Chronic limb-threatening ischemia (CLTI) represents the most advanced stage of peripheral artery disease. While many patients can be treated with endovascular or surgical revascularization, a subset of individuals remain ‘no-option’ candidates when conventional therapies fail or distal targets are absent. In this episode of BackTable, host Dr. Ally Baheti speaks with Dr. Mary Costantino, interventional radiologist at Advanced Vascular Centers, and Jill Sommerset, vascular technologist and Director of Clinical Education and Training at Aveera Medical, about the emerging role of spinal cord stimulation (SCS) as a potential therapy for patients with no-option CLTI.
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SYNPOSIS
This episode explores where spinal cord stimulation may fit within the treatment landscape for advanced CLTI, particularly for patients who are not candidates for revascularization or deep venous arterialization (DVA). Dr. Costantino describes how interest in the therapy developed through multidisciplinary collaboration and early physiologic observations using pedal acceleration time (PAT) measured with duplex ultrasound alongside angiography. A representative case highlights immediate, setting-dependent improvements in PAT following stimulation, and the group reviews early trends from a small patient cohort suggesting improved distal perfusion in individuals with severe infrapopliteal disease. The conversation also addresses practical barriers to adoption, including site-of-service and reimbursement challenges and the difficulty of implanting permanent stimulators in patients with active wounds. Jill Sommerset adds perspective from the vascular lab, discussing ultrasound-based methods to quantify physiologic changes after DVA and how similar perfusion metrics may help evaluate spinal cord stimulation. The episode concludes with a discussion of the potential role of neuromodulation in this population and the need for larger datasets to better define its clinical impact.
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TIMESTAMPS
00:00 - Introduction
02:02 - Why CLTI Needs Options
06:25 - First No Option Case
11:06 - Trial Turns Flow On
14:38 - Timing and Reimbursement
19:59 - Early Results and Adoption
22:45 - How Spinal Cord Stimulation Might Improve Flow
26:46 - Patient Selection and Access
30:24 - Treatment Algorithm and Timing
32:37 - Quality of Life and Mobility
37:57 - Implant Delays and Coordination
39:41 - Data
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RESOURCES
Paper on Maturation after DVA
https://www.sciencedirect.com/science/article/pii/S1078588426000523
