Peripheral Embolic Events During Lower Extremity Endovascular Procedures
By: Subhash Banerjee, MD
The reported incidence of 1–2% adverse events related to atheroembolic events during peripheral interventions is an underestimation. Doppler-signal recordings of distal embolization are registered during 100% of peripheral arterial interventional procedures. In the MC-LEADER trial, over 85% of Proteus embolic capture balloons retrieved macroscopic debris. Angiographic slow or cessation of antegrade flow is reported in 3.8–24% of peripheral interventional cases. Clinically significant distal embolization was reported in nearly 30% of angioplasty and/or stent procedures and in 90% of atherectomies in the Preventing Lower Extremity Distal Embolization Using Embolic Filter Protection (PRO-TECT) registry. Angiography underestimates the true incidence of peripheral embolic events during endovascular treatment of peripheral arterial disease, and may be the leading cause for underdeveloped embolic protection strategies during peripheral arterial interventions.
We have recently reported Doppler ultrasound detection of distal embolic signals during phases of percutaneous lower extremity (1). There are few reports which have demonstrated detection of distal embolic signals (ES) with continuous transcutaneous doppler ultrasound (2-4). Our report included ES recordings during endovascular treatment of SFA CTO, during phases of an endovascular recanalization of SFA CTO: crossing, atherectomy/debulking, predilation, stent implantation, and post-dilation. As presence of an infra-inguinal CTO is associated with more extensive PAD and incremental risk of limb ischemia or loss from peripheral emboli, knowledge of ES during lower extremity interventions may allow operators to include strategies that mitigate this risk.
The Proteus embolic capture balloon is a relatively new angioplasty catheter which provides a viable option for both peripheral artery balloon angioplasty, comparable to any conventional peripheral balloon, along with an innovative embolic debris capture technology. In our experience, we have retrieved embolic debris is 100% of cases. A case example demonstrating the use of this balloon catheter is depicted in the attached video clip. Despite the promise of this device and its ability for macroscopic embolic debris capture during peripheral arterial endovascular interventions, the use, application and clinical significance need to be vigorously tested in a clinical trial/registry setting.
Proteus_clip_JIC export MPEG.mp4
References:
1. Recording Peripheral Embolic Signals During Endovascular Treatment of Infra-inguinal Chronic Total Occlusion. Cardiovas. Revasc. Medicine; October 2010 (accepted, in press)
2. 2. Kudo T, Inoue Y, Nakamura H, Sugano N, Hirokawa M, Iwai T. Characteristics of
3. peripheral microembolization during iliac stenting: Doppler ultrasound monitoring. Eur J Vasc Endovasc Surg 2005;30:311-4.
4. Al-Hamali S, Baskerville P, Fraser S, Walters H, Markus HS. Detection of distal emboli in patients with peripheral arterial stenosis before and after iliac angioplasty: a prospective study. J Vasc Surg 1999;29:345-51.
The Proteus product line, Embolic Capture Angioplasty are trademarks of Angioslide Ltd.
About Angioslide
Angioslide is a privately held company with headquarters in Herzliya, Israel. Its U.S. distribution headquarters is located in Minneapolis, MN. Its European distribution headquarters is located in Karlsruhe, Germany.
Dr. Subhash Banerjee is Chief of the Division of Cardiology and Co-director of the Cardiac Catheterization Laboratory at VA North Texas Health Care System, Dallas, Texas and Associate Professor of Medicine of the University of Texas Southwestern Medical Center at Dallas, Texas.
