FFR and peripheral disease - Zoltan Ruzsa

1. Pressure wire measurement in
the peripheral circulation
AimRadial 2016
ZOLTÁN RUZSA MD PhD
I have no conflict of interest to declare

2. Potential applications
• 1. SUPRAAORTIC VESSELS ??
• 2. VISCERAL VESSELS- RENAL ARTERY
• 3. LOWER LIMB
– ILIAC ARTERY
– FEMORAL ARTERY
– BELOW-THE-KNEE VESSELS

3. AD 1. SUPRA-AORTIC VESSELS
• Subclavian artery- No study
• Carotide artery and intracranial vessels 1
Han YF. Catheter Cardiovasc Interv. 2016 Aug;88(2):255-61.

4. AD 2. RENAL ARTERY ANGIOPLASTY
- Indication
However….Clinical outcomes of RAS
≥50 % stenosis +
Uncontrolled hypertension
(3 antihypertensive)
Or
Poor or decreasing renal function
Or
CHF, Unstable angina
- Hypertension improved in 56%
- Renal function improved in 27%
- Restenosis in 16%
- Major complication 2%
CORAL Study--- neg

5. Renal FFR- Clinical outcome (Office BP)
Jason A Michell. Catheterization and Cardiovascular Interventions 69:685–689 (2007)
Group I. FFR < 0.8
Group II. FFR > 0.8

6. Renal stenting outcomes
(ABPM SYS RR) and renal Pd/Pa
J Kedziela. Blood Press. 2015 Feb;24(1):30-4.

7. Renal stenting outcomes
(ABPM SYS RR) and renal rFFR

8. RAS and Clinical Improvement
Massoud A. Leesar, Endovascular Today, 2012

9. DSA- Pt with hypertension
and angina

10. Coronary angiography

11. FFR: 0.85
SY Gradient: 8 Hgmm
FFR: 0.74

12. AD 3a. LOWER LIMB VESSELS (iliac)
• Iliac artery stenosis FFR- correlation with ABI
– post-exercise ABI and p-FFR at hyperemia (r=0.857, p<0.001)
– post-exercise ABI and peak-to-peak pressure gradient at
hyperemia (r= -0.626, p=0.013).
Hioki H. J Endovasc Ther. 2014 Oct;21(5):625-32

13. AD 3b. LOWER LIMB VESSELS (femoral)
• Dose of intra-arterial papaverin 1
– 20-30-40 mg Papaverin
• FFR correlates with PSV and the final FFR might have
impact on POBA restenosis 2
• Impact of final FFR on stent restenosis 3
– Post-stenting FFR was significantly lower in the restenosis group (poststenting mean FFR
0.85±0.07 vs 0.93±0.05, p=0.001; poststenting systolic FFR 0.76±0.14 vs 0.87±0.08, p=0.015).
– The best post-stenting mean FFR cutoff value for predicting restenosis was
0.92 (sensitivity 0.64, specificity 0.91).
1. Kobayashi N. et al. J Atheroscler Thromb. 2016;23(1):56-66.
2. A.S. LOTFI, M.D et al. J Interven Cardiol 2012;25:71–77
3. Kobayashi N. et al. J Endovasc Ther. 2016 Sep 7.

14. AD 3b. LOWER LIMB VESSELS (BTK)
Background
• Critical limb ischemia is characterized
with
– Ischemic pain and / or tissue loss
(ulcer or gangrena)
– Ankle pressure < 60 Hgmm or
- Toe pressure 40 Hgmm
• Distal perfusion  results in
tissue loss, infection, inflammation
• Diabetic foot:
– ischemic, neuro-ischemic, neuropathic

15. Gold standard-Angiography: limitations 1
• Which artery is responsible for ischemia ?
– Angiosome concept 1
• Which lesion is responsible for ischemia ?
– Short critical lesion—ok
– Short borderline lesion ???
– Short lesion and haziness ???
– Long and multiple lesions ???
– Medial calcification and bordeline lesions
• Is the final result satisfactory?
– Non invasive assessment (laser, toe pressure, echo, pulzoxy)
– Invasive assessment (DSA, pressure wire?, IVUS ?, OCT)
• DSA- residual stenosis?, flow ?, pedal blush ?

16. Angiography: Different BTK lesions
Focal Long Diffuse- CTO

17. IVUS

18. Pressure wire measurement
Maximal coronary flow:
Maximal coronary flow in stenosis:
Fractional flow rezerv:
QN =
(Pa - Pv)
R
QS =
(Pd - Pv)
R
FFR =
Pd
Pa
Q: myocardial flow
Pa: mean arterial pressure
Pd: distal coronary pressure
Pv: central venous pressure

19. Aim of the study
• The aim of the study was to assess the correlation
between non-invasively versus invasively measured
parameters by pressure wire during rest and after
maximal hyperaemia (peripheral fractional flow reserve
(pFFR) before and after below-the-knee (BTK)
angioplasty.
• To assess the final distal pressure and pFFR after the
intervention and to assess the correlation between the
non-invasive parameters
• To examine, whether postPTA pressure and pFFR has a
prognostic value on restenosis, on long-term changes
of non-invasive parameters or on clinical outcome.

20. Methods I.
• Patient population:
- 31 consecutive patients with CLI
• Inclusion criteria were:
- chronic critical ischemia of the lower limb (Fontaine III-IV)
- angiographically proven significant lesion of the distal lower limb (DS
> 69%).
• Exclusion criteria:
- chronic total occlusion or other morphologic appearance to the
wound, that makes pFFR measurement impossible or unacceptably
risky
- diabetic foot syndrome
- Severe venous varicosity or right heart failure
- non-viable distal lower limb.

21. Methods II.
• Fontaine and Rutherford classification
• Angiography (QCA)
• Pressure wire measurement
- Resting peripheral blood pressure (invasively assessed)
- Hyperemic peripheral blood pressure (invasively assessed)
- Calculated pFFR value (hyperemia induced by 40mg intra- arterial
Papaverin),
• Ankle-Brachial Index (ABI) and Ankle-Toe index (ATI)
• Toe pressure
• Ultrasound derived Peak Systolic Velocity (PSV)
• Laser Doppler
– Doppler perfusion Units (DPU)
– Transcutaneous O2 tension (TcO2)

22. Pre-procedural During PTA 3-month FU 12-month FU
Ankle-Brachial Index x x x
Toe pressure x x x
TcpO2 x x x
Doppler UH
-Peak Systolic Velocity
-DI
x
x
x
x
x
x
Angiography
-Length of the stenosis
-Stenosis diameter
-Reference diameter
x
x
x
x
x
x
x
x
Presure wire measurement
-Resting pressure
-FFR
X
x
X
x
Clinical Follow-up x x x

23. 1. LD+heating unit
2. tcpO2/pCO2 unit
3. Pressure unit
LD+ Heating Toe pressuretcpO2
PeriFlux System 5000

24. Pressure wire measurement
• 1. Equalisation
• 2. Pre-interventional measurement
– Rest - (DP, FFR rest) FFR rest
– Stress measurement- (Papaverin 40 mg) FFR papaverin
• 3. Wedge pressure
• 4. Postintervetional measurement
– Rest (DP, FFR rest) FFR rest
– Stress measurement (Papaverin 40 mg) FFR papaverin
24

25. Demographic and clinical data

26. Angiographic and procedural data

27. Procedural and
laeser Doppler
results

28. Pressure wire measurements

29. Laser Doppler measurements

30. Ultrasonography
Apo (PSV) ATA (PSV) PTA (PSV) PeA (PSV)
Preinterventional 52,12 ± 12,9 25,3 ± 12 26 ± 16,2 29,2 ± 12,4
Postinterventional 55,4 ± 17,8 47,8 ± 32 * 30,2 ± 17,4 39,1 ± 11,5 *
Distal measurements
ATA pre ATA post
0
50
100
150
200
ATA (PSV)
PSV(mm/s)
PTA pre PTA post
0
20
40
60
80
PTA (PSV)
PSV(mm/s)
PeA Pre PeA Post
0
20
40
60
80
PeA
PSV(mm/s)

31. Correlational data – Baseline measurements
(r values, p <0.05 *, p <0.01 **)

32. Correlational data between QCA and
PW- baseline measurements
(r values, p <0.05 *, p <0.01 **)

33. Linear regression

34. Study patient No 10
LD PU LD PU
stress
Change
in %
TC O2 TC O2
stress
Change
in %
9.93 42.78 330.66 10.77 14.0600 30.56
8,24 62,98 664,36 6,82 13,89 103,61
DP FFR rest FFR stress
Pre 82 0.55 0.38
Post 55 0.64 0.56

35. Pt No25.
LD PU LD PU
stress
Change
in %
TC O2 TC O2
O2 inh
Change
in %
24,1 223,99 829,5 33,47 214,34 540,34
21,01 345,07 1542,57 40,59 243,29 499,42
DP FFR rest FFR stress
Pre 40 0.85 0.66
Post 3 0.97 0.83

36. Laser Doppler data Pt No 25
LD PU LD PU
stress
Change in
%
TC O2 TC O2
O2 inh
Change in
%
24,1 223,99 829,5 33,47 214,34 540,34
21,01 345,07 1542,57 40,59 243,29 499,42

37. Procedural results
• Angiographic results
– Good angiographic result: 31 (100%)
– Angiographic FU- Not complete
• Clinical improvement
– At 2 month FU all patients were pain free
– Ulcer and gangrena healing was not complete, but
satisfactory
– Long term FU- Not complete
• Procedure
– Balloon angioplasty 31 (100%)
– Stenting 18 (62%)

38. Limitations of the study
• Patient number is still low (now 40 pts)
• We need to compare and the vasodilatation effect
of adenosin and papaverin

39. Conclusion
• DP and the change in LD PU shows significant
correlation in this patient group, but the tendency
seems to be promising in all parameters
• The invasive and non-invasive parameters
improved in all patients after successful
intervention
• The intraarterial administration of Papaverin cause
significant change in microcirculation with change
of distal pressure but the real dose must be clarified
• Further and larger patient series are necessary to
clarify the real benefit of the direct pressure
measurement during BTK interventions

40. Thank You !!

41. Study Pt
No 8
LD PU LD PU
stress
Change
in %
TC O2 TC O2
stress
Change
in %
Pre 8.2400 62.98 664.36 6.82 13.89 103.61
Post 35.44 69.66 96.52 5.53 12.65 128.93