Diagnostic standards for PE - prof. Tomasz Rakowski
Generalised atherosclerosis - dr Antonio Micari
1. Generalized atherosclerosis: result of
cardiac and peripheral
revascularizzation
Antonio Micari, MD,
Director Laboratory of Invasive Cardiology
Maria Eleonora Hospital, Palermo, Italy
6. In presence of sseevveerree ddiiffffuussee ppoolliivvaassccuullooppaatthhyy
FFaacciinngg tthhee SSiinnggllee PPaattiieenntt
WWhhiicchh DDiissttrriicctt FFiirrsstt
?
Single or Staged
Procedures
Single or Staged
Procedures
7. Gender: Female
Age: 69 year
Risk factors: Active Smoker, HTN, IDDM
Clinical History: Bilateral intermittent claudicatio
since 8 months
Main clinical Problem: Critical Limb Ischemia (Left Foot Calcaneal Ulcer, rest pain,
Ankle pressure < 70 mmHg).
Duplex: Left popliteal occlusion (Fibro-lipid plaque). Collateral flow in the BTK arteries
Associated clinical conditions: Chronic renal failure (eGFR 43 ml/min/1.73 m2), β
Thalassemia (Hb: 9.6)
Therapy: ASA, Lercadipine, Simvastatin
CChheesstt P Paainin w whhiliele H Hoossppititaalilzizeedd ! !
12. CClliinniiccaall pprroobblleemmss
• Do we need to re-vascularize the Limb?
• How we should re-vasularize the Limb?
• What about concomitant CAD (Syntax Score:
24)?
13.
14. When we have to perform PCI/PTA we need a
DAPT having:
1)Proven efficacy relatively independent from
patient genetic backgroud
2)Good results in terms of long term outcomes
3)Is not harmful for patients with advanced age
15. 15
10
5
0
K-M estimate of first primary efficacy
end-point (composite of CV death, MI or stroke)
Clopidogrel
0 30 60 90 180 270 360 450
HR 0.81
(0.73-0.90)
P=0.0004
Prasugrel
Days Endpoint (%)
12.1
9.9
138
events
NNT = 46
Wiviott et al N Engl J Med. 2007
19. When we have to perform CLI PTA in a patient
that will undergo CABG we should consider that
Patient should go to surgery as soon as possible…
this time is determined by the bleeding risk after
last intake of DAPT
20. Major Fatal/Life-Threatening Bleeding by Days
from Last Dose of Treatment to CABG
100%
80%
60%
40%
20%
0%
Ticagrelor
Clopidogrel
1 2 3 4 5 6 7 >8
% Patients with Bleeding
post-CABG
Days
Bleeding differences favor ticagrelor >5 days post discontinuation
Courtesy of Sanjay Kaul
21. PTA of the Popliteal artery
1) Predilation with an undersized balloon
2) Prolonged dilation with a Drug Coated Balloon
23. Clinical outcome
•Discharged at home on day 4 (Serum creatinine
Back to baseline)
•Medical therapy was tuned for CAD
•DAPT for 30 days
•Healed Ulcer after 3 weeks
25. CCoonncclluussiioonnss
1.CAD is frequent In PAD Patients
2.CAD Managment is crucial to allow good
acute and long term results
3.The appropriate drug seletcion can
reduce ischemic/bleeding risk
4.Use of stent should be limited to bail-out
situations
Editor's Notes
Patients with evidence of additional ischemia are at an even greater cross-risk of MI and stroke.
Additional ischemia puts all three patient types (recent MI, recent stroke, established PAD) at increased cross-risk of MI or stroke.
Cupples and colleagues evaluated the long-term prognosis of 828 patients post MI who were enrolled in the Framingham Heart Study. They found that patients with the preexisting condition of stroke who suffered an MI were at up to 103% increased risk of a second MI. Patients with intermittent claudication (a symptom of peripheral arterial disease) were at up to 104% increased risk of a second MI.[1]
Preexisting atherosclerotic conditions in patients with signs of additional ischemia including MI elevate the risk of subsequent events, ie, a second MI or a stroke.[1,2]
This chart is based on epidemiological data and is not intended to provide a direct basis for comparison of risks between event categories. Data for the associated risk increase in events were taken from different sources. The increase in risk of events was based on 10-year follow-up except for risk of stroke following stroke, which measures subsequent risk per year.
Cupples LA, Gagnon DR, Wong ND, Ostfeld AM, Kannel WB. Preexisting cardiovascular conditions and long-term prognosis after initial myocardial infarction: the Framingham Study. Am Heart J. 1993;125:863-872.
Kannel WB. Risk factors for atherosclerotic cardiovascular outcomes in different arterial territories. J Cardiovasc Risk. 1994;1:333-339.
