Tips and tricks in femoropopliteal lesions

Lower extremity peripheral artery disease is the progressive deterioration of lower extremity arterial blood circulation due to systemic atherosclerosis. Morbidity and mortality rates are high in this disease [1]. In the prevalence studies conducted in our country, the incidence in the society with increasing age is 20%-30% [2]. The diagnosis can be made by measuring the ankle brachial index. The incidence of coronary artery disease and congestive heart failure increases in individuals with lower extremity peripheral artery disease [3]. For this reason, we wrote this article on tips and tricks in Femoropopliteal Lesions (FPL), which have an important place in lower extremity peripheral artery disease.


Introduction
Lower extremity peripheral artery disease is the progressive deterioration of lower extremity arterial blood circulation due to systemic atherosclerosis. Morbidity and mortality rates are high in this disease [1]. In the prevalence studies conducted in our country, the incidence in the society with increasing age is 20%-30% [2]. The diagnosis can be made by measuring the ankle brachial index. The incidence of coronary artery disease and congestive heart failure increases in individuals with lower extremity peripheral artery disease [3]. For this reason, we wrote this article on tips and tricks in Femoropopliteal Lesions (FPL), which have an important place in lower extremity peripheral artery disease.

Femoropopliteal lesions
Retrograde puncture and crossover (contralateral) technique: An 8F sheat is entered by puncturing the contralateral femoral artery. Then, aortic bifurcation is reached with a 4F LIMA catheter over a 0.035 inch hydrophilic wire. In the aortic bifurcation, the mouth of this catheter is turned towards the common iliac artery. Following this, the hydrophilic wire is advanced from the common iliac artery to the femoral artery. Later, the LIMA catheter is advanced over the hydrophilic wire to the other femoral artery. After this catheter is advanced into the femoral artery, the hydrophilic wire is removed. And the supracor or super amplatz stiff wire is advanced through the LIMA catheter in the femoral artery to wire the SFA. Later, the LIMA catheter is removed and sent over the supracor stiff wire, usually 90 cm sheatless, depending on the location of the lesion. Then, the supracor stiff wire is removed and the lesion is reached with a 0.014-0.018 inch compatible Minie support catheter, supercross microcatheter or other microcatheters with ASTATO 30 or TRESSURE 12 wires. ASTATO 30 is a penetration wire and is changed with TRESSURE 12 after the lesion is passed. The lesion is tried to be passed with various maneuvers. If there is a subintimal progression, it is tried to fall into the lumen by supporting the wire with a microcatheter. If the lumen cannot be reduced despite reaching the distal cap, the existing microcatheter can be changed with Bern, Quikcross or navicross microcatheter to direct the wire to the lumen. If the lesion cannot be passed with a 0.018 inch wire, a 0.035 wire can be used. If the 0.035-inch wire lesion does not pass, the proximal cap can be crossed with the back stiff side of the wire in total occlusions. However, in this case, attention should be paid to perforation. As the proximal cap is passed, the microcatcher is advanced in the lesion and the procedure is continued with the soft part of the wire.
Although the guides recommend a stent in FPL, if there is no residual lesion after 4-5minutes of balloon infl ation, or dissection limiting the fl ow, stenting is not recommended by experienced operators. After balloon dilatation, run off is evaluated in 3 stages. Stage 0 is the stage where there is no fl ow, stage 1 is the slow fl ow and stage 2 is the normal fl ow [4]. Stent restenosis is particularly high in long stents. If the residual lesion is below 50%, grade D and higher dissection, ie dissection that limits the fl ow with peak translesional systolic pressure gradient above 10 mmHg, the procedure is considered successful. If there is more than 50% of the residual lesion and a dissection limiting the fl ow, a stent can be inserted [5]. Care Citation: Değirmenci  • Using a rigid angled glidewire angled less than 5-6mm on the straight glide or Quick croos catheter support.
• Lumen re-entry devices (using angled microcatheters such as a bern or navicross catheter) when approaching the distal cap • Using a stiff wire such as Cross-it 300-400 for the 4F bernstein microcatheter to perforate the intimal fl ap and drop it into the true lumen.
• Shaping the back of a stiff wire to J shape and using (Road runner, glidewire, confi anza etc.) • Using the proximal portion of a V18 wire formed after cutting the proximal loose part with a clamp forceps.

Recommendations for atherectomy
Excisional atherectomy is mostly used, and in this technique, our main goal is to prevent barotrauma and plaque shift that occur during balloon angioplasty. Treatment of severely calcifi ed SFA lesions with atherectomy devices is still diffi cult and there is a risk of embolization. SilverHawk atherectomy catheter (Medtronic) is the best atherectomy device designed for the treatment of new and restenotic atherosclerotic lesions. This device is used with 0.014 inch wire. This device is used with 7-8 F sheath depending on the size. It has a blade rotation speed of 8000/min (10).
The patients who need to use a distal fi lter in chronic total occlusion of SFA are as follows [11]: It means enough landing area; it means reaching the disease-free area over 5-10 mm above the infrapopliteal trifurcation with a wire [11].

New technologies in femoropopliteal lesions
Intravascular lithoplasty system in peripheral artery disease: In this system, balloon angioplasty is performed with sound waves and calcifi ed plaque is broken. With this system, calcifi ed plaques, which are diffi cult to treat with drug-coated balloons or stents, are treated without damage to the vascular wall thanks to the low pressure balloon with the effect of sound waves. Shockwave peripheral intravascular system is a device known as M5, which contains over the wire balloon, 3.5-7 mm in diameter, 60 mm in length, can be used with a 6F or 7F sheat. Recently, 4 additional catheter sizes (2.5 mm; 3 mm, 3.5 mm and 4 mm; 40 mm length, compatible with 5F sheat, known as S4) have been defi ned. The S4 lithotripsy device has a smaller Citation: Değirmenci  In order to transmit the shock waves, the isotonic-contrast fi lled balloon is infl ated at subnominal pressure (4 atm) in the calcifi ed peripheral vein. Then, the shock waves are generated from the generator by pressing the intravascular lithotripsy button. This lithotripsy device is advanced through the calcifi ed vein. An average of 160-300 shock waves are generated per device [12,13].

Pantheris lumivascular atherectomy system
It is a directional atherectomy system including optical coherence tomography. Provides three-dimensional visual guidance with optical coherence tomography. In addition, optical coherence tomography has the benefi t of reducing damage to the vessel wall during plaque removal [14]. Pantheris Lumivascular Atherectomy system consists of catheter, sheat, lightbox imaging console and lightbox imaging sled. The catheter part is 135cm and contains the optical fi ber part of the optical coherence tomography [14,15].

Lithoplasty and pantheris studies
35 patients with moderate to severe calcifi ed femoropopliteal lesions were included in the DISRUPT PAD 1 study (2017). The mean initial stenosis of these patients was 76.3% and the mean lesion length was 61.5mm. 64.1% of these patients had severe calcifi cation and the mean calcifi ed lesion length was 80.3 mm.
The Lithoplasty system has been successful in all patients. The criterion for success was residual stenosis below 50%. Residual stenosis averaged 23.4%. 30-day patency rate was 100% while 6-month patency rate was 82.1% [16].  [14], which is associated with the Pantheris system.
In this study, the mean lesion length was 58 mm, the mean stenosis rate was 78.7%, and the chronic total occlusion rate was 20.2%. Cases with moderate to severe calcifi ed lesions, patients with iliac artery lesions, cases with graft lesions, patients with restenotic lesions, cases with acute ischemia, and patients with thrombosed lesions were excluded from the study. In this study, the residual stenosis rate was below 50% in 192 of 198 lesions with the Pantheris system. With the Pantheris system alone, the average initial stenosis rate fell from 78.7% to 30.3%.

Conclusion
Knowing the technical approach to FPL will contribute to the reduction of morbidity and mortality.