In this interactive case, Dr. William Harris demonstrates the use of the Rotarex™ Atherectomy System for the treatment of peripheral arterial disease. This experience allows viewers to engage with the procedure while highlighting procedural approach, device operation, and key clinical considerations in managing complex vascular lesions.
All right. Welcome back, everybody. So we've got an arterial case to add for the, the course, and so, We do a lot of critical limb ischemia here at Vic. We do a lot of tibial access to. I like tibial accesses. eases the patient's ability to get up pretty quickly walking through the Posterior tibial artery sitting right there. Kind of winking at us in the right. So it's a pretty decent size one. So All right. So we're into the posterior tibial artery. Yeah. And again, we'll start off with the inner portion of a micropuncture which we like. It's an 018 compatible system. You don't injure anything by starting off that way. We've got pretty good flow down here. DSM. So that's a pretty robust artery, move pretty quickly. We didn't get a chance to see much of it. I get a 6, please. And so, Actually, you have a 6 halo? I'll take a 6 halo. What 6 Halo. So, um, We use uh the slender type technology for several different uh sheaths. Um, Halo is one of them. It's the one, produced by BD. And they have them in different lengths too, which is kind of nice from the pushability standpoint, but. So we're into the artery here, and the conduit. And some people ask, uh, with frequency if we use um some sort of tibial, can I get a 100 centimeter bird too? If we use a tibial cocktail, we don't, we just use heparinized saline, heparinize the patient throughout the case. So. wasn't Yeah, that's correct. Yes sir. So pretty good. Life pretty healthy looking gorgeous tibules. Less. Can you go higher. Wow, that's impressive. That Yeah. Can I get an 085. So from our preoperative ultrasound, He knew that she had SFA stenosis, and I think she has an occlusion too. So we run a 035 catheter over an 018 wire and keep a 2 and a flow switch on the back. And that allows us to maintain our wire access and still take pictures and have an idea of where we're going at the same time, it gives us a roadmap. We'll take a picture of DSM. And it looks like there's a problem. Plus Yeah So it looks like 100% inclusion mid SFA. So far. Oh, it's Good. We've expanded our wire. This is an 08. It's a Boston Scientific V-18. This catheter is a. It's a Cortis. Um, bird too, they're pretty inexpensive, but you can use whatever crossing catheter you like. But essentially occluded all the way up to the proximal common femoral artery. So let's, um, let's ibis this really quick and take a look and figure out femoral that's the com I think that's a just a long common femoral. You know, pretty robust profound ephemeras coming off, so. We're in common femoral right there. Femoral head is right there. So we're gonna go in with Ibis, take a look. Ibis is really helpful in guiding our choice of therapy. Uh, from a multitude of standpoints, it kind of guides what kind of arthorectomy device we may use, size of the vessel, things like that. So we're coming up through the posterior tibial artery, which is a good point on the posterior tibial artery. Um, when you put an ibis catheter, it always amazes me how big the posterior tibial artery actually is that you see it on ibis. As you can see, it's a really a 3 millimeter artery. And so the treatments that people do in tibial arteries are usually undersized. Chronically undersized, so this is interesting. This is in the popliteal artery. This is kinda behind. Come on now. The problem in this situation is we're behind the joint, so we can't really see that well, but obviously, definitely some soft arthromatous disease in behind in the popliteal with some severe stenosis there. And a little bit more calcium, approximately. Pretty significant. But there's some fairly soft plaque in that area too. So, you know, the question is, is what kind of device do you want to use in this situation? You've got a fair amount of soft plaque, but you've also got some heavy calcium burden also. But with all the soft plaque you see surrounding the catheter. I actually think this is probably a pretty good Rotorex case. So let's get a 6110 Rot record. So we're in the common femoral here, you can see the profunda femoris coming off the lateral aspect in the ivis. And really at the origin of the common femorals or at the origin of the superficial femoral artery, there's pretty extensive disease and it's pretty soft, a little calcium, but. Just a lot of heavy. A lot of flag And we're truelo the whole way. I think that's really important to note. You know, we didn't go subminimal at all throughout the whole thing. You can tell that based on the intravascular ultrasound. Spot, can you tell me where that is. Well that's Yeah, so it's really behind that knee portion that we see a somewhat significant amount of plaque, but it's not terrible. It's probably about 50%. We stop occurring. That there is actually a little bit bigger spot. Joe alive on Is. Yeah, I know I'm trying to figure out where life. Oh, there it is. OK So that And that's not the lesion that. So Hey that fur again. So the RotorX pack, the 6 French rotor, or the RotorX comes in 6 French and 8 French system, and we're gonna use the 6 French today. Uh, we're gonna go through the tibial through this six French, uh, halo sheaths that we've got in here. Um, we're going to use a 110 centimeter device if we have a 110 centimeter device still. I think I've used 2 or 3 of them already today in the other room. That's a DT, right? Yes, sir. Yes, access is in the posterior tibial. Um, the spot. The RotorX device itself comes with an 018 wire in the pack. It's a really good wire. It's a braided metal wire. Flush Live on X-ray. Yeah, I'll take the, the And the RotorX is very similar technology to the Asperex that you saw earlier. It, um, eats up the clot and thrombectomizes it at the same time. So it's really, really cool to watch it, I can't tell you enough how much it's changed my practice. Uh, you guys couldn't see it, but in the other room just now, we just did a case in which the patient had a thrombosis bypass graft. Uh, and, uh, we were able to, uh, open up the bypass graft with the, uh, with the rotoric, and it was chronically occluded, so. Um, I use it a lot for my instant, um. Recurrent instant stenosis, uh, Works very well for that sort of situations and we also use it, you know, in patients with fairly soft thrombus, not a heavy calcium burden. So the setup involves, for those of you not familiar with RotorX, the setup involves um Using this handle that's attached to the power unit right there, you can use either a hand switch that you control with your finger or you can use a foot pedal. I prefer to use the hand switch just like the Aperex, and really this, if you saw the Asperex case earlier, this looks exactly the same. It's just a 6 French version. It's a little bit smaller. And so we connect this power unit to the disposable handle. And then again, this is an 08 system, so when you're done doing your case, you've got a really workable wire that you can do along with. You can deliver scents and balloons and things like that without any issues. Again, this was on the market in Europe for 12 years before it ever came to the United States and so. It's sad that we were so late to the punch, but thank God we've finally gotten it. It's really, really a, it's a game changer. Can't speak highly enough about. So what we do is immerse it in pepper nice sealing. When we flush it. And this runs heron nice ceiling through the system to essentially lubricate and keep it cool. So we're in good shape there. Put this back We run the catheter. OK I'm gonna run it through this papa teal space too. And you just go really slowly. You can't see it behind the. The metal prosthetic there, but on ibis, that's where the stenosis, that's where we're the sit on it. Yeah, we'll try and treat it a little bit better there. So we're running up the SFA now. Sorry, what's that? Yeah Yeah. And so, Wendy here is milking the The system making sure there's flow coming back through. The flow helps keep it lubricated, helps keep it cool. Which is really important. So when you hear the sound change like that, yeah, sometimes I'll slow down. She has pain, so I'll, I'll, I'll go through that spot, spot. They go to higher with it by throwing the tree. The only problem with coming from the tibial sometimes in a long CTO you lose a little bit of pushability. Go ahead. Oh, wipe it off. Can I get a uh 3 long balloons. Per wire In a situation like this where I'm having issues with pushability, sometimes I'll put a, a longer balloon in and kind of Decrease the friction on it more proximate, more caudally from coming from the tibial which will allow for more pushability going up it, yeah, a little bit of pre-dialing, yeah, that's for you have 150. 220 is fine. 220. I'll take 220. Yeah, sure. So we'll take an ultraverse balloon up 3. Now, Riles is green. Where. Yeah Well, can I get a uh 5240 at some point too. OK. Or a 5, 220 ball. So we'll just go up low pressure for just a second, just to kind of create a channel. And then we'll go back in with the device. Let's see if we can clean a little bit Hey, Susan, how much do we give? Perfect. Thanks. Uh, other reasons we come from the tibial, we don't have to worry about using filters. It's another reason to use the Rotorex we don't usually use a filter. Um, we can control embolic control as far, you can see how far away I am from the sea arm, so it decreases my radiation dose, which is. Um, We, uh, also don't seem to use as much contrast as we do if we're coming up and over for situations. So I'll take a right actually. I. And. Um, and so, and then from the tibial, if I've got tibial access, I can catch any clot that comes down here and actually just take it out through my sheath. Go ahead. So every time you go in and out with the device, you want to flush it, make sure you get saline coming through. Again, that kind of clears the device and cools it. If the device gets bogged down in the system, if it gets hot, just walk it out and reflush it just like this. OK. Very good. Perfect. What So we'll start again in the system right here. You can just go slowly and you can rotate the device around. There are different windows. You want to get one quarter versus another. There's a fair amount of Aspiration that goes on with this. It's really tremendous. And again, oftentimes I'll walk it out with it. you that. I'm just securing the shit with the towel. So I can walk things off without it. You know, without losing the sheet access. But you can keep it on while you're walking off. It's an Archimedes screw type, so it'll continue to aspirate. Are you coming north. Let's go ahead and hop. And I'll take that 51. OK. Some people are hesitant about sticking the tibia with single vessel, um, runoff, right. Um, we haven't had very many problems with it. We can definitely. If you're considering putting in, say, a, a big covered stent covered. Uh, set, you may have problems. That mid first is pretty tight, yeah. Yeah, well, I mean, you know, the question is, if it's a small tibial, you know, upsizing to a 6 or a 7 with a really small tibial, then you're gonna have problems. Um. But, you know, ultrasound, you usually have a pretty good idea of how big that tickle is. Um. I. you know, doing this accordingly, and that's why we use the inner portion of the micropuncture sheet for our access. It really It's really a nice technique cause you don't hurt anything by doing it by accident. I mean, I'm sure you could, but Spa. I practice. spot. Gotcha. It's about where that popatility. It's good. Who, uh, DCBs factor into your out, yeah, so in an outpatient lab, you know, they're not really reimbursed well. I like DCBs. I like DCB technology. I use it more often for recurrent disease, um, than I do for de novo disease, um. So I'm, I use them. I don't use them a ton. I'm not afraid to stunt something. Um, spot. And so, um, You know, I think DCBs have their place most certainly. Um, But we don't use them a tremendous amount in our practice. We have, we have some. It's like the Catherine. So that's pretty good. It's a good marker of flow, you know, you haven't embolized. You've got good pulsatile flow coming out of the tibial, so that's really a good start. It's dark. Is she oxygenating OK? Already a little behind the power curve. Stay right there. Can you angle off that anymore? done. Spot. That's pretty good. Yes sir Well TSA, yeah. You see it slowly falling back though I shot the picture. Runs out pretty well. We'll dissect it. go higher. You wanna go LA? Yes sir. That's really pretty darn good. Go ahead. OK Yes sir. So dissection kind of in that mid portion in that proximal portion right there, we'll probably fix that. It looks like a pretty ugly dissection. You're good, PSA. All the way up to the proximal portion. Give me a moment. You have a 6150 rounds. Give me a little steeper LAO, would you please? Uh, PSA. Do that again, dear sir. In. Sure, I'll take a 617. just Oh really? Yeah. Sorry. It's a pretty significant dissection coming down that area, so. We're put in a life stent. So this is a pretty nice stent. It's a triaxial deployment. It has P2 indication. So it has a fair amount of flexibility too. I think with dissection is this bad. Yeah. Stenting this makes a lot of sense. Some of these come in 5 French. This is a 6 French system just cause it's so long, a stent, but. What's this? This is 6170. I'm sorry if I missed it at the beginning of the case, but when you heronize, do you do weight-based or do you just give a standard? I do kind of a mix. I give a standard. We don't give, you know, cardiac heronization. I only gave her 4000 spot. Got it. You know, for some big males, I may give 5, or 6000. Stay still. The good thing on her is on the X-ray, I think you can see. You can see the uh profunda coming off, so I have a good target as far as that goes. I'm just going slowly. The thumb wheel deployment. Now I've gotten most of it out. Continue the rest of the deployment. Good Lord. Thanks, Susan Roll I've been out pretty well. That's perfect. F DSA. It's a little high. It crept up a little bit, but there's still good flowing into the fun of, so I'm not terribly worried about it. It's an open cell stent right there. That's pretty good, DSA. It's fine. Yes sir. She is Oh Is that right there spot? Almost made it with that stint, DSM. I know. That's a pretty significant dissection. I think we're gonna fix that. You got a 660, 660 snap. 680, yeah, I'll take it. It Through the stent deployment system runs through great. I'm pretty happy with that. We go home So, and again we check our flow distal. Close, this is, this is what we go for this, this outstanding flow here. So, great case. Thanks to BD for having us today. This is fantastic. Thanks to Cech for their technology. Um, thanks to all my staff for sticking around and doing this and And uh have everybody, thanks for thanks for coming. Appreciate it, sir. And uh yeah, hope to hope, hope to do this again. Yeah, appreciate it. awesome. Yeah, thank you.
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