Pave-and-Crack Technique Update at Seven Years

(Leipzig, Germany) January 31, 2020 -- A novel endovascular strategy to target severe calcified occlusions, the so-called “pave-and-crack” technique, was the focus of a presentation by Manuela Matschuck, MD, from University Hospital Leipzig. “We want to show that this technique is a safe alternative to open surgery, treating these patients with a bypass,” she said.

Dr Matschuck, who works alongside Dierk Scheinert and Andrej Schmidt at the interventional angiology labs in Leipzig, provided key technical tips as well as the latest long-term data evaluating the technique.

The pave-and-crack technique was first described by the Malmö group for iliac arteries to enable aortic stent-grafts to be passed safely through diseased access vessels. Without this technique, severe calcification risks compromising the intraluminal passage of guidewires and balloon catheters and could also block stents and anti-restenotic therapies such as drug-coated balloons (DCBs).

Dr Matschuck presented the latest results from a retrospective analysis for patients who underwent the adapted version of the technique for heavily calcified femoropopliteal lesions. Here, a Viabahn stent-graft (W.L. Gore), was implanted to pave heavily calcified femoropopliteal lesions. Paving acts as a kind of scaffolding that prevents vessel rupture, while aggressive predilatation is carried out until the calcified plaque is cracked.

The entire lesion is then lined in preparation for the delivery of a Supera (Abbott Vascular) interwoven stent. “We adapted the technique for the kind of lesions we were unable to treat before due to severe calcification,” she explained. “These were cases where we weren’t able to do the endovascular procedure before.”

At LINC, Dr Matschuck presented long-term data, building on 12-month data already published.¹ Her group collected retrospective data on 67 consecutive patients treated between November 2011 and February 2017 in Leipzig. A third of the patients had critical limb ischemia (CLI), most lesions were TASC D, and 92% were occlusions. The mean lesion length was 26.9 ± 11.2 cm and 62% of the patients had grade 4 calcification, according to the peripheral arterial calcium scoring system (PACSS).

“In these patients who are usually treated with a bypass, the technique we developed is an endovascular alternative showing good results at seven years,” she said. Indeed, at one year the primary and secondary patency estimates were 79% and 91%, respectively; freedom from target lesion revascularization (TLR) was 85%. In other words, despite having extremely long and complex calcified lesions, at 12 months, the patients experienced what the researchers described as excellent technical success, safety, and durable results.

The primary patency and secondary patency at up to seven years to be presented is a continuation from the 12-month results, said Dr Matschuck. “It tells us this is a good alternative for patients with severe disease,” she said.

Indeed, a primary reason to avoid bypass is that so many of the patients undergoing the pave-and-crack technique also suffer from several comorbidities. “For a bypass you have to put patients under anesthesia, resulting in a higher risk for them,” she explained. “But this procedure can be performed without anesthesia.”

Dr Matschuck noted that other groups have started to adopt the technique; however, learning to properly carry out the technique is vital.” You have to train in order to become familiar with this technique, but it’s getting more and more popular,” she said. “Many other hospitals have started using it.”

During her talk, Dr Matschuck will provide technical advice on how to carry out pave-and-crack. “The technique itself is very challenging, passing a severely calcified occluded lesion,” she explained. “Sometimes you have to puncture the lower limb below the knee in a retrograde approach.”

Getting the hang of the technique pays dividends, however, said Dr Matschuck. “This is a feasible alternative for patients with severely calcified lesions, compared to open surgery under special circumstances.”

Reference

1.  Dias-Neto M, Matschuck M, Bausback Y, et al. Endovascular Treatment of Severely Calcified Femoropopliteal Lesions Using the “Pave-and-Crack” Technique: Technical Description and 12-Month Results. J Endovasc Ther. 2018;25(3):334-342.