In this case presentation from Lakeland Vascular Institute, Dr. Elmasri and Dr. Whitney demonstrate treatment of in-stent restenosis in a patient with advanced peripheral arterial disease using the Rotarex™ Atherectomy System. The patient presents with recurrent rest pain and a history of prior interventions, highlighting the complexity of managing progressive lower extremity disease. [
Uh, welcome everybody to Lakeland Baskin Institute in, uh, Lakeland, Florida, Central Florida. Uh, we have a, a case, uh, uh, Doctor Whitney will be, uh, giving a vignette about the patient. So welcome to Lakeland, as Doctor Ramasri just mentioned, I appreciate you joining us. Uh, basically, we have a 79-year-old female. She has advanced peripheral arterial disease. She's had multiple prior endovascular interventions in the past. Um, she's a type 2 diabetic, has hypertension, hypercholesterolemia. She initially presented with wrist pain bilaterally in the in the feet, and she's also had severe lifestyle limiting intermittent calf claudication. She's had, as you can see shortly, that she's had multiple stents placed in the bilateral SFAs and popliteals, and so, uh, she most recently was treated for the right leg back in November with resolution of her wrist pain and her claudication. She's ecstatic about that, but now she's had recurrence of her, um, uh, dorsal left foot pain, keeps her up at night, and then also, uh, some calf claudication, so. We're going to see, uh, what exactly is going on. We know she has some instant restenosis based on the angiogram from a few months ago. Uh, hopefully, it hasn't completely occluded in the interval, but, uh, she does have some Doppler signals in the left foot, but they're weak, uh, much, much stronger on the right, um, some diminished capillary refill on the left, and some mild elevation pallor. Uh, no tissue loss, so at this point we'll give her a Rutherford 4. Uh, disease and, uh, I think without further ado, we've already started numbing her up. We're going to get access into the right common femoral and we'll go from there. So, so let's talk about access. Uh, can we switch to the floor image? As you see here, there is a total hip replacement. And also there are stents. Uh, in the SFA. All the way to the ostium. So ultrasound, uh, access is uh guided, is mandatory. I don't think anybody should gain access without using ultrasound. I'm just curious. So we use the palpation, then ultrasound, and of course fluoroscopic. Um, guidance just to see our axis is at the, uh, uh, humeral head, the junction, middle middle third to the distal third of the humeral head. So if we apply the three rules, uh, the. Complications are minimized. And we do this in in every single patient. Uh, ultrasound, floor first with a clamp. Uh. To see where we are. Same thing one more time. And we're going to have to oblique it probably to get that femoral head, uh, prosthesis off there. So, that looks like it's going to be a mid femoral 6, so that's good. Good good. And you see the, uh, the, uh, stents in the SFA. So in the past, at least on the right side, she's had life stents and some relining with some Vbonds. Uh, when the The left side, you know, she has these overlapping life stents, and so. We'll see, like I said, what it looks like today. I Believe she may have a single vessel run off via the anterior tibial on the left. We haven't evaluated her iliac inflow in a while. She has good femoral pulses. Fair amount of scar in the groin. From her prior interventions So usually for our large, uh, uh, arterior axis. Uh, uh, we do, we do a, a venogram, an arteriogram through the axis if we're gonna do, uh, a 20 French or 18 French axis for. Endografted, we tend not to. Do an arteriogram and then we'll put the sheath. She is currently on Eliquis. You solve the Eliquis, what, 24 hours or 424. Yep, 24 hours. OK. And just from the floral image here, you expect the tortuosity of the uh. Of the That's how the wire went up. Hey, Nicole, when you get a chance, let's go forward on the injector, please. Good, come on back. And also we do our aortograms, a runoff while we're outside of the room. Just to minimize radiation, radiation is becoming a big problem, especially for people of high volume. So you're going to see us walking out of the room. during the The aortogram and, and the runoff. OK, like Doctor Amaji said, we're gonna get our aortogram here and, uh, pull down. We'll do bilateral pelvic oblique images to evaluate the iliacs and the, uh, femoral bifurcations as well, and then we'll go to our runoff. Looks like from the picture there she's had a Celt closure on the left side. OK. So a little bit of redundancy and tortuosity in the aorta, but no stenosis in the iliacs and maybe there's something there on the left common. It doesn't look terrible. And then one thing we're looking at too, obviously with the intent of using Rotorex is what's the aortic bifurcation look like. So, one oblique and then we'll get the other oblique and, uh, Yeah, some narrowing on the left, left mid common. I'm not sure if there's something real there or not. This oblique is important to open up the right side to see our axis, the right femoral. On the left side, you see the little clip that's from the uh uh CeltT closure device. We use a variety of closure devices in our practice, uh, kelp, mins, cascade occasionally, Plo, obviously for larger boar. Very helpful in the outpatient setting when you can send your patients home in a few hours and obviously decrease the risk of. Of bleeding. So, we're gonna see if the Benson will go through that iliac, uh, Our will need a glide. So a couple of things to pay attention to, um. Uh, if you're planning to use, uh, uh, rotor axis, the, uh, angle of the aortic of the iliac artery, so if, if it's steep or or obtuse. So the decision should be made after your wire and sheath is placed because sometimes the Aortic bifurcation could look very acute here, but once you put your wire. And sheath, and then it splays open. So uh that's the time we will make a decision if it's a go or no, not based on the anatomy initially. 260 glide and it's different for regular, uh, probably just use regular, to be honest. So look how tortuous the the iliacs are and also just look at how the aorta, the iliac arteries play open with this wire and obviously the final decision is going to be once the sheath goes over and how so far the bifurcation started looking better now that's by the wire opening up the the iliac arteries. Uh A stiffer wire. You want to see if you want to get to the SFA or I was just gonna shoot the runoff from here and OK. Maybe an L. All right, let's hook up. Come on back. Good. Fortunately, her kidney function is normal. Creatinine is 0.5. I'm gonna walk around the other way. Sometimes we'll do a bilateral runoff at the same time. Uh, if there's any concern for creatinine issues, renal function issues, and a lot of times I'll focus on the leg that we're designed, you know, here to treat, and then come back and if we haven't used too much dye, then run off the ipsilateral leg that we're not treating. Um, Also, if there's, if you know there's going to be a CTO or something where there's Preferential flow down one leg or the other and that will sometimes dictate which leg we're going to follow and so sometimes I will. You know, just look at the, again, the, the leg that we're going to be treating. I think a dedicated, um, run. Uh, is better, especially as a patient like this where you see the stents goes all the way to the, to the popliteal. And evaluate the need to have aplasia better. So as you see in this case. Uh, the, uh, need to have aplasia and So again, tippy trunk is patent, but it kind of not much as far as the PT or perineal. It looks like the anterior tibial is the dominant runoff. That's good. We're going to see what the subtraction is going to show, but I think it's, it's just an AT, right? It looks like a single vessel. And at this point we're thinking about what device to use. To debulk the instant restenosis, I think the options are kind of limited. You're down to a couple of choices if you're gonna try any kind of artherectomy. I mean, I think, you know, laser and Rotorex are probably the. Two options. As I see the need to have a pleasure, that's a really high grade. And so far it's a single bus runoff. So this brings another point with the single bas runoff is you've got to be. Got to be very careful not to lose that single vessel runoff with a with a. Uh, hysterectomy. Um, uh, we mostly use here at the OBL, uh, Rotorex and laser. Uh, I think here, uh, Rores, uh, the added advantage is the ability for, uh, for suction. So it has a dual Arterectomy thrombectomy action. I did a little bit of safety net, especially in an OBL where you don't have all the stuff you could have. Kind of staring at these pictures, not to interrupt you, Fakir, but like it looks like there's almost like a posterior communicating branch that comes off and supplies the. The PT, the common plantar, right, you know, and the Is there a reconstitute, must be a reconstituted perineal right there. Uh, maybe kind of like a short anterior communicating back to a posterior communicating, and, and I agree. I don't think the 80 is a continuous. I think that's a short segment. Let's do a dedicated disease. OK, let's, uh, let's, you have a 6:45. Who heronize. Probably need the Benson to get the sheath up and over unless this is a stiff. Is it stiff? This is a Benson. Yeah. Yeah, the chain, the, uh, Benson we have. This is, uh, who makes this Benson? That would be. Well, that's a good shot. And of course this is mostly soft, so it shouldn't be an issue to cross. To Amaji's point about the the concern for the runoff is obviously we want to preserve. Every little Arterial branch So we're upgrading to the 645. Destination. I think for this size too, a. 6 French is adequate. You know, the Rotorex obviously has the 8 French variety. You can see the bifurcation. I think that's what you're getting ready to point out. Yeah, exactly. Look how, how it's layed open. So this is a wide, uh, and a lot of people, they roll out the case and they feel that the aortic bifurcation is very acute, but once you put the sheath, it, it, uh, it opens up. So I kind of buried the sheath into the SFA so we didn't have to. Re-catheterize that at least. Thanks. Uh, yeah, we could come out with everything. Or do you want to go just with the uh oh yeah, we can do the road, yeah, either way. Uh, we can see if we can cross. I think it's, I think it's a decent wire. Uh, you could be able to cross with it. Um, 5000 of heparin You go to ACT in 10 minutes. Did it flushes? I will say the one caveat, you really have to flush it well, keep it wiped down. And you'll see once we introduce the device, you know, we're gonna flush the system with the wire in place. Thanks. So like Al Madri said, the tip is, is, uh, angled, pre-shaped, and very steerable. So that area of the narrowing and the water did go. OK, now we've got a loop too it's going easily smoothly. It's going out the teepee trunk there. You want a catheter to shoot down the tibial and see if the if the tens is real. They have a long catheter and a 100 to see exactly what we're starting with, yeah. Because once we do the arterectomy and we do the postarterectomy runoff and we find, we won't find if that lesion is caused uh from our procedure, so I think the best thing is to do a very detailed uh tibial all the way to the foot before you touch anything so that later on you won't be having any doubt about if this was a pre-existing or is this something, uh, you know, you call. And this is important anytime you do any femoral popliteal work, you wanna establish your, your baseline outflow, what your tibial look like, and then of course afterwards too, it's paramount to image your outflow to make sure there's no disturbance. That you haven't lost any vessels or Unfortunately, we get a lot of referrals outside that often have incomplete arteriograms and uh. I don't care. The what? And let it float a little bit. All right, but I, yep, so. OK, good flow. So that's a high grade. Not totally occluded, but yeah. Do another run here. It's coming down the foot You want to get more leak or, you want to try. Get a lateral. OK, so. Plantars pretty much peter out as well. So that's So again, all good information to have. So that's a good question now. Do you fix or you don't fix that tibial? There are no wounds. Right, it's arrest pain Um, so, uh, if, um, you want to increase the outflow, uh, that's something, you know, could be fixed, but I think in the lack of, uh, tissue loss, I don't think we need to do anything. Yeah, I think you could argue it either way. I think for rest pain, I honestly, I think we'll get her out of rest pain just by opening up her SFA and pop, um, and, and obviously it had worked before, prior, pro, you know, prior to the recurrence of her instant restenosis. So I tend to agree with you in this case. So we established this is a good case for Rottare. It's instanty stenosis. Also established the The aortic bifurcation, we saw the sheath, it's not acute. And also the advantage of having a device that does. Aterectomy and ability for thrombectomy or at least suctioning any material because we have a single vessel runoff, so we are very cognizant about uh, Any potential complication with a single vessel runoff could be. And this procedure really depends on having a really a good tech with you because the device you are moving back and forth and we want to make sure that the tip. Is not going to be moving back and forth and then you're going into a complication, uh, but uh in in real life, uh, a physician and a tech, you, you have to train your tech to make sure that the tip of the wire doesn't go deep and end up with a perforation. Right, that's I think probably the most important thing, uh, I, I worry about when I'm using uh uh Rotorex and Agree. And, uh, we didn't have any problems, we, you know. Yeah, I think the major watch outs are if you're sub-intimal at all, it's uh off-label use. So basically what Doctor Whitney is doing is putting into the uh bin with saline and then we're gonna, just, just submerging this into the saline. That's. Uh, Doctor Omaji's got it held upright, uh, with the bag is on the, uh, towards the ground. Second thing I would like to point out in this handle here. There is a uh uh a button here where you could actually spin with it. Uh, we don't use, we use the foot pedal, uh, so that this is, this is moving back and forth without having to, to push the uh uh uh this button, so. I do not have wire, by the way, drawing an ACT. Some big watch outs really as I started to mention the subintimal passage of the wire. Clearly not an issue in this case. The bifurcation, not so much an issue in this, in this case. You know, they talk about like having the bifurcation being split by about 4 centimeters. Um, and I think vessel size is important. Again, it doesn't really impact this case, but certainly you want it above 3 millimeters. And try to avoid, especially the mid and distal tibial and pedal, especially if they're borderline small. You may want to measure with ibis first if you're unsure. Can you also show us here at Katie's hand, if you could. So here, there is a plunger. Let's put it on a slide here. See that plunger? Could be out here and could be in. So, while you're moving it in, the plunger is, is pushed in. Once you're in position, you put that plunger out, so. OK. I just watched the wire because it came back just a smidge. So I can feel like a little, just a really subtle transition as it goes over the bifurcation. I felt like a little nudge. Can can we spend some time here on the next step of the motion of this of the tips of the terectomy? Uh, Obviously this device is unique where you have to go back and forth, and the idea is when you have to come back to there with the lumen blood so that it washes out. So, uh, uh, the, the, the importance is moving this in the in the in the proper way. So we're going to go 1 centimeter at a time going back and then you go to the next level 1 centimeter going back, so. Uh, it's going to be demonstrated next, correct, and I agree. You want to start in an area where there's there's active flow, whether you're dealing with an acute or a chronic occlusion. You want to make sure that you're dealing with an area at least starting with some an area with some flow so we can. Go ahead. The softer the. Clot or thrombus or plaque. I'm generally speaking, gonna take a little bit more time in that area. And if there's a CTO or if there's an area that I'm concerning for fresh cloth, you save that. Then I'm gonna try to clean up. Everything proximal to the distal cap of the occlusion. Just to make sure to minimize my chance for distal embolization. Can you comment on the sound? How it's gonna change with this somatic segment? You're going to see this one go distally. Yeah, I mean right now it sounds pretty homogeneous throughout. I haven't heard a whole lot of variation in the sound. Pitch. But it will start to kind of change. And of course we're watching too as it goes through the stent. And it has also a built-in safety. There's a clutch where it's going to stop it if, uh, if it has that high resistance, so. So we're getting towards the end. Of the uh Actually, no, still a little bit. Those are 3 coaxial sensors, it's like Full metal jacket here. That's an excellent technique by Dr. Whitney. Doing OK with the wire? So the sound is a little bit different here if you notice. OK, I think we're probably good there. The wire is visible, so that's good. We're gonna come back. When you come back also, it should be on suctioning, uh, in case of any debris, uh, to, to suck it out. I remember the 2nd. Would you do a 2nd pass? Yeah, why not? It's a stented, so it's not a native vessel, so we can see the blood loss is really minimal. I mean we're probably at what, 70. Uh, some of it is saline. Some of the saline, exactly. OK, we're gonna do another run through here. Let me, uh, get it out of the sheath. OK, go ahead. This is the speed you use in a native SFA. Rottara has become my new uh thrombectomy, uh, device of choice for down bypass grafts. I don't know about you for cure, but. Um, you know, there's obviously other aspiration devices on the market. And, uh, you know, laser is still out there. There's good old uh lytic therapy, which is always a consideration. But a lot of times with down bypasses, especially synthetic grafts, I feel like you don't really get a good aspiration in the synthetic grafts. If you have no inflow or outflow, you just end up sucking in the tube and you get a lot of vacuum phenomena and air filling the space which was previously clogged. So with I actually prefer debulking with rotor res, and sometimes you can do it in a single setting. And if you're paying attention at camera 2, at Katie's hands, it's important for that to maintain that uh that technique, otherwise that wire could go all the way to the patient's big toe, you know what I mean? You gotta, you gotta maintain that wire tip diligently, and this is where people get into trouble. And the wire is in uh uh its position and obviously you don't want to get close to the floppy tip. So we're gonna leave this on as we pin pull it back or as Katie pin pulls it back. And also the other thing I want to point out when there was a problem, Katie said stop clearly so that uh she came to the end of the wire. And that's important to avoid problems. So you have to train your techs in this device and uh the reps do a beautiful job in training them, uh. To do a proper technique. So we'll do a post now. After we get the device. Out and see what it looks like now and Mm Certainly, most likely have to post dilate. I've got wire. Welcome to leave it on. They did really a beautiful job with that, with the exception of that focal area. We could go back and hit it again. And here we could mark it here on the screen. I think that whole little segment there looks OK, yeah, I think from, from here, yep. Agree, we don't have to touch the rest of the vessels. We're just going to work on this. We're kind of focusing on about a 12 centimeter segment that's a little bit irregular and still persistently narrowed with aggressive neoonal hyperplasia there. Don't have that. OK. So we're also being aware of how the drainages, the bags, you know, on the ground dependently being hung to gravity. Hit the button. And so we're kind of monitoring the the output. And like Al Majri said, we can cut it open at the end and see. What all we've aspirated. Do an extra due diligence right in some of these troubled areas. We're gonna go one more pass forward. You, you hear the change in the sound a little bit in that stenotic segment. And of course after that we're going to balloon uh the whole area but they did a beautiful job, uh, throughout the length of the stent with the exception of that small stubborn area, so. We're going to see now, uh, Um, what's the result of the, so you may have already commented on it, but you know, Katie was putting the, the torqueor there as a to facilitate holding the wire and And moving with the device. So this is my First line agent for. Thank you. Soft plaque, mixed morphology. Try to avoid it in heavily calcified. And again, using it more and more for Acute thrombotic occlusions. Still a little bit right in that same spot do better above and below, but that small area which obviously. We have really good results with the exception of that small area.
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