Ep. 336 My Algorithm for Below the Knee CLI with Dr. Peter Soukas

In this episode, host Dr. Christopher Beck interviews Dr. Peter Soukas about his algorithm for below the knee (BTK) critical limb ischemia (CLI) interventions as well as his implementation of new evidence-based guidance.

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SHOW NOTES

Dr. Soukas serves as the director of vascular medicine, the interventional peripheral vascular lab, and the endovascular medicine fellowship at Brown University in Providence, RI. In addition, he holds the position of associate professor of medicine at The Warren Alpert Medical School at Brown University. Dr. Soukas began his career as an interventional cardiologist. Over the course of his 13-year tenure in Providence, he has dedicated his career to the treatment of CLI and BTK disease.

Prior to any interventional work, Dr. Soukas follows a comprehensive work-up including an ankle-brachial index (ABI), arterial duplex, and evaluating kidney function for safe administration of contrast. For a majority of cases, he uses the common femoral artery as the access point, but prefers to prep multiple access sites in the event of needing both anterograde and retrograde, or pedal, access. He discusses the use of the chronic total occlusion crossing approach based on plaque cap morphology (CTOP) classification on angiogram in determining the need for a retrograde approach. The type I morphology is characterized by the convexity of the plaque pointing away and is often treated successfully by an anterograde approach alone, as CTOP types II, III, and IV benefited from the addition of retrograde tibiopedal access. Once access is gained and the plaque morphology is evaluated using angiography, it becomes crucial to address any issues with the inflow to the affected vessel. This step ensures proper blood flow and provides a stable foundation for further interventions. Intravascular ultrasound is then used to assess the size and extent of the plaque, and then depending on the amount of calcification, either intravascular lithotripsy or calcium modifying technology can be used. Scoring balloons with low pressure may also be used for vessels that are moderately calcified and have been shown to have low rates of recoil and dissection. The main initiative of the procedure is to provide blood flow to the target angiosome which is dependent on the location of the wound.

During his last remarks, Dr. Soukas comments on the future of BTK interventions, including Paclitaxel vs Sirolimus eluting stents, the use of self-expanding stents, and LimFlow, a minimally invasive technology that creates a channel between an artery and vein allowing the vein to provide blood flow to the foot. With the increasing prevalence of critical limb-threatening ischemia (CLTI) and high 12-month mortality rates in patients with amputations, Dr. Soukas ends the discussion by emphasizing how revascularization should be the preferred initial approach in treating CLTI due to the potential benefits it offers in terms of limb preservation and mortality reduction, urging practitioners to educate patients in being aggressive in their care.

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RESOURCES

CTOP article:

https://evtoday.com/articles/2018-may/using-plaque-cap-morphology-to-determine-cto-crossing-approach

Disrupt PAD III Observational study:

https://pubmed.ncbi.nlm.nih.gov/34380334/

PRELUDE BTK Study:

https://pubmed.ncbi.nlm.nih.gov/34802313/

Intravascular Ultrasound study:

https://www.jacc.org/doi/10.1016/j.jcin.2022.01.001

Intravascular US in Medicare Beneficiaries:

https://pubmed.ncbi.nlm.nih.gov/35998803/

PROMISE II study:

https://limflow.com/us/clinical-evidence/promise-ii-study-results/