An educational video: Navigating complex PAD cases

Navigating complex PAD cases
Managing complex peripheral arterial disease (PAD) requires more than technical skill. It begins with careful planning and a clear understanding of the disease. In this educational video, Drs. Peña and McMackin share how they approach challenging PAD cases, emphasizing the importance of careful preparation before the procedure begins.

Their discussion focuses on how clinicians assess complexity in PAD, including disease location, procedural objectives, and available options for vascular access. These experts illustrate how complex cases can be thoughtfully organized into manageable steps, helping clinicians navigate uncertainty and procedural challenges with greater confidence.

Special attention is given to high-complexity presentations such as total occlusions and chronic limb-threatening ischemia (CLTI). Through practical insight and real-world perspective, this video reinforces the importance of structured planning and strategic decision-making in the management of complex PAD.

Caroline Jackson (00:11)
We’re here today to talk about peripheral arterial disease. I have Dr. McMackin and Dr. Peña here, and I’d like to know about how you tackle complex PAD challenges.

Katherine McMackin (00:23)
Well, the complex PAD challenges really start with the planning. So, it’s how am I going to prepare my patient? What preps am I using? Where am I going to access and build up from there? Am I using one point of access, two points of access? Do I need a through-and-through wire? Setting yourself up for success before you even start, and then thinking about what’s the safest, most efficient way to cross the lesion and treat the lesion. At each one of those points, there’s a variety of different decision trees that lead you down different paths.

Caroline Jackson (00:48):
Yeah, I can imagine. How about for you, Dr. Peña?

Constantino Peña (00:51):
I would echo that. And that is, I think when you’re dealing with complex PAD, it starts with planning and assessment. Where is your disease? What are you trying to fix? How are you trying to access it? What are your options for access? Which ones may have the best results, which one may have the less risk? And planning from there. And really, taking a complex situation and try to break it down into smaller building blocks to try to get the best results.

Caroline Jackson (01:16):
Gotcha. Yeah. I mean, planning is huge, right? Knowing what you’re getting into. So, if you know, for example, a patient has a complex total occlusion, or perhaps they have CLTI, how does that change in your strategy, Dr. Peña?

Constantino Peña (01:32):
Yeah, when we’re dealing with a total occlusion or an occlusion of an artery, I think it’s important to understand that sometimes these can be very challenging to cross.

Constantino Peña (01:40):
And our first step is really trying to figure out how we can cross the occlusion so we can then treat it appropriately. Sometimes, we need to be as close as we can to the lesion. So, we may start with an access that may be on the same side. So, then we look at the size of our access, and we have proper size and proper devices so that we don’t lose pushability, and we’re able to then cross the lesion. So, that goes into selection of our sheath, selection of our wires and our access site.

Caroline Jackson (02:07):
Great. You mentioned staying on the same side. So, do you have any success stories that maybe you can talk about antegrade access?

Constantino Peña (02:16):
Yeah, I think when you look at antegrade access and other types of access is you’d like to be able to be in an area that you’re working what we call “downhill.” In other words, you’re right close to it and you’re not really fighting the forces. So being able to be on the same side or an antegrade access, you’re much shorter distance to where the lesion may be. And you really control and keep your forces all going towards one direction. This helps us to be able to cross—sometimes lesions are very calcified, very tough—by having to be able to kind of focal force or really have the force in that area as we’re pushing to try to cross a lesion.

Caroline Jackson (02:55):
Yeah. Dr. McMackin, in the same or similar scenario, how do patient comorbidities play a role in your planning process and severe calcification disease?

Katherine McMackin (03:05):
Yeah, when you’re thinking about access, that pushability is a huge part of it. The longer your sheath is, the harder it is. But when you think about antegrade access, especially in patients that maybe more rotund in their bellies and they have a pannus that’s overlaying their access, sometimes that makes antegrade access extremely difficult. So, then you’re thinking, “Okay, yes, it would be better in one scenario to be going straight at the lesion, but because of the patient comorbidities, it’s a safer bet to go— from the contralateral leg, go up and over and be able to avoid that pannus.” Similar thinking starting in the foot or something like that, to be able to avoid some of those groins that may be hostile.

Caroline Jackson (03:40):
Gotcha. Yeah. Now, in these similar cases that we’re talking about this, you know, complex severe calcification, I’d be curious, Dr. Peña, what are some of your crossing techniques? And is that determined at the moment, or is that something that you have pre-planned?

Constantino Peña (03:57):
Yeah, a lot of times we have a plan and an algorithm, kind of an escalation plan to cross a lesion. Our most challenging are those occlusions that could be calcified. And you’re basically trying to start with the devices that are going to have enough force that, as you push, you’re able to start to be able to get through that lesion and obviously stay in the vessel and stay in the best part of the vessel, or intraluminal, if you can, or subintimal, which is on the wall of the artery, to try to get through and be able to get a wire from one part of the artery back to a second part where you’re in the artery. Once you’re able to do that, then you’re able to treat. And I think my strategy is usually I start with— if I think it’s going to be tough, I’ll start with a stronger wire. So, I may go to an 0.035 wire as opposed to an 0.018 or 0.014. I may have a 0.035 catheter. So usually that’ll be a 4 Fr. You can use a crossing catheter, such as a CXI® type catheter, which is braided, has an angled tip, and you have some guys kind of focus on the tip, so you can try to guide your wire through that area of occlusion.

Caroline Jackson (04:59):
Great, great. Now, you mentioned subintimal versus intralumen. Is there a preference, Dr. McMackin? Do you have a preference?

Katherine McMackin (05:08):
Sure. So ideally, you want to be staying intraluminal. It gives you the best option with some further devices to get that true luminal gain as opposing just going subintimal. Sometimes subintimal is the only option. That intraluminal space is completely obliterated by plaque. You’re not going to be able to get through it. So, you do need to be able to have both options, but ideally, you’d be intraluminal if the options were both there.

Caroline Jackson (05:31):
Gotcha. And what are some of your key techniques for crossing? Can you verbalize some of those?

Katherine McMackin (05:37):
Yeah. So, when I’m thinking about crossing or reentry or getting back to true lumen, whether I’m subintimal or coming through a completely occluded segment, I’m thinking first about where’s the best place to end? Am I getting rid of any surgical options if I end up a little bit lower than I think I’m going? And how can I try to maximize exactly where I’m going in? You know, sometimes I say, “Okay, you really only get one shot to get back exactly where you want before you start dissecting that vessel a little bit further, a little bit further with each reentry try.” So, angulation, making sure that you’re in your mind visualizing what direction you’re going, which is not always easy in 2D space, to try to make sure that first attempt, you know exactly where you want to reentry and exactly which angle you want to be doing it at.

Caroline Jackson (06:21):
Yeah. Staying on that topic, you know, I know that sometimes you don’t have an option, like you said, that that calcium burden is too great when you’re in subintimal. Can you talk to me, Dr. Peña, about some of your strategies when you see that you have to go subintimal?

Constantino Peña (06:35):
Yeah, I think we go subintimal more than we think. Sometimes it’s very difficult to tell if you’re intimal or subintimal. But I think I would echo that approach of starting a lot of times antegrade or coming down the SFA or down the artery, trying to recanalize and then being able to plan. I think it’s really important to have that algorithm. Do I know where I want to start? Do I know where I want to end up? Do I know how far down I’m willing to go subintimal before I reenter? And then having your other strategy, hey, this is going to be my first attempt, I’m going to go antegrade. Then my second approach may be retrograde. I may have a pedal approach or a tibial approach. I already have that in my mind. What’s my algorithm? What’s step A, step B, step C, and then be able to pivot quickly once that happens. So, a lot of times my approach is to go through, try to go in an antegrade approach. If I see that I can’t reenter, at which point I usually go retrograde, whether a pedal approach or a tibial approach, and go a lot of times just by placing a wire in the small sheath and using that enough to be able to go retrograde. And that may help me recanalize. Then there are a lot of other techniques. We have reentry type catheters like the BeBack® catheter and things like that that may help us from an antegrade and retrograde for these complex reentries.

Caroline Jackson (07:50):
I want to hear more about how you plan your patients based off of their symptoms. So, if they are a claudicant versus a CLTI, how does your strategy differ?

Katherine McMackin (08:01):
Sure. So, for anyone presenting with peripheral arterial disease, my first thought is, are they appropriately medically managed? Who am I partnering with that am I taking over their medical management? Do they also work with a cardiologist? Do they also work with their primary care? What are their other comorbidities and medications and how are these going to mix with them? But a statin and an antiplatelet for everybody to give them the best possibility for success long term. And then, anyone in the claudication space, a walking program, 30 minutes, three times a week, ideally supervised. And that can be digitally supervised, virtually supervised, or in-person supervised, to try to get them to create brand new blood vessels and increase the flow through those collaterals. So, planning through all of that and then setting yourself up for success, if you do end up intervening, knowing exactly what their anatomy is, any previous interventions, and having a plan for where you’re going to access and how you’re going to access even more than how you’re going to treat.

Caroline Jackson (08:53):
Well, thank you so much, Dr. McMackin, Dr.Peña. Appreciate this discussion.

Drs. Peña and McMackin are paid consultants of Cook Medical.
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