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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3803_Библиотеки_им_академика_М_И_Перельмана
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A. Stathis et al.
D
S
M
Diameter reduction
≥ 50% of lumen?
no
Spiral shape?
no
no
FLIPI 1
no
FLIPI 2 or 3
Multiple ≥2cm
One ≥2cm long
Any number of
dissections <2cm
F
yes
yes
yes
dissections
dissection
SCAFFOLD
RECOMMENDED
SCAFFOLD
RECOMMENDED
SCAFFOLD
RECOMMENDED
SCAFFOLD
RECOMMENDED
CONSIDER
SCAFFOLDING
CONSIDER
SCAFFOLDING
Fig. 5.3 Flowchart for the management of dissections in peripheral arterial interventions
Summary
Balloon angioplasty remains the cornerstone of endovascular treatment for occlusive arterial disease. Controlled dissection to facilitate luminal expansion is its main
goal. However, that vascular injury may trigger a cellular response that leads to
negative remodeling, restenosis and return of ischemic symptoms. Furthermore,
uncontrolled dissection and deep blood vessel wall injury may result in acute
FLIPI 0
One of more ≥2cm
dissections
Multiple <2cm
dissections
One single <2cm
dissections
CONSIDER
SCAFFOLDING
CONSIDER
TO LEAVE
LEAVING
RECOMMENDED
5 Blood Vessel Compliance, Barotrauma and Angioplasty-Induced Dissection…
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occlusion and early target lesion failure. An understanding of the mechanisms of
PTA and the pathophysiology which results is critical for interventionalists to guide
PAD management and procedural decision-making.
Disclosures RV is a consultant for Abbott Vascular, Medtronic, Boston Scientic, Intact Medical,
BD Bard, Surmodics and Intervene. No other authors have relevant disclosures.
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Chapter 6
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Controlling Dissections inPeripheral
Arterial Interventions
NicolasW.Shammas
Injury to the deeper layers of an infrainguinal artery is a potent trigger for restenosis, loss of patency, and the need for future target revascularization [1–3]. Dissections
are an inevitable consequence of balloon angioplasty (PTA) and are the main mechanism to gain minimal luminal area (MLA) and prevent vessel recoil [4]. Recent
research has focused on how to balance the occurrence of dissections and the gain
in MLA without a detrimental disruption to the deeper layers of an artery. Also the
interaction between residual narrowing, dissections’ extent, dissection repair, and
the use of antiproliferative therapy needs to be better explored because paclitaxelcoated balloons and dissection repair have been shown to partially mitigate some of
the negative consequences of dissections. In this chapter, I will explore this concept
more based on some ndings from clinical trials.
Traditionally, the NHLBI classication has been used to classify dissections
based on angiographic ndings [5] (Table6.1). This classication was adopted from
the coronary literature and has several limitations. It only considers the single worst
dissection regardless of number of dissections and does not consider the length,
depth, and extent of dissections. Deeper injury is also not well appreciated using
angiography, and therefore, this type of injury is not adequately or accurately captured by the NHLBI classication. These deeper injuries may not be visible or may
appear low grade on angiogram. Larger arcs of dissections can also be missed on
angiography and may not be well represented by the NHLBI classication. Despite
its shortcomings, the NHLBI classication has been able to predict acute vessel
Modied from original publication “The Quest for Optimal Peripheral Angioplasty: Controlling
Dissections” in the Journal of Arterial Venous and Lymphatic Interventions (https://javelinjournal.
org/the- quest- for- optimal- peripheral- angioplasty- controlling- dissections/).
N. W. Shammas (*)
Midwest Cardiovascular Research Foundation, Davenport, IA, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
N. W. Shammas (ed.), Peripheral Arterial Interventions, Contemporary
Cardiology, https://doi.org/10.1007/978-3-031-09741-6_6
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Table 6.1 NHLBI classication for coronary dissections
Dissection Description
Type A Small radiolucent area within the lumen of the vessel disappearing with the passage
of contrast material
Type B Appearance of contrast medium parallel to the lumen of the vessel disappearing
within a few cardiac cycles
Type C Dissection protruding outside the lumen of the vessel persisting after passage of the
contrast material
Type D Spiral-shaped lling defect with delayed runoff of the contrast material in the distal
vessel
Type E Persistent luminal lling defect with delayed runoff of the contrast material in the
distal vessel
Type F Filling defect accompanied by total coronary occlusion
N. W. Shammas
closure and loss of patency [6, 7]. NHLBI types C–F showed a signicantly lower
patency rate (p<0.001) and higher clinically driven TLR (p<0.001) compared to
type A and B dissections.
Recently, a new angiographic-based classication was published which is dedicated to peripheral arteries. In the DISFORM study, Voute etal. [8] obtained expert
consensus on features of dissections in the femoropopliteal artery that can potentially predict a poor outcome following intervention. An expert panel of 17 interventionalists ranked dissection features that have the potential to lead to acute technical
failure and/or early restenosis and which combination of features would require
repair of these dissections to improve outcome. Panelists recommended scaffolding
in the presence of signicant diameter reduction, spiral shape, ow impairment, or
adverse morphology (Fig. 6.1). The Flow Impairment in Peripheral Intervention
(FLIP) method was adopted (Table6.2). The relationship of this classication to
clinical outcome is yet unclear and needs to be determined in future studies.
Precise Imaging
Precise imaging within the vessel wall is critical to evaluate the degree and extent of
dissections. The iDissection grading system uses intravascular ultrasound (IVUS) to
classify dissections in infrainguinal interventions. The depth of dissection is graded
as A (intima), B (media), and C (adventitia). The arc of dissection is graded as 1
(less than 180°) or 2 (more or equal 180°). This six-grade classication (A1, B1, C1,
A2, B2, C2) is reliable and can quickly be performed during the procedure (Fig.6.2,
Table6.3) [9].
The iDissection grading system was used for the rst time in a small study evaluating the number, depth, and extent of dissections following atherectomy [10]. In
this study, Jetstream atherectomy (n=13) and B-laser (n=2) were used. De novo
and non-stent restenotic lesions were included. Angiography and IVUS (Eagle Eye
Voûte, M. T. et al. J Am Coll Cardiol Intv. 2021;14(21):2391-2401.
6 Controlling Dissections inPeripheral Arterial Interventions
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CENTRAL ILLUSTRATION: Flowchart for Management of Postangioplasty
Dissections of the Femoral and Popliteal Arteries
99
D
M
Diameter reduction
≥50% of lumen
no
S
F
Spiral shape
no
FLIPI 2 or 3
no
M2
M1
M0
Multiple ≥2 cm
dissections
OR
One ≥2 cm or multiple
<2 cm dissections
OR
One <2 cm dissections
yes
yes
FLIPI ≥1
FLIPI 0
yes
FLIPI 1
FLIPI 0
FLIPI 1
FLIPI 0
FLIPI 1
SCAFFOLD
SCAFFOLD
SCAFFOLD
(Moderate
Recommendation)
SCAFFOLD
SCAFFOLD
(Moderate
Recommendation)
SCAFFOLD
(Moderate
Recommendation)
SCAFFOLD
(Moderate
Recommendation)
NO SCAFFOLD
(Moderate
Recommendation)
NO SCAFFOLD
(Moderate
Recommendation)
Fig. 6.1 Central illustration: owchart for management of postangioplasty dissections of the femoral and popliteal arteries
FLIPI 0
NO SCAFFOLD
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Table 6.2 The FLIPI score for peripheral artery dissections
Score descriptor
FLIPI 0 Normal antegrade ow
FLIPI 1 Mild reduction in antegrade ow
FLIPI 2 Minor antegrade contrast penetration, faint ow beyond the
dissection
FLIPI 3 No ow-through, only collateral lling distal to the
dissection
Fig. 6.2 Dissection
involving the media and
less than 180°. Based on
iDissection classication,
this is a B1 dissection
N. W. Shammas
Table 6.3 iDissection, depth of injury, and arc of injury
iDissection Depth of injury
A Intima
B Media
C Adventitia
iDissection Arc of injury
1 <180°
2 ≥180°
Platinum, Philips) were performed at baseline, post-atherectomy, and postadjunctive balloon angioplasty. Core angiographic (Midwest Cardiovascular
Research Foundation, Davenport, IA) and intravascular ultrasound (Midwest
Cardiovascular Research Foundation, Davenport, IA, and St John Hospital, Detroit,
Michigan) laboratories evaluated all images. In this study, critical limb ischemia
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was present in 26.7% of patients, and 60% of lesions had grade 3 and 4 PACCS
grade calcication. Adjunctive balloon angioplasty was performed in all patients
(Shockwave 33.3%, drug-coated balloons 100%). Mean balloon pressures and ination times were 10.3 atmospheres and 310s. Procedural success (<30% residual
narrowing at the end of procedure) was accomplished in all patients, and residual
narrowing post-angioplasty was 19.7%. Dissections were identied four to six times
more on IVUS when compared to angiography (post-atherectomy and adjunctive
angioplasty IVUS to angiographic dissection ratios were 5.75–1 and 3.55–1, respectively) (Fig.6.1). Wider dissections >180° were also noted on IVUS in 13% and
31% post-atherectomy and adjunctive PTA, respectively. Furthermore, deeper dissections involving the media and adventitia occurred in 39.1% and 33.3% postatherectomy and adjunctive PTA, respectively. Finally, IVUS identied intramural
hematoma in 13.3% of vessels post-atherectomy. These results showed clearly that
Jetstream atherectomy can create a damage to the inner layer of the arterial wall and
potentially this may offset some of its benet in reducing restenosis from plaque
removal.
The iDissection classication also was tested with the Flex VP (VentureMed
Group) atherotome and was found to have a low number of deeper dissections. The
FLEX Vessel Prep System (VentureMed Group) is a one-size-ts-all device with
three atherotomes mounted on a self-expanding treating element designed to create
multiple longitudinal, controlled-depth, continuous micro-incisions across the
entire lesion length. IVUS-based analysis post-FLEX VP was recently published
and conrmed less deep dissections (media and adventitia) than seen with historical
data from some atherectomy devices [11]. In 15 patients treated with the FLEX VP
followed by adjunctive balloon angioplasty (Shockwave 33.3%, PTA 26.7%, drugcoated balloon 40%) for de novo or non-stent restenotic femoropopliteal disease,
procedural success was 86.7% (<30% residual narrowing at the end of procedure).
Minimal luminal area increased from a median of 5.2 to 15.0mm2 (p<0.001) with
no change in reference lumen diameter or plaque burden area (p=0.32). Of all new
dissections (n=37) post-FLEX VP and PTA, 18.9% were more than 180° in circumference, and 21.6% involved the media and adventitia. These numbers appear
favorable compared to rotational and aspiration atherectomy, but head-to-head comparison data are not available. The low number of large aps and deeper dissections
may offer an explanation to the low provisional stenting seen with this device. The
impact of these encouraging acute results on long-term outcomes is not yet known.
A recent study with the Auryon laser system has shown a very minimal number
of C dissections based on the iDissection classication system [12]. In a prospective
study of 29 patients, adventitial injury was assessed by IVUS following Auryon
laser treatment and adjunctive balloon angioplasty. Core laboratory analysis was
carried on all cases except for one patient (that crossed over to Jetstream atherectomy). Bailout stenting occurred in 21.4% patients (three for dissections, two for
residual >30%, and one for both). By IVUS, there were 9 new dissections post-laser
(1 adventitial; 3 ≥180°) and 21 new dissections post-laser and PTA (3 adventitial; 1
≥180°). This small number of deep dissections can be attributed to the physics
property of the long wavelength (355nm) of the Auryon laser. The Auryon laser
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thermal injury dissipates quickly as it travels away from the tip of the catheter making deeper thermal injury less likely.
It is clear from precision imaging that various devices have the ability to remove
a different amount of tissue from the treated vessels and lead to a range of deep
damage to the inner layers of the artery. A balance between the extent of tissue excision and deep injury is likely to be of paramount interest when it comes to reducing
long-term adverse events. The interaction of tissue removal, deep injury, dissection
repair, and the application of antiproliferative therapy needs to be explored further.
N. W. Shammas
The Relationship Between Deep Injury, Plaque Excision,
Dissection Repair, andAntiproliferative Therapy
Several studies suggested an association between arterial dissections and high residual narrowing on poor outcomes in the treatment of infrainguinal arterial disease.
However, the applications of antiproliferative therapy and dissections’ repair seem
to mitigate at least partially the subsequent adverse outcomes of dissections and
high residual narrowing. Below are some studies that may give some insights into
this interaction.
Aggressive Debulking, High Rate ofDeeper Dissections,
andAntiproliferative Treatment
The Jetstream atherectomy device is a high-power device in plaque excision and
leads to low residual narrowing on its own (typically less than 50%). However, it
also causes its share of deeper dissections into the vessel wall by IVUS although
angiographically this may not always be apparent [9]. In the JET Registry [13], a
prospective study of Jetstream atherectomy with no drug-coated balloons (DCB),
the freedom from TLR was 79–80% at 1year. In the JET-SCE [14], a retrospective
study of all comers treated with the Jetstream atherectomy device, freedom from
TLR was reduced to 69.8% at 1 year, but the cohort of patients receiving
Jetstream+DCB had a freedom from TLR of 95.2%. Recently, data from the JETRANGER [15] study presented at TCT 2021 have shown that freedom from TLR
was 100% at 1year in the cohort of patients who received the Jetstream atherectomy
and either the Ranger DCB or IN.PACT DCB balloons. In the JET-RANGER, there
was no bailout stenting in the Jetstream + DCB cohort based on lack of angiographic presence of a ow-limiting dissection or the presence of more than 30%
residual narrowing. These studies point to the following:
(a) Aggressive debulking does not on its own lead to a better outcome.
(b) The administration of antiproliferative therapy had a strong mitigating factor on
reducing the poor outcomes of deeper dissections with (JET-SCE) or without
(JET-RANGER) repair in the setting of aggressive debulking device.
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