Non-Cornoary Intervention for the Interventional Cardiologist

756 views
670 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
756
On SlideShare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
19
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Non-Cornoary Intervention for the Interventional Cardiologist

  1. 1. Non-Coronary Intervention for the Interventional Cardiologist Keith G Oldroyd Department of Cardiology Western Infirmary Glasgow
  2. 2. Total Body Revascularisation <ul><li>CHD and PVD frequently co-exist </li></ul><ul><ul><li>CHD commonest cause of morbidity and mortality in patients with PVD </li></ul></ul><ul><ul><li>PVD has a negative impact on the management of ACS and CHF </li></ul></ul><ul><ul><li>Potential for combined diagnostic and revascularisation procedures </li></ul></ul>
  3. 3. Total Body Revascularisation <ul><li>Ilio-femoral </li></ul><ul><li>Subclavian </li></ul><ul><li>Renal </li></ul><ul><li>Carotid </li></ul>
  4. 4. Indications for lower limb PTA <ul><li>Critical ischaemia - limb salvage </li></ul><ul><li>Severe limiting claudication </li></ul><ul><li>Complications following femoral arterial cannulation </li></ul>
  5. 5. Ilio-femoral disease
  6. 6. Ilio-femoral disease
  7. 7. Ilio-femoral disease
  8. 8. Subclavian Disease <ul><li>Subclavian steal </li></ul><ul><ul><li>hypoperfusion of LIMA </li></ul></ul><ul><ul><li>Vertebrobasilar symptoms </li></ul></ul><ul><li>Carotid to subclavian bypass </li></ul><ul><li>Stenting </li></ul><ul><ul><li>Ochsner - 27 patients; 100% success </li></ul></ul><ul><ul><li>22 (95%) asymptomatic or improved at 28 months </li></ul></ul>
  9. 9. Renovascular Disease <ul><li>Patients undergoing coronary angiography </li></ul><ul><ul><li>15-20% </li></ul></ul><ul><li>Patients undergoing peripheral angiography </li></ul><ul><ul><li>30-40% </li></ul></ul><ul><li>Commonest cause of secondary hypertension </li></ul><ul><ul><li>overall 4% of hypertensive population </li></ul></ul>
  10. 10. Renovascular Disease and “Flash” Pulmonary Oedema <ul><li>55 patients with renovascular hypertension + uraemia </li></ul><ul><li>23% had recurrent pulmonary oedema </li></ul><ul><li>Predictors of pulmonary oedema </li></ul><ul><ul><li>No BP Renal function </li></ul></ul><ul><ul><li>Yes CHD Bilateral RAS </li></ul></ul>Bloch et al , Lancet 1999
  11. 11. Renovascular Disease and “Flash” Pulmonary Oedema <ul><li>41% patients with bilateral RAS had history of pulmonary oedema </li></ul><ul><li>12% patients with unilateral RAS had pulmonary oedema </li></ul><ul><li>77% with bilateral RAS had no further episodes following PTA/stenting </li></ul><ul><li>1 of 3 treated patients with unilateral RAS remained free of pulmonary oedema </li></ul><ul><li>Evidence of stent restenosis or thrombus if pulmonary oedema recurred </li></ul>Bloch et al , Lancet 1999
  12. 12. Renovascular Disease <ul><li>60 year old female </li></ul><ul><li>Admitted 3x in 2years with severe pulmonary oedema </li></ul><ul><li>PMH - hypertension; R ureteric calculus; hydronephrosis </li></ul><ul><li>Rx - lisinopril, frusemide </li></ul><ul><li>Echo - LV hypertrophy; normal LVEF </li></ul>
  13. 13. Renal artery thrombus Pre and post tPA
  14. 14. Renovascular Disease
  15. 15. Renovascular Disease Indications for renal stenting <ul><li>Bilateral disease or unilateral disease with single kidney + </li></ul><ul><ul><li>deteriorating renal function </li></ul></ul><ul><ul><li>previous failed trial of ACEI </li></ul></ul><ul><ul><li>? refractory severe hypertension </li></ul></ul><ul><ul><li>? unstable angina </li></ul></ul><ul><ul><li>? congestive heart failure </li></ul></ul>
  16. 16. Renovascular Disease <ul><li>Ochsner Clinic </li></ul><ul><ul><li>149 stents in 133 arteries in 100 consecutive patients </li></ul></ul><ul><ul><li>Procedural success 99% </li></ul></ul><ul><ul><li>Normalisation of BP 76% </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>SAT (1) </li></ul></ul><ul><ul><li>Transient contrast nephropathy (2) </li></ul></ul><ul><li>Angiographic restenosis 19% </li></ul>
  17. 17. ASTRAL <ul><li>RCT </li></ul><ul><li>Stenting plus best medical therapy vs best medical therapy </li></ul><ul><li>MRA now allowed for diagnosis </li></ul><ul><li>Split function GFR – kidney with most severe stenosis may still provide majority of function </li></ul>
  18. 18. CAROTID STENTING
  19. 19. Indications for Carotid Endarterectomy in Symptomatic Patients <ul><li>Recent ( < 6/12) non-disabling stroke/TIA </li></ul><ul><li>Ipsilateral 70 to 99% stenosis </li></ul><ul><li>Surgeon’s perioperative stroke rate must be < 6% (at least 50 consecutive cases over 2 years) </li></ul>
  20. 20. Indications for Carotid Stenting <ul><li>Increased surgical risk </li></ul><ul><ul><li>Medical comorbidity </li></ul></ul><ul><ul><li>Advanced age </li></ul></ul><ul><ul><li>Contralateral occlusion </li></ul></ul><ul><li>Patient refuses surgery </li></ul><ul><li>Randomised trial </li></ul><ul><li>Anatomically difficult lesions </li></ul><ul><ul><li>Restenosis </li></ul></ul><ul><ul><li>post-irradiation </li></ul></ul><ul><ul><li>Too low </li></ul></ul><ul><ul><li>Too high </li></ul></ul>
  21. 21. CAROTID STENTING
  22. 22. CAVATAS - 1 0.001 6.7% 1.2% Major haematoma 0.001 8.7% 0 Cranial neuropathy NS 9.9% 10% Death/any stroke NS 5.9% 6.4% Death/major stroke p CEA Angioplasty
  23. 23. CAROTID WALL-STENT 3.5% 12% 1 year 3.5% 10.2% 30 days CEA (n=113) Stenting (n=108) Death/ipsilateral stroke
  24. 24. Angioguard
  25. 27. SPIDER
  26. 28. The GuardWire  Protection System <ul><li>GuardWire  </li></ul><ul><ul><li>0.014” & 0.018” nitinol Guidewire design </li></ul></ul><ul><ul><li>Low Entry & Exit Profile NOW . 028” </li></ul></ul><ul><ul><li>Low pressure elastomeric occlusion balloon (<2ATM) </li></ul></ul><ul><li>MicroSeal  Inflation Adapter </li></ul><ul><ul><li>Low pressure inflation </li></ul></ul><ul><ul><li>Removable Hub </li></ul></ul><ul><li>Export  </li></ul><ul><ul><li>Aspiration catheter </li></ul></ul><ul><ul><li>Rail-like design </li></ul></ul>
  27. 29. The GuardWire  Protection System
  28. 30. The GuardWire  Protection System
  29. 31. CAFE-USA Registry Percusurge in Carotid Stenting <ul><li>212 patients </li></ul><ul><li>99% procedural success </li></ul><ul><li>8% required “staged” protection </li></ul><ul><li>Visual embolic material in every case </li></ul><ul><li>Mean 12 min of balloon occlusion </li></ul><ul><li>30 day - mortality: 1.4% stroke: 2.4% </li></ul>
  30. 32. CAFE-USA Registry TCD Sub-study 0.002 68 164 Total 0.002 5 27 Post dilatation 0.004 17 75 Stent deployment 0.001 12 32 Predilatation p Protection Control
  31. 33. CAVATAS - II <ul><li>RCT </li></ul><ul><li>Carotid wallstent vs CEA </li></ul><ul><li>Mandatory distal protection </li></ul><ul><li>Minimum 10 supervised stent procedures </li></ul>
  32. 34. Total Body Revascularisation <ul><li>Transferable technical skills </li></ul><ul><li>Team approach </li></ul><ul><ul><li>interventional cardiologist </li></ul></ul><ul><ul><li>vascular/endovascular surgeon </li></ul></ul><ul><ul><li>interventional radiologist </li></ul></ul><ul><ul><li>neurologist </li></ul></ul><ul><ul><li>appropriate patient/lesion selection </li></ul></ul>
  33. 36. Atherosclerotic Renovascular Disease <ul><li>Case reports of flash pulmonary oedema with ARVD. </li></ul><ul><li>6% renal allograft recipients develop ARVD </li></ul><ul><li>11 patients with ARVD </li></ul><ul><ul><li>9 bilateral </li></ul></ul><ul><ul><li>2 unilateral </li></ul></ul><ul><li>Revascularisation improved BP, renal function and eliminated heart failure </li></ul>Pickering et al 1988
  34. 37. Renovascular Disease <ul><li>29 patients; 32 arteries stented </li></ul><ul><li>Procedural success 100% </li></ul><ul><li>6m follow-up </li></ul><ul><ul><li>BP improved in 50% </li></ul></ul><ul><ul><li>renal function </li></ul></ul><ul><ul><ul><li>improved 33% </li></ul></ul></ul><ul><ul><ul><li>stabilised 29% </li></ul></ul></ul>Taylor et al, (WIG/Gartnavel)
  35. 38. Renovascular Disease <ul><li>29 patients; 32 arteries stented </li></ul><ul><li>Procedural success 100% </li></ul><ul><li>6m follow-up </li></ul><ul><ul><li>BP improved in 50% </li></ul></ul><ul><ul><li>renal function </li></ul></ul><ul><ul><ul><li>improved 33% </li></ul></ul></ul><ul><ul><ul><li>stabilised 29% </li></ul></ul></ul>Taylor et al, (WIG/Gartnavel)
  36. 39. Atherosclerotic Renovascular Disease <ul><li>Complications 24% </li></ul><ul><ul><li>pseudoaneurysm </li></ul></ul><ul><ul><li>dissection </li></ul></ul><ul><ul><li>renal failure </li></ul></ul><ul><ul><li>atheroembolisation </li></ul></ul><ul><ul><li>renal artery perforation </li></ul></ul><ul><li>Follow up angiography </li></ul><ul><ul><li>restenosis rate 16% at 6m </li></ul></ul>Taylor et al, (WIG/Gartnavel)
  37. 40. Indications for Carotid Endarterectomy in Asymptomatic Patients <ul><li>Surgical risk < 3% </li></ul><ul><ul><li>Proven - > 60% stenosis (ACAS) </li></ul></ul><ul><ul><li>Acceptable - as above in patient scheduled for CABG </li></ul></ul><ul><ul><li>Uncertain - > 50% stenosis </li></ul></ul><ul><ul><li>N.B. ECST criteria for stenosis generally assigns a higher stenosis than ACAS </li></ul></ul>
  38. 41. Indications for Carotid Endarterectomy in Asymptomatic Patients <ul><li>30 day stroke rate in surgical arm of ACAS was 1.5% </li></ul><ul><li>Surgical risk 3-5% </li></ul><ul><ul><li>Proven - none </li></ul></ul><ul><ul><li>Acceptable </li></ul></ul><ul><ul><ul><li>Ipsilateral > 70%; contralateral 70-100% </li></ul></ul></ul><ul><ul><li>Uncertain </li></ul></ul><ul><ul><ul><li>Ipsilateral stenosis > 70% </li></ul></ul></ul><ul><ul><ul><li>CABG required; bilateral stenosis > 70% </li></ul></ul></ul><ul><ul><ul><li>CABG required; unilateral stenosis > 70% </li></ul></ul></ul>
  39. 42. Indications for Carotid Endarterectomy in Asymptomatic Patients <ul><li>30 day stroke rate in surgical arm of ACAS was 1.5% </li></ul><ul><li>Surgical risk 5-10% </li></ul><ul><ul><li>Proven - none </li></ul></ul><ul><ul><li>Acceptable - none </li></ul></ul><ul><ul><li>Uncertain </li></ul></ul><ul><ul><ul><li>CABG required; bilateral stenosis > 70% </li></ul></ul></ul><ul><ul><ul><li>CABG required; unilateral stenosis > 70% </li></ul></ul></ul>
  40. 43. CAROTID STENTING
  41. 44. CAROTID STENTING
  42. 45. Microvena Trap
  43. 46. CAROTID STENTING

×