CLI: Treatment Techniques and Management

Treatment techniques and management of complex CLI were the topic of an afternoon session moderated by Constantino Pena, MD, and Jihad Mustapha, MD. The moderators introduced Michael Jaff, DO, who began the session with a discussion on reducing PVD mortality by optimizing medical management.

He reviewed data from several trials, including FOURIER and COMPASS, and he posed the question, does medical management reduce mortality in PAD? “It absolutely does,” Dr. Jaff said. However, although medical management is getting better, adherence rates in medical therapy are poor from both the physician and patient standpoints, he noted.

Bulent Arlans, MD, spoke next and shared techniques in recanalizing an occluded SFA. He discussed disease management principles and mentioned the TASC 2 consensus document for treatment recommendations based on lesion length. However, he said that there are often exceptions and treatment is also based on economics, experience, availability of tools, and other factors. He went on to present several difficult cases with accompanying imaging and history.

Brett N. Wiechmann, MD, came to the podium to discuss access for tibial treatment. “Primary access is drifting away from CFA in specific situations,” he said. “Pedal and metatarsal access is safe and feasible when necessary, and planning ahead for alternative access is critical.”

Following Dr. Wiechmann, Thomas Zeller, MD, discussed determining endpoints of interventional therapy. CLI trials have a more challenging patient population compared to claudicant trials, and duplex ultrasound for determination of patency is of limited value in infra-popliteal lesions trials. “Therefore, small proof-of-concept trials must be the first step, followed by larger scale clinical endpoint-driven CLI trials limited to devices or treatment algorithms with proven efficacy.

The next speaker was Richard Neville, MD, who talked about the role of surgical bypass in infrainguinal disease. He concluded that there is a role for surgical bypass and endovascular therapy to provide optimal care for the patient with CLI, but randomized controlled trials are needed to provide Level `1 evidence for the ideal revascularization strategy.

Moderator Jihad Mustapha, MD, came to the podium as a presenter to share the elements needed to create a successful CLI team. The support of the institution for 3 hour endovascular cases is needed, but “It’s the right thing to do,” he said. He added that a village of people are necessary to bring a CLI team to fruition, including a physician champion and a nurse navigator. Staff training is also extremely important. Dr. Mustapha shared a detailed algorithm he created that his staff uses to effectively screen patients over the phone.

Constantino Pena also took a turn as presenter, as he shared data from the ZILVER PASS trial. “ZILVER PTX is obtaining outstanding primary patencies, also in long and more complex SFA lesions” he said. “Final 12-month and preliminary 24-month results show at least a non-inferiority of Zilver PTX versus prosthetic bypass surgery ATK, with similar patency rates and complications.”

The session also included TOBA II trial one-year results presented by George L. Adams, MD, and advice from Richard Neville, MD, on how to improve care of patients with wounds by using a multidisciplinary approach. Wrapping up the afternoon, Merve Ozen, MD, presented a featured abstract on midterm outcomes after BTK interventions for Rutherford 5-6 CLI patients, and Pradeep Nair, MD, presented a featured abstract on utilization of the occlusion perfusion catheter to administer antiproliferative medications in PAD intervention.

—Lauren LeBano