Dr. John Phillips from Ohio Health Vascular Institute shares his experience and case-based evidence using a new technology for repairing post-PTA dissections. The Philips Dissection Repair Device, Tack Endovascular System, is purpose-built to treat dissections and improve PTA and limb salvage outcomes.
Hello. My name is john phillips. I'm an interventional cardiologist at Ohio health riverside hospital and I'd like to share what I think is an interesting case of a patient with critical limb ischemia who had multiple areas of focal stenosis that ultimately after blue an angioplasty created some focal dissections and I think we were able to treat these with the phillips vascular attacked with a very successful result. So my patient presentation, this is a 71 year old gentleman who has rutherford class five critical limb ischemia involving the left leg. He has typical risk factors for PhD including previous prior coronary artery disease. Hypertension display body me in diabetes his medications are pretty typical including an anti platelet ace inhibitor beta blocker Staten. And he is on injectable insulin. He has um s schema ulcers that are present um over the left heel. Um and also over the great several of the toes. He also interestingly has a venus also over his media mail Eolas. So it looks like some mixed vascular pathology, both arterial and venus. On exam he has a palpable femoral pulse. Doppler signals were noted over the papa till the posterior tibial and DP. However they were faint over the papa teal and the posterior tibial artery. Very very faint over the D. P. The foot was robberies. He did have some dry gangrene over digits three and four as well as the as well as the heel ulcer and the medium valueless Venus. Also that we noted his left sided a. b. I was .65. Uh And if you appreciate the graph here he had really no flow going to the to the great toe and at least moderate lead diminished wave forms at the level of the metatarsal region. So he was taken for an angiogram. His inflow up until the SF. A, looked pretty good. He had focal stenosis here in the P. Two segment of the populace. Hell as well as a focal stenosis more distantly, unfortunately, has a single vessel runoff via a posterior tibial artery. Uh And then in this slide here, you can also appreciate a high grade stenosis. Fear. So he had, you know, three areas of high grade stenosis. This vessel here by ISIS was about 55 and this was about 35. The runoff against single vessel going to the posterior tibial. So multiple ways to kind of skin this cat. But I like to first start off with with ultrasound and these are images from the post proximal posterior tibial artery, then working away into the popular teal and again, dense, bulky plaque that is causing the high grade stenosis and the inclusive disease. I elected to perform a balloon angioplasty with a scoring balloon. This is a 35 scoring balloon in the osteopath proximal portion of the posterior tibial artery. And then we used a four oh balloon, Both in the excuse me, 50 balloon. In the in the popular and here you can see the waste where the which corresponds to the two lesions. I only treated the posterior tibial artery with the scoring balloon. But we did treat the pop little artery with a six millimeter drug coated balloon. I was maybe a little bit aggressive but also wanted to get appropriate Luminal gain. After the angiogram. You're able to see a flow living dissection in the more distal portion of the papal tail artery. And I'll kind of zoom in here with respect to the posterior tibial artery. There was a dissection in this section as well as a very focal dissection at the osmium. And given these focal dissections and in my opinion, they were flow limiting. And gentlemen, with single vessel disease, I think it's an excellent opportunity to use attack the implant just for scaffolding. I don't want to have to put long, at least in this case a balloon expandable or coronary stent. And here again the papa till it was a very focal focal stenosis. Or excuse me dissection within the focal stenosis and the plaque burden was such that it wasn't heavily calcified and I felt like I would get enough support from, from the scaffold. And so that's what we elected to do. So, here's kind of zoomed in a little bit on that area of of dissection that I wanted to treat more approximately. There there was a little dissection, but I elected to leave that alone. So we placed two tech implants and then within the posterior tibial artery. We placed a total of three tax in this dissection and a single tax in the more proximal dissection. Um And here here you can see um the the angiogram after the tax were placed. And then this is without without contrast, it's always important to get a fresh balloon when you post dilate the tax. So this is a fresh three oh coronary balloon. Um And then here we did intravascular ultrasound. What I what I like about this is that this this ultrasound is in the more proximal portion where we placed attack in the posterior tibial artery. And it really shows kind of the adaptive size of the tax itself. So it conforms to to fit the dissection. Um And and also kind of close that flap which is which is what the attack is made for. And it worked beautifully in this case. And then here's an example of the post tax dilatation in the more proximal section of of the of the pop little artery. So our final angiogram is seen here again, nice work with respect to providing good balloon expansion and Luminal game. But we also were able to attack up the three dissections that we noted both in the papa teal as well as the poster tibial artery. Uh And again I would draw your attention to the left side here where we now have what appears to be a normal wave form within the metatarsal region is and we also now have a waveform within the digit. So I think this was a successful case. Again, we minimize the amount of metal that we needed to to place in this gentleman, particularly in kind of areas where we try not to stint that being below the knee as well as the tibial tibial arteries. Um And we had a nice, nice and geographic result with improvement of the patient's A. B. I. And I actually have seen the patient recently and he has gone on to heal the ulcers on the toes and the heel, however, will need to treat his venus disease probably with the catheter based a blade blade of technology. Thank you for your time and I hope you found this case to be informative and educational.