Biondi-Zoccai: Peripheral interventions gbiondizoccai@gmail.com – metcardio.org Basic principles...

transcript

Basic principles of Basic principles of peripheral peripheral

interventionsinterventions

Giuseppe Biondi ZoccaiGiuseppe Biondi ZoccaiUniversity of Turin, Turin, ItalyUniversity of Turin, Turin, Italy

gbiondizoccai@gmail.comgbiondizoccai@gmail.com

Educational Fellowship Course In PCI For Young Educational Fellowship Course In PCI For Young InterventionalistsInterventionalists

Session 2 - How do I treat: Case based discussionSession 2 - How do I treat: Case based discussion

22 October 2009 – 16:35-16:4722 October 2009 – 16:35-16:47

rgDISCLOSUREDISCLOSURE

I am giving a lecture at a Fellows’ Course

rgLEARNING GOALSLEARNING GOALS

Why peripheral interventions are important for everybody

General approachWhat is similar and what is different between coronary and peripheral arteries

District-specific tips & tricks

rgWHY SO IMPORTANT?WHY SO IMPORTANT?

PAD is often present in patients with established CAD

PAD may be the first and/or only manifestation of atherothrombosis in several pts

Peripheral complications during PCI or other cardiac interventions are not rare and should best be managed by YOU in the cath lab

A GLOBAL MANAGEMENT A GLOBAL MANAGEMENT APPROACH IS A MUSTAPPROACH IS A MUST

rgTAKE CARE AT PREPPING TAKE CARE AT PREPPING

ALWAYS BEGIN YOUR ALWAYS BEGIN YOUR TRAINING AND YOUR SINGLE TRAINING AND YOUR SINGLE PROCEDURE WITH A GOOD PROCEDURE WITH A GOOD QUALITY ANGIOQUALITY ANGIO

IMAGING WITH DSA IS A IMAGING WITH DSA IS A MUST FOR ALL VESSELS < MUST FOR ALL VESSELS <

5.0 MM5.0 MM

rgMINIMIZE RADIATION RISKMINIMIZE RADIATION RISK

2 MONTHS AFTER

PROCEDURE

6 MONTHS AFTER

PROCEDURE

2 YEARSAFTER

PROCEDURE

Garcia et al, Catheter Cardiovasc Interv 2009;74:27-36

COMMON ACCESS SITES FOR COMMON ACCESS SITES FOR PERIPHERAL=FOR PERIPHERAL=FOR

CORONARYCORONARY

Garcia et al, Catheter Cardiovasc Interv 2009;74:27-36

LESS COMMON ACCESS SITES LESS COMMON ACCESS SITES FOR PERIPHERAL≠FOR FOR PERIPHERAL≠FOR

CORONARYCORONARY

DEVICE TYPES ARE ALSO DEVICE TYPES ARE ALSO BROADLY SIMILARBROADLY SIMILAR

SheathsShuttle sheathsGuidewiresBalloonsStentsFiltersThrombectomy catheters

BUT DEVICE SIZES AND BUT DEVICE SIZES AND FEATURES ARE VERY FEATURES ARE VERY

DIFFERENT!DIFFERENT!Sheaths (3-9 Fr)

Shuttle sheaths (30-90 cm)

Guidewires (0.014”, 0.018”, 0.035”)

Balloons (1.25-15.0 mm)

Stents (balloon-, self-expandable)

FiltersThrombectomy catheters (4-6

2.0-4.0

5.0-7.0

4.0-7.0

4.0-6.0

6.0-9.0

5.0-9.0

5.0-7.0

7.0-10.0

6.0-8.0

2.0-4.0

5.0-7.0

3.0-5.0

SIZE SIZE MATTERMATTER

RENAL ARTERY STENOSISRENAL ARTERY STENOSIS

LOWER-LIMB LOWER-LIMB INTERVENTIONS:INTERVENTIONS:

TASC II 2007 vs. TASC 2000TASC II 2007 vs. TASC 2000

IMPORTANCE OF SUBINTIMAL IMPORTANCE OF SUBINTIMAL ANGIOPLASTY FOR LOWER-LIMB ANGIOPLASTY FOR LOWER-LIMB

PTAPTA

BTK PTA: TOOLS OF THE BTK PTA: TOOLS OF THE TRADETRADE

Biondi-Zoccai et al, J Endovasc Ther 2009

ENDOVASCULAR ENDOVASCULAR ANEURYSM REPAIRANEURYSM REPAIR

CAROTID ARTERY CAROTID ARTERY STENOSISSTENOSIS

McDonald et al, Stroke 2009

What about stroke?

TAKE HOME MESSAGESTAKE HOME MESSAGES

rgTAKE HOME MESSAGESTAKE HOME MESSAGES

Peripheral intervention skills must be mastered by all interventional cardiologists for bail-out indications

Motivated interventionists can pursue further improvements by focusing on district-specific indications, anatomy, and devices

No other specialist beats an experienced cardiologists in peripheral interventions

rgThank you for your attentionThank you for your attention

For any correspondence: For any correspondence: gbiondizoccai@gmail.com

For these and further slides on these topics feel For these and further slides on these topics feel free to visit the metcardio.org website: free to visit the metcardio.org website:http://www.metcardio.org/slides.html

rgABSTRACTABSTRACT

Cardiovascular specialists care for patients with cardiovascular disease which is often extensive and not localized in a single anatomic district. Thus, even interventional cardiologists should have a working knowledge of the indications, contraindications, general principles and specific techniques required for safe and succcessful peripheral interventions. Notwithstanding the need to overcome the limitations of angiographic luminology, a thorough knowledge of a single patient vascular anatomy, proficiency in obtaining vascular access, and availability of dedicated devices, paying attention in particular to device size and shaft length, are pivotal. This presentation offers a brief but comprehensive viewpoint on the basic principles that should be followed by interventional cardiologists willing to begin a peripheral intervention program.

MULTIPLE CHOICE MULTIPLE CHOICE QUESTIONSQUESTIONS

Question 1- Which of the following accesses is inappropriate for the corresponding target vessel:a) right axillary artery for right carotid stenting;b) antegrade left femoral artery for left posterior tibial angioplasty;c) left radial artery for left renal stenting;d) retrograde right femoral access for left common iliac stenting; e) antegrade right femoral access for right superficial femoral angioplasty.

Question 2 - Which of the following peripheral interventional procedures would you consider not clinically indicated:a) right carotid stenting in a symptomatic patient with a 60% stenosis of the right internal carotid artery;b) left popliteal artery angioplasty in a patient with severe claudication and 75% stenosis of the left popliteal artery;c) left renal artery stenting in a non-hypertensive patient with 95% stenosis of the left renal artery;d) endovascular aneurysm repair in an asymptomatic patient with a 60-mm abdominal aorta aneurysm;e) left posterior tibial angioplasty in a patient with a left heel ischemic ulcer and focal occlusion of the posterior tibial artery.

Biondi-Zoccai: Peripheral interventions gbiondizoccai@gmail.com – metcardio.org Basic principles...

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