Continuing with my theme of PAD pearls, I want to share with you a simple method of embolic protection when performing fem-pop atherectomy. There are currently two commonly used embolic protection devices including the EmboShield NAV6 from Abbott and the SpiderFX from Medtronic. CSI has a device that I’m not too familiar with (Wirion) which had some trouble and was recalled in November 2021. Regardless, EPDs are nice because you can protect your patient from terrible complications such as trashed runoff vessels which can turn a case of chronic ischemia to acute very quickly. Nobody wants to see that!
Despite the peace of mind EPDs give you, they can be somewhat of a hassle to deal with and practically speaking, they cost money. In particular, you can’t perform orbital atherectomy using the less expensive SpiderFX, forcing you to use the nearly cost-prohibitive NAV6 from Abbott. While we want to always do the right thing for patients, we need to stay in business and be mindful of costs to keep our competitive financial advantage in the OBL setting.
So instead of using these fancy devices, why not make it simple and obtain pedal access as a “natural filter”? Yes, it really works.
Placing a 4 Fr Merit Prelude Ideal sheath in a patent PT and AT can make a world of difference. Simply open the sheaths and let them bleed while you are performing atherectomy and while deflating an angioplasty balloon of the treated segment. While you’re at it, take a careful look at what comes out the sheath and you may be surprised. By opening the sheath we are in essence creating a pressure gradient which preferentially sends blood down the vessels which have open sheaths. It’s a great way to protect our runoff. Can also use it as an access point to intervene on occluded tibial vessels which are crucial in patients with critical limb ischemia.
Yes, at first I thought it was somewhat overkill to gain alternative access for purposes of filtration, but after having done it over 30 times now, I’ve found it to be easier, and I definitely find it preferable to worrying about a distally placed EPD and being mindful of the filter location while working. To be clear, I only do this in patients with critical limb ischemia. For one, I don’t treat claudicants unless they’ve exhausted all aspects of conservative management (a post for another day). If I did treat a claudicant, I wouldn’t mess with their pedal vasculature though I do believe it is safe for many high volume operators.
There are many ways to get a case done, and this is by no means the “right way,” but it’s a way that I like and you may find it beneficial.