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11 Long-Term Medical Management
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311
11.1.6 Medication Failure Versus
Non-responders
Resistance to aspirin and clopidogrel has been
well studied and documented. Although the
phenomenon is real, occurring in up to 30–40%
of patients, the mechanisms behind such resistance are varied [14]. In some instances, the
resistance is due to pharmacokinetic factors
limiting the absorption, metabolism, and bioavailability of the drug. In other instances, however, there does appear to be a true genetically
determined resistance to the antiplatelet drug,
mostly by altered metabolism of the drug.
Despite the intellectual appeal of testing for
clopidogrel and aspirin resistance to guide therapy, the results of such strategies have been
mixed and there is no consensus on how to best
manage these patients.
• From a clinical standpoint, when encountering
a patient in whom clinical failure or resistance
is suspected, it is critical to rst conrm
complete adherence to the antiplatelet
medication.
• If clinical failure is determined, it is reason-
able to measure clopidogrel or aspirin resistance using commercially and clinically
available platelet function analyzers to help
identify an appropriate regimen.
• Treatment decisions must be individualized
and may include the various antithrombotic
drugs approved for clinical use and described
in this chapter.
11.1.7 Statin Therapy
11.1.8 Cilostazol
The mechanism of action of cilostazol has not
been fully elucidated, but it is clear that it
improves claudication symptoms. In a metaanalysis of 8 randomized control trials involving
over 2700 patients with moderate-to-severe
claudication, cilostazol lead to a 50% and a 67%
increase in mean walking distance and pain-free
walking distance, respectively [16].
• Cilostazol should be started at 50 mg twice
daily and after 3–4weeks the dose should be
increased to the target dose of 100mg twice
daily. It should be taken on an empty stomach.
• In real-life registries, over 50% of patients
stop the drug after 36 months due to side
effects, such as diarrhea, headaches,
palpitations, or dizziness.
• There is a black box warning against the use
of cilostazol in patients with a history of
congestive heart failure or an ejection fraction
lower than 40%.
11.1.9 PCSK9 Inhibitors
The role of PCSK9 inhibitors in patients with
PAD has been highlighted in the FOURIER trial.
PAD patients who received the PCSK9 inhibitor
Evolocumab (Repatha) had a 27% risk reduction
in the composite of cardiovascular death,
myocardial infarction, or stroke compared to
placebo. In a PAD subanalysis [17], the number
needed to treat to prevent major adverse cardiac
events was 29 patients over 2.5years.
All patients with peripheral arterial disease
should receive high-intensity statin therapy [15].
Per current lipid guidelines, patients should be
treated with a minimum of atorvastatin 40 mg
daily or rosuvastatin 20mg daily, ideally targeting
an LDL level less than 100, and possibly less
than 70mg/dL.
11.1.10 Hypertension Management
Patients with peripheral arterial disease and
hypertension should be treated to achieve a goal
of blood pressure less than 130/85 mmHg,
preferably with an ACE inhibitor. In the landmark
HOPE trial, patients with atherosclerotic vascular
312
I. Del Conde and S. Madassery
disease had a 22% reduction in the relative risk of
myocardial infarction, stroke, or cardiovascular
death compared to placebo [18].
11.2 Venous Disease
Management
IanDel Conde
Although a comprehensive review of the medical
management of patients with acute deep vein
thrombosis (DVT) is beyond the scope of this
chapter, readers are referred to the most recent
update of the American College of Chest
Physicians update on the management of venous
thromboembolism [19]. For the purpose of the
interventionalist treating patients with acute
DVT, the discussion will be focused on the acute
management of patients with DVT as it relates to
endovascular therapy.
• Most patients with lower extremity deep vein
thrombosis can be managed medically
(usually in the ambulatory setting) using a
target-specic oral anticoagulant, such as
apixaban or rivaroxaban, which do not require
parenteral heparin products at treatment
initiation.
• As discussed in prior sections, catheter-
directed therapies are often considered in
patients with more extensive lower extremity
DVT, such as DVT involving the inferior vena
cava or the iliofemoral segments. These
patients generally require hospitalization and
should be treated with either a low molecular
weight heparin at a therapeutic dose, or an
unfractionated heparin drip.
The duration of anticoagulation in patients
with acute proximal lower extremity DVT
depends on the presentation. There are three
clinical factors obtained by history that identify
patients as having an increased risk of recurrent
venous thromboembolism:
1. Patients with active cancer.
2. Those with a prior history of venous
thromboembolism.
3. Those with unprovoked DVT (i.e., without
preceding major transient risk factors, such as
surgery or immobilization).
Patients at increased risk of recurrent venous
thromboembolism usually complete 3–6months
of therapeutic anticoagulation (generally with a
target-specic oral anticoagulant) and are
subsequently considered for extended treatment
for the prevention of recurrent venous
thromboembolism. Extended treatment is
accomplished with a reduced dose of rivaroxaban
[20] or apixaban [21], which has been shown to
have a favorable risk: benet prole.
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Index
A
Abbott Supera stent, 178
Abdominal aortogram, 83
Accommodative padding, 17
Acute kidney injury (AKI), 71
Adjacent tissue transfer, 27
Adjunctive atherectomy, 200
American College of Radiology (ACR), 35
Amputation, 285, 286
Angioplasty balloon catheters, 98
Ankle atherectomy, 199–203
Ankle brachial index, 37–38
Antegrade femoral approaches, 101
Antegrade SFA access, 102
Anterior tibial artery (ATA), 90, 206
Antibiotic therapy, 289
Anticoagulation, 54
Anti-heparin-PF4 antibodies, 145
Antihypertensives, 52
Antiplatelets, 53
Antithrombotic therapy, 308–310
Aortic bifurcation, 85
Aortobifemoral bypass, 87–88
Aortoiliac disease (AOID), 79
Aortoiliac interventions, 80
Aortoiliac occlusive disease (AIOD), 87, 221–225
Aortoiliac stenting, 81
Arterial duplex, 31–33
Arterial revascularization
ankle atherectomy, 199–203
antegrade femoral approaches, 101
aortobifemoral bypass, 87–88
aortoiliac occlusive disease, 221–225
axillary and brachial access, 109
BEST-CLI trial, 230–232
blue toe syndrome, 161–164
clinical evaluation, 89
CO2 angiography
advantages, 110–112
adverse effects, 116–117
carbon dioxide delivery, 112–114
complications, 116–117
disadvantages, 112
imaging parameters, 114
lower extremity runoff, 114–116
patient monitoring, 112
standard aortogram, 114–116
CTOs, 99, 100, 130–133
deep vein arterialization, 208–219
distal embolization, 157–160
drug-eluting technology, 166–174
EVUS, 95–100
femoral artery, 177–186
femoro-femoral bypass, 88–89
heavy calcium
access, 117–119
crossing, 118–123
laser history and background, 127–130
treatment, 120–125
hybrid deep vein arterialization, 219–221
hypogastric considerations, 81–84
instent restenosis
axillofemoral bypass, 138
blue toe syndrome, 162
classication system, 134
crossing in-stent occlusions, 134
detour approach, 139–141
distal popliteal and trifurcation disease
management, 154–157
drug-eluting technology, 169
femoral artery, 179
femorotibial bypass, 135–139
brinolytic therapy, 146
knee stenting, 152–154
limus-based therapy, 172
management, 134–135
mitigating risk, 142–143
pedal surgical bypass, 195
popliteal artery aneurysms, 177
solo profunda, 191
thrombolysis, 146, 147
tibial calcium management, 147–154
limb preservation, 226–230
limus-based therapy, 170–172
orphan heel, 205–208
pedal approach, 89–100
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. Madassery, A. Patel (eds.), Limb Preservation for the Vascular Specialist,
https://doi.org/10.1007/978-3-031-36480-8
315
316
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Index
Arterial revascularization (cont.)
pedal surgical bypass, 191–195
peripheral arterial disease, 104–109
popliteal access, 100, 101
popliteal artery aneurysms, 174–177
postoperative care, 93–94
postoperative complications, 95
primary pedal intervention, 92–95
radial sheath entrapment, 108
retrograde SFA access, 103
solo profunda, 186–190
stubborn valves, 214–218
ultrasonic features of, 98–99
ultrasound based femoropopliteal atherectomy,
195–199
upper extremity access, 107–108
Artery endovascular revascularization, 283
Atherectomy, 149
Axillofemoral bypass, 138
B
Bare metal stents (BMS), 154
BEST-CLI trial, 230–232
Bifurcated patch, 188
Big artery disease (BAD), 147
Bioengineered cellular therapies, 21
Blue toe syndrome, 161–164
Bone biopsy, 13
C
Calcication, 120
Calcied disease, 196
Calciphylaxis, 15, 162
Campisi Staging System, 58
Carbon dioxide (CO2), 109
Cardiovascular and Interventional Radiological Society
of Europe (CIRSE), 303
CEAP classication system, 252, 254
Cellular based therapies, 21
Chimney CERAB (C-CERAB), 84
Chocolate balloon, 150
Chronic ilio-caval occlusion
clinical presentation of, 270
endovascular management of, 270–271
etiologies, 268–270
intra-procedural considerations, 271–274
pharmacotherapy, 274
post-procedural management, 274
pre-procedural considerations, 271
Chronic kidney disease (CKD), 34
Chronic limb threatening ischemia (CLTI), 1, 79, 283
Chronic non-healing wounds, 21
Chronic occlusions, 141
Chronic tobacco abuse, 103
Chronic total occlusions (CTOs), 46, 99–100,
130–133, 141
Chronic venous disease, 303
Chronic venous insufciency (CVI), 253
Chronic wound, 13
Cilostazol, 55, 311
Clopidogrel, 309
Coaxial catheter system, 121
Common femoral artery (CFA), 117, 184
Common femoral artery (CFA) disease, 177
Common femoral artery endarterectomy (CFE), 178
Compression therapy, 274
complications, 277
contraindications to, 277
types of, 275–277
Computed tomography angiography, 34
Computed tomography arteriography, 39
Computed tomography venography (CTV), 40
Contrast-enhanced MR arteriography (CE-MRA), 39
Contrast-enhanced MR venography (MRV), 40
Conventional approach, 186
Coronary revascularization, 172
Covered endovascular reconstruction of aortic
bifurcation (CERAB), 84
Critical limb ischemia (CLI), 1, 203
Crossing devices, 131
Culotte technique, 156
Cutting Balloon (Boston Scientic) angioplasty, 150
Cyanoacrylate glue (VenaSeal), 259
D
Debridement, 7, 289
Debulking atherectomy, 152
Decubitus ulcer, 6
Decubitus wound, 5
Deep femoral artery (DFA), 178
Deep vein arterialization (DVA), 208–219, 221
Deep vein thrombosis (DVT), 37, 257, 269, 301
Deep venous disease, 261–267, 301–303
Detour approach, 139–141
Diabetes mellitus (DM), 41, 52, 103
Diabetic foot classication, 5
Diabetic foot ulcer (DFU), 68
Diagnostic angiography, 72
Diet modication, 50
Digit amputation, 16
Digital subtraction angiography (DSA), 92, 109
Distal CO2 injection, 114
Distal embolization (DE), 157–160
Dorsal metatarsal artery, 43
Dorsalis pedis artery (DPA), 206
Dropped bifurcation technique, 189
Drug-coated balloons (DCB), 108
Drug-eluting stents (DES), 108
Drug-eluting technology, 166–174
Dry eschar, 14
Dual antiplatelet therapy (DAPT), 54
Duplex ultrasound (DUS), 297
Dyslipidemia, 103
Index
317
E
Early Venous Reux Ablation (EVRA), 257
Elgiloy-braided stents, 270
Embolic disease, 161
Embolic protection devices (EPD), 158, 164
Embolization protection device (EPD), 166
End stage renal disease (ESRD), 41
Endarterectomy, 188
Endovascular popliteal aneurysm repair (EPAR), 176
Endovascular procedures, 293–295
Endovascular therapy (EVT), 166, 170, 177, 184
Endovenous laser therapy (EVLT), 255
Ergonomics, 102
Excimer Laser, 93
Excisional biopsy, 13
Exercise therapy, 50
External Iliac artery, 86
External iliac artery lesions, 105
Extra-vascular ultrasound (EVUS), 95–100
F
Femoral artery, 177–186
Femoro-femoral bypass, 88–89
Fibrous disease, 196
Foot deformity, 4
Free aps, 27
Full thickness skin graft (FTSG), 26
G
Gas gangrene, 65
Gender disparities, 228–229
General anesthesia (GA), 212
Global inequalities, 229–230
Glucagon-like protein (GLP)-1 receptor agonists, 53
Glucose-lowering therapies, 52–53
H
Heel eschar, 14, 15
Heel ulcers, 205
Heparin-Induced Thrombocytopenia (HIT), 144–147
Home-based exercise therapy (HBET), 51
Hybrid deep vein arterialization, 219–221
Hyperbaric oxygen therapy (HBOT), 19, 37
Hypercoagulability, 162
Hyperspectral imaging, 289
Hypertension, 52
I
Iliac vein occlusion (ILVO), 263
Iliac venous conuence, 266–268
Iliocaval disease, 270
Iliocaval stent reconstruction, 302
Incisional biopsy, 13, 14
Indocyanine green angiography (ICGA), 73
In-stent restenosis (ISR), 127, 134
Intraoperative ultrasound, 45
Intravascular ultrasound (IVUS), 141
IR-podiatry relationship, 288
Ischemic ulcer, 6
Ischemic wounds, 5, 14
J
JET Stream, 142
K
Kaplan–Meier analysis, 182
Kissing stent technique, 157
Knee arterial disease management, 155
Knee stenting, 152–154
L
Laser atherectomy, 128–129
Lateral plantar artery, 44
Limb classication, 70
Limb ischemia, 283
LimFlow (LimFlow Inc.) system, 221
Limus-based therapy, 170–174
Lipid-lowering therapies (LLT), 51
Liposuction, 59
Long-term imaging
bypass follow-up, 300
deep venous disease, 301–303
EVT patients, 300–301
peripheral arterial disease, 297
Lymphedema management, 57–60
M
Magnetic resonance angiography (MRA), 35
Magnetic resonance venography (MRV), 36, 37
Maximum Intensity Projection (MIP), 34
May-Thurner Syndrome (MTS), 302
Medial artery calcication (MAC) scoring, 219
Mini-crush technique, 156–157
Minor amputations, 285, 286
Mixed wound, 9
Myocardial infarction (MI), 49
N
National Kidney Foundation (NKF), 35
Nephrogenic systemic brosis (NSF), 35
Neuropathic ulcer, 5
Neuropathic wound, 5
Non-contrast MR arteriography (NC-MRA), 39–40
Non-contrast MR venography (ncMRV), 40–41
Noninvasive imaging, 31, 36
Nonocclusive mimickers, 162
Non-thermal axial ablation therapy, 258–259
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Index
O
Ofoading, 8, 16
Ofoading pads, 17
Orphan heel, 205–208
Osteomyelitis, 65
Oxygen therapy, 18–20
P
Paclitaxel-coated balloons, 167
Paclitaxel-coated devices (PCDs), 167, 168, 170
Paclitaxel dosing, 168–169
Paclitaxel-eluting stents (PESs), 167
Pain management, 216
Patch angioplasty, 185
Patient empowerment, 289
PCSK9 inhibitors, 311
Pedal acceleration time (PAT), 43
Pedal anatomy, 42
Pedal ow hemodynamics, 43–45
Pedal surgical bypass, 191–195
Pentoxifylline, 55
Percutaneous DVA, 210
Percutaneous old balloon angioplasty (POBA) balloons,
151
Percutaneous transluminal angioplasty (PTA), 142, 199
Perfusion, 69
Periodic restaging, 71
Peripheral artery disease (PAD), 31, 45, 104, 139,
170–172, 226, 297, 301, 307
antihypertensives, 52
antithrombotic therapy, 53–55, 308–310
cilostazol, 55
diet modication, 50
exercise therapy, 50
glucose-lowering therapies, 52–53
lifestyle modication, 50–51
LLT, 51
medical management of, 307–308
medication failure vs non-responders, 311
pentoxifylline, 55
recommendations for, 57
risk reduction, 50–51
walking program, 308
Peripheral vascular disease (PVD), 1
Peroneal artery (PA), 206
Philips laser, 128
Phoenix, 93
Popliteal access, 100, 101
Popliteal artery aneurysms (PAAs), 174–177
Post procedure management
amputations, 285, 286
assessing plateaus, 285
deaths, 286
initial follow-up, 284
life after healing, 286
monthly wound checks, 284
wound monitoring, 287–289
Post thrombotic syndrome (PTS), 262
Posterior tibial artery (PTA), 206, 209
Post-thrombotic syndrome (PTS), 269
Powerlink/AFX, 81
Preprocedural aortography, 222
Primary pedal approach, 89
Primary pedal intervention, 92–95
Profunda femoris artery (PFA), 186
Profunda revascularization, 190
Profundoplasty, 187–190
Proximal DVA, 209
Pseudoaneurysm, 181
Pulse volume recordings (PVRs), 31, 32
Punch biopsy, 13, 14
R
Racial disparities, 228
Radial sheath entrapment, 108
Radiofrequency ablation (RFA), 255
Re-entry devices, 92
Regional aps, 27
Reintervention, 294
Restenosis, 215
Revascularization, 69–70, 73
Rotablator, 93
Rotarex, 142
S
Saphenopopliteal junction (SPJ), 253
Secondary lymphedema, 58
Secondary revascularization, 294
Self-expanding scaffold, 154
Self-monitoring, 289
SELUTION SLR drug delivery system, 173
Serranator PTA serration balloon catheter, 151
Shockwave Intravascular Lithotripsy (IVL), 151
Single stent technique, 155–156
Skin and soft tissue infections (SSTI), 22, 23
Skin perfusion pressure (SPP), 33, 207
Skin substitutes, 20–21
Skin thickening, 59
Small artery disease (SAD), 148, 199, 293
Smart dressings, 289
Society of Vascular Surgery (SVS), 297
Sodium-glucose transporter 2 (SGLT2) inhibitors, 53
Soft plaque, 197
Solo profunda, 186–191
Spear techniques, 211
Split thickness skin graft (STSG), 26
Standard patch, 188
Statin intensities, 52
Statin therapy, 311
Supercial femoral artery (SFA), 45, 100, 140, 178, 187, 298
Supercial venous disease, 253–255, 257, 260
Superior mesenteric artery (SMA), 81
Systemic/catheter-directed brinolytic therapy, 146
Index
319
T
Thermal axial ablation therapy, 258–259
Thrombolysis, 146, 147, 263
Thrombolytic-assisted intervention, 142
Thrombosis, 53, 145, 181
Thrombotic syndrome, 253
Tibial calcium management, 147–154
Tibial disease, 45
Tissue oxygen testing (TcPO2), 32
Tobacco cessation, 50
Tobacco use, 227
Toe brachial index (TBI), 32, 38
Topical oxygen therapy, 19–20
Transcutaneous oximetry (TcPO2), 289
Trans metatarsal amputation (TMA), 203
Transradial access (TRA), 104
T-stenting technique, 156
Type 2 diabetes, 53
U
Ultrasound based femoropopliteal
atherectomy, 195–199
Ultrasound-guided foam sclerotherapy, 258–259
Ultrasound testing, 36
Unna boot, 275
Upper extremity access, 107–108
V
Venous appearing wounds, 31–32
Venous Clinical Severity Score (VCSS), 252
Venous disease, 31
Venous disease management, 312
Venous distribution, 35
Venous interventions
chronic ilio-caval occlusion (see Chronic ilio-caval
occlusion)
compression therapy, 274–277
deep venous disease, 251, 253, 261–267
supercial venous disease, 251, 253–255, 257, 260
surgical options, 274
Venous leg ulceration (VLU), 7, 254
Venous stent placement, 270
Venous wound, 6
Vorapaxar, 309
W
Wet gangrene, 65
WIfI classication, 71
Wire test, 142
Wound care
amputation optimization, 27
basics of dressings, 10–12
bone biopsy, 13
calciphylaxis, 15
debridement, 7, 9, 10
decubitus wound, 5
foot deformity, 4
HBOT, 19
HBOT vs TOT, 20
infection, 4
ischemic wound, 5
lower extremity wounds, 13
mixed wound, 9
neuropathic wound, 5
ofoading, 8, 16
oxygen therapy, 18–20
reconstructive options, 25–27
site of cultures, 13
skin substitutes, 20
soft tissue breakdown, 4
SSTI, 22
topical oxygen therapy, 19–20
vascular exam, 3–4
venous mixed wounds, 7
venous wound, 6
wound environment, 8
wound vac, 15
Wound debridement, 9, 10
Wound environment, 8
Wound healing, 18
Wound monitoring, 287–289
Wound Severity Classication, 25
Wound vac, 15, 16
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