, they are above 85% primary patency out to one year…
Podcast Contributors
Dr. John Rundback
Dr. John Rundback is a practicing Vascular Interventional Radiologist at AIVS LLP in the New York City area.
Dr. Sabeen Dhand
Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.
Cite This Podcast
BackTable, LLC (Producer). (2022, May 30). Ep. 212 – New Tools to Treat Severe Distal Femoropopliteal Disease [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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