Novel Lower Extremity Interventions: Chocolate TOBA, or Something Like That?

12th Biennial Meeting of the International Andreas Gruentzig Society:  Rio de Janeiro - February 2-6, 2014

Moderator:     Dieter Liermann
Panelists:      Robert Bersin, Tyrone Collins, Gyula Gal, Klaus Mathias, Sigrid Nikol, Souheil Saddekni, Jiri Vitek

Framing the question at hand, what is the state of the current knowledge?

To date, we have a large number of studies and publications starting from the early beginning of recanalization techniques in the lower limb. Unfortunately, we have no sufficient explanation for why the SFA is so resistant to recanalization compared to other segments of the artery system.
Our target should be to find out which technique is superior and if there the long-term follow up has been performed. Beyond the Endovascular Radiation Therapy Studies from the early 90s are there any promising non-stent strategies to solve the problem of restenosis in the lower extremity?

What are the Gaps in the Current Knowledge?

One of the remaining gaps is for why the SFA and the lower limb are difficult to recanalize and to keep open after PTA, stent, or any other therapy. Which technique keeps the recanalized and stented vessel open for a long period of time? Which technique will ultimately prevail? We lack comparative data to answer these questions. Unlike endovascular radiation therapy, which has been analyzed in a smaller collective because of the difficult handling of the method, the drug-eluting balloons are not approved in a long-term follow-up study. In addition, they will not be reimbursed in most countries. It is expensive and it might be difficult to get a sufficient number of patients for a randomized trial. Which group of physicians is performing these vascular interventions in peripheral arteries?

Our Summary and Recommendations

There are some essential preconditions to be solved before establishing a recommendation for future treatment of the novel lower extremity interventions. A good interdisciplinary vessel management between radiologists, angiologists and vascular surgeons concerning indications and therapies has to be established first. Even some techniques like drug-eluting balloons are not reimbursed in some countries. To collect significant high numbers of patients for prospective randomized trials, you have to be especially careful to make sure these studies will be well designed. These are preconditions to get the sufficient comparative data for an international database.