An Aspirational Atherectomy Case Presented by Fadi Saab, MD

At the 5th Annual Amputation Prevention Symposium, faculty member Fadi Saab, MD, shared a pre-recorded case using aspirational atherectomy with attendees. Vascular Disease Management asked Dr. Saab to share details of this case and to discuss the techniques used. 

VDM: Could you describe the case, when it was performed, and how you chose the treatment plan?

Saab: This aspirational atherectomy case is unique enough that it encompasses multiple aspects of revascularization in patients with peripheral vascular disease and critical limb ischemia, but it’s also common enough that I think a lot of physicians will find it helpful in their practice. This particular case was interesting in the sense that the patient presented to my office with complaints of what seemed to be rest pain involving his right lower extremity. At the time it didn’t make sense because the patient had few risk factors. 

We went through the workup, which was a noninvasive workup with ankle-brachial index, and we did an arterial duplex that showed that he had actually decreased blood flow in his right lower extremity. One of the things that we were concerned about was if this patient had a thrombotic process creating the decreased blood flow to the right lower extremity, but we could not find any etiology behind it, including a detailed hematological workup, an echocardiogram and so on. So, the workup included ruling out any etiology beyond the hypercoagulable state, any source of thromboembolic disease, from the heart or from any other areas. Ultimately the patient underwent a peripheral angiogram that showed what I thought was a thrombotic process in the popliteal segment in the right lower extremity. I was then faced with the decision to treat endovascularly or treat conservatively. We decided to actually proceed with the route of conservative management. So we place the patient on anticoagulation and antiplatelet therapy. 

He was relatively young so he could tolerate this triple therapy, and we watched the patient closely for a period of 3 months. To my surprise, the patient’s symptoms continued to trend downward and he started complaining of more frequent intermittent rest pain. So we made the decision to revascularize the patient, but the dilemma in this particular case was the location of the lesion itself. It was in a difficult location -- the trifurcation of tibial disease in the lower extremity. Again, this was a relatively young, healthy man, and at the time the vascular surgeon offered only a tibial bypass as a surgical option. So we had a discussion with the patient and our vascular surgery colleagues and we ultimately decided to try to salvage the trifurcation and resolve the stenosis from the three vessels below the knee. 

In our practice, when we have challenging cases, we have a vascular conference where a lot of colleagues meet together and we discuss all of these complex cases. And you know the stakes are high. This is a relatively young person with no wounds or ulcers and a lesion that threatens his whole limb, his whole life even, so the decision to treat him endovascularly was made. Now, in terms of which device to use, that’s what we had to discuss. There were multiple options to use in this patient. Because of the nature of the lesion that we felt was thrombotic in nature and because we felt that it’s been there for about 2 to 3 months, we thought aspirational atherectomy would offer a really useful treatment option for this patient. We would aspirate some of that chronically organized thrombus in that region and also if there is an underlying atherosclerotic disease, we can still impact. 

The bulk of the CLI work in our practice is performed via antegrade access, and that’s one of the messages that we try to use in AMP: If you are trying to do tibial work and pedal work, antegrade access should be one of those tools that you want to utilize in your practice. It’s very, very important. We always get asked how we get very good outcomes in our practice and I think a big part of it is the tools that are available at our disposal. 

Another unique and useful technique is extravascular ultrasound. You will notice us using extravascular ultrasound at AMP, with an ultrasound probe on the outside of the thigh, visualizing our catheter, our equipment, traversing the occlusion within the popliteal area. This is something that we feel strongly about, we think that it’s very good for the patients, it’s very good for the physicians, it decreases the amount of radiation and contrast. We held a hands-on ultrasound workshop at AMP this year to show our colleagues that it’s really attainable and something that you can add to your practice. 

From that point, we considered the nuances of a thrombus that can go anywhere in the leg and can make things worse, and went over our options and planned safety nets. Ultimately what we chose to do was treat two vessels in an antegrade fashion and the third vessel that was completely occluded we tackled in a retrograde tibial-pedal access fashion. Again, this was ultrasound guided. 

The decision making process is always interesting. The utilization of aspirational atherectomy above the knee and below the knee enabled us to use two devices to salvage three vessels that otherwise we would not have been able to. If we had gone the surgery route, it would have been one vessel tibial bypass in an ultimately young patient, but at the end of the procedure the patient ended up with three-vessel runoff and we were able to salvage his leg. 

VDM: Were you surprised by the outcome at all?

Saab: Whenever you approach any peripheral vascular CLI case, you always enter with the mindset that you are ready for anything. I am ready for anything and everything -- including complications. So I would say that the device behaved the way I wanted it to behave and achieved the result I wanted it to achieve, which is no less than perfect. If you look at it, a patient walked in with a 100% occluded vessel and walked away with three-vessel runoff without leaving any metal in his leg, not that that is a bad thing, it’s sometimes required, but our approach also leaves the options for therapy for the future for this gentleman. This patient felt better within 40 minutes of the end of the procedure. He walked the next day. It’s satisfying to see the patient doing so well.

VDM: So you think the takeaway message is to consider all the options and combination of options?

Saab: I think we as physicians and healthcare providers would like to say that it’s always 1+1=2. With CLI, you can’t do that. There are general guidelines but you as a physician have always to be ready to think outside the box and be able to apply the right tool in the right place. All of us would like to always know everything all of the time, but this isn’t always reality. Talk to your colleagues, discuss with your colleagues, attend meetings and conferences like this where you can share ideas. At this meeting I have 800 colleagues who I can bounce ideas off and see how they would respond -- that’s what we need. We need more conversation, more discussion among ourselves about when to choose what device or therapy.  

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Dr. Saab is an interventional cardiologist at Metro Health Hospital in Wyoming, Michigan, and faculty member of the Amputation Prevention Symposium. Dr. Saab reports no disclosures related to this article.