We talk with Dr. Luke Wilkins about his stenting algorithm for treating peripheral artery disease, including a step by step discussion of the decision tree when deciding whether or not to stent.

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SHOW NOTES

In this episode, our host Dr. Aparna Baheti interviews interventional radiologist Dr. Luke Wilkins about his treatment algorithm for Peripheral Arterial Disease (PAD). This algorithm is linked below, under “Resources.”

Dr. Wilkins starts by explaining his treatment decisions for non-occlusive lesions. If the lesion is less than 10 cm he prefers to use directional atherectomy and percutaneous transluminal angioplasty (PTA). However, if the lesion is greater than 10 cm, directional atherectomy poses the risk of distal embolization, so he will only perform PTA. In both cases, he recommends using IVUS to evaluate the efficacy of the treatment and then proceeding with a drug-coated balloon (DCB) to prevent re-stenosis.

On the other hand, if the disease is occlusive, Dr. Wilkins first attempts to cross the lesion. This can be achieved by going through microchannels with a guidewire or boring through the occlusion with a crossing device. If the lesion is unable to be crossed, he attempts subintimal recanalization. We discuss spontaneous re-entry into the true lumen, as well as re-entry devices like the Outback and the Pioneer catheters. We also take a detour into the Subintimal Arterial Flossing with Anterograde-Retrograde Intervention (SAFARI) technique that can be used if re-entry is challenging. After crossing is complete, Dr. Wilkins evaluates vessel diameter. In his experience, vessels that are wider than 5 mm have better stent patency, so he will place a drug eluting stent. In vessels of smaller diameters, Dr. Wilkins relies on other approaches such as interwoven stents with smaller diameters, directional atherectomy, and Tacks (to treat dissection flaps).

Finally, Dr. Wilkins discusses medical management and follow-up care for PAD patients. He recommends dual antiplatelet therapy, smoking cessation, and if claudication was an initial concern, patient education on the importance of walking. He follows up with patients in 1, 6, and 9 months, and then annually. During each follow up appointment, he checks ABI, PVR, and arterial duplex for clinical improvement.

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RESOURCES

PAD Stenting Algorithm Decision Tree:
https://www.backtable.com/shows/vi/podcasts/200/pad-stenting-algorithm

TASC Guidelines:
https://journals.sagepub.com/doi/10.1177/1358863X15597877?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Articles Mentioned:
Schneider PA, Laird JR, Doros G, Gao Q, Ansel G, Brodmann M, Micari A, Shishehbor MH, Tepe G, Zeller T. Mortality not correlated with paclitaxel exposure: an independent patient-level meta-analysis of a drug-coated balloon. Journal of the American College of Cardiology. 2019 May 28;73(20):2550-63.
 
Secemsky EA, Kundi H, Weinberg I, Jaff MR, Krawisz A, Parikh SA, Beckman JA, Mustapha J, Rosenfield K, Yeh RW. Association of survival with femoropopliteal artery revascularization with drug-coated devices. JAMA cardiology. 2019 Apr 1;4(4):332-40.
 
Freisinger E, Koeppe J, Gerss J, Goerlich D, Malyar NM, Marschall U, Faldum A, Reinecke H. Mortality after use of paclitaxel-based devices in peripheral arteries: a real-world safety analysis. European heart journal. 2020 Oct 7;41(38):3732-9.