Critical Limb Ischemia: Will Atherectomy and Laser-Directed Therapy be the Answer?

Clair, Daniel G.

doi:10.1053/j.semvascsurg.2006.03.006

Cited by 3 publications

(2 citation statements)

References 37 publications

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“…151 Excimer laser-assisted angioplasty can facilitate the crossing of complicated long stenoses and total occlusions when PTA might prove difficult or inadequate, removing plaque burden without undue barotrauma or shifting. 152,153 The technique does not require that the lesion be crossed in advance by a guidewire; using a well-documented step-by-step approach, the excimer device can be advanced in tandem with the guidewire. 153 The device can be used for difficult-to-treat tibial disease, removing the plaque burden throughout the vasculature to allow treatment of lesions, possibly without the use of stents.…”

Section: Endovascular Approaches For Treatment Of CLImentioning

confidence: 99%

Medical and Endovascular Management of Critical Limb Ischemia

Lumsden

Davies

Peden

2009

Journal of Endovascular Therapy

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Critical limb ischemia (CLI) is the term used to designate the condition in which peripheral artery disease has resulted in resting leg or foot pain or in a breakdown of the skin of the leg or foot, causing ulcers or tissue loss. If not revascularized, CLI patients are at risk for limb loss and for potentially fatal complications from the progression of gangrene and the development of sepsis. The management of CLI requires a multidisciplinary team of experts in different areas of vascular disease, from atherosclerotic risk factor management to imaging, from intervention to wound care and physical therapy. In the past decade, the most significant change in the treatment of CLI has been the increasing tendency to shift from bypass surgery to less invasive endovascular procedures as first-choice revascularization techniques, with bypass surgery then reserved as backup if appropriate. The goals of intervention for CLI include the restoration of pulsatile, inline flow to the foot to assist wound healing, the relief of rest pain, the avoidance of major amputation, preservation of mobility, and improvement of patient function and quality of life. The evaluating physician should be fully aware of all revascularization options in order to select the most appropriate intervention or combination of interventions, while taking into consideration the goals of therapy, risk-benefit ratios, patient comorbidities, and life expectancy. We discuss the incidence, risk factors, and prognosis of CLI and the clinical presentation, diagnosis, available imaging modalities, and medical management (including pain and ulcer care, pharmaceutical options, and molecular therapies targeting angiogenesis). The endovascular approaches that we review include percutaneous transluminal angioplasty (with or without adjunctive stenting); subintimal angioplasty; primary femoropopliteal and infrapopliteal deployment of bare nitinol, covered, drug-eluting, or bioabsorbable stents; cryoplasty; excimer laser-assisted angioplasty; excisional atherectomy; and cutting balloon angioplasty.

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Section: Endovascular Approaches For Treatment Of CLImentioning

confidence: 99%

Medical and Endovascular Management of Critical Limb Ischemia

Lumsden

Davies

Peden

2009

Journal of Endovascular Therapy

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“…The preferred approach to excimer laser debulking of a total occlusion in the infrainguinal vasculature is to proceed slowly through the lesion, at a rate not exceeding 1 mm per second. 9 When the lesion cannot be crossed with a guidewire alone or with a guidewirecatheter combination, the excimer laser may be applied in a step-by-step fashion, advancing the device in tandem with the guidewire at a rate of 0.5 to 1.0 mm per second (Fig. 3).…”

Section: Excimer Lasermentioning

confidence: 99%

Excimer Laser-Assisted Angioplasty for Infrainguinal Artery Disease

Das

2009

Journal of Endovascular Therapy

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After nearly 2 decades of research and experimentation with laser-assisted angioplasty, the xenon-hydrogen chloride excimer laser emerged as the laser device best suited for the treatment of peripheral artery disease. Emitting light at a wavelength of 308 nm, this laser utilizes a nonthermal mechanism of action to ablate plaque and thrombus in powerful discrete pulses. The excimer laser is particularly useful for the treatment of complex conditions, such as long chronic occlusions in the superficial femoral artery and in those patients with below-the-knee disease and critical limb ischemia who may not be good candidates for bypass surgery. A number of investigators have noted that the excimer laser will often uncover distinct, more focal lesions in what appears to be an extensive and complex occlusion, potentially simplifying treatment of these segments. The Laser Angioplasty for Critical Limb Ischemia phase 2 trial, a prospective registry of 145 patients at 11 US and 3 German sites, achieved good procedural success (86%) and an excellent 6-month limb salvage rate (93%). A new specialized deflecting sheath designed to direct excimer ablation in blockages of the larger main arteries above the knee has produced clinical improvement in a single-center feasibility study and a 16-center prospective registry. Less promising results were reported in a single-center real-world retrospective registry, warranting careful case selection with this device for patients with diabetes and renal failure.

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