Educational ExhibitAbstract No. 363 - Protecting the runoff during lower extremity arterial interventions using embolic protection devices

Abstract

1. Identifying lesions and procedures at risk for distal embolization. 2. Discussing the risks and benefits in using protection devices during lower limb interventions. Embolic protection devices were first introduced in 1990 to prevent cerebral infarcts during carotid artery stenting. The routine use of protection devices significantly decreased stroke risk and have also been implemented in other vascular beds. Percutaneous endovascular lower limb arterial interventions are increasingly being done for the treatment of peripheral arterial disease. Identifying vulnerable lesions and high risk procedures more likely to cause distal embolization is important to minimize periprocedural complications, maximize procedural success and minimize re-interventions. Distal embolization during lower extremity interventions is a variably reported complication with incidence varying from 1.5% to 19% for clinically significant embolic events depending on the case series of patients. Unstable lesions more at risk for distal embolization include intervening on chronic total occlusive disease, in-stent lesions, complex long complex lesions, heavily calcified lesions, ulcerated friable atheromatous plaque or thrombus-laden/occluded bypass grafts. High risk procedures include catheter-directed pharmacomechanical thrombolysis, use of atherectomy devices and recanalization of occluded stents and bypass grafts. Subclinical microemboli are near ubiquitously dislodged even during simplest interventions including crossing the target lesion with a wire or during balloon/stent angioplasty. It is important to note that protection devices are not complication free nor do they completely negate the risk of distal embolization. The profile of individual devices can limit the crossability past certain lesions which in of itself may propagate distal emboli during manipulation or allow emboli to pass unhindered if there is an incomplete seal against the vessel. Embolic protection devices can prevent embolic debris during lower limb interventions. Knowledge of at-risk lesions and interventions can assist the inteventionalist in choosing to employ these devices on a case-by-case basis.