1) This document discusses a case of a female patient presenting with critical limb ischemia and diffuse polyvascular disease including coronary artery disease. 2) Treatment involved percutaneous angioplasty of the occluded left popliteal artery using a drug-coated balloon, with optimization of medical therapy for her coronary artery disease. 3) The document emphasizes the importance of evaluating and managing concomitant coronary artery disease in patients with peripheral artery disease to achieve good long-term outcomes, and discusses optimal antiplatelet therapy choices to balance ischemic and bleeding risks.

1. Generalized atherosclerosis: result of
cardiac and peripheral
revascularizzation
Antonio Micari, MD,
Director Laboratory of Invasive Cardiology
Maria Eleonora Hospital, Palermo, Italy

2. AA GGeenneerraalliizzeedd
DDiisseeaassee……………………

4. IInn pprreesseennccee ooff sseevveerree
ddiiffffuussee ppoolliivvaassccuullooppaatthhyy
FFiirrsstt SStteepp??
•TToo kknnooww pprreecciisseellyy tthhee cclliinniiccaall ssttaattuuss
ooff oouurr ppaattiieenntt..
•CCoonnssiiddeerriinngg tthhee mmaajjoorriittyy ooff ppaattiieennttss
wwiillll ddiiee ffoorr ccoorroonnaarryy ddiisseeaassee..
TToo kknnooww pprreecciisseellyy tthhee cclliinniiccaall ssttaattuuss
ooff oouurr ppaattiieenntt..
CCoonnssiiddeerriinngg tthhee mmaajjoorriittyy ooff ppaattiieennttss
wwiillll ddiiee ffoorr ccoorroonnaarryy ddiisseeaassee..

5. IInn pprreesseennccee ooff sseevveerree ddiiffffuussee
ppoolliivvaassccuullooppaatthhyy::
MMoosstt IImmppoorrttaanntt CClliinniiccaall VVaarriiaabbeess
AAggee,, DDiiaabbeetteess,, CCoonnttrroolllleedd oorr UUnnccoonnttrroolllleedd BBlloooodd PPrreessssuurree
RReennaall ffuunnccttiioonn:: nnoorrmmaall vvss ddeepprreesssseedd
AAnnggiinnaall ssttaattuuss:: ssttaabbllee vvss uunnssttaabbllee
CCAADD:: 11VVDD,, 22VVDD,, 33VVDD,, MMuullttii--VVDD,, LLeefftt MMaaiinn SStteemm,, RRee--ooppeerraattiioonn
LLeefftt vveennttrriiccuullaarr ffuunnccttiioonn:: nnoorrmmaall vvss ddeepprreesssseedd
NNYYHHAA ccllaassss:: II,, IIII,, IIIIII,, IIVV
NNeeuurroollooggiiccaall ssyymmppttoommss:: ssyymmppttoommaattiicc vvss aassyymmppttoommaattiicc // ssiilleenntt cceerreebbrraall
iisscchheemmiiaa
CCaarroottiidd ppaatthhoollooggyy:: mmoonnoo--llaatteerraall vvss bbiillaatteerraall
CCaarroottiidd ppllaaqquuee cchhaarraacctteerriissttiiccss:: llooww vvss hhiigghh eemmbboolliizzaattiioonn rriisskk
PPeerriipphheerraall aarrtteerriiaall oocccclluussiivvee ddiisseeaassee:: ccrriittiiccaall lliimmbb iisscchheemmiiaa

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 ! !

8. CX and Om Lesion

9. LAD-Diag Lesion

10. Long RCA Lesion

11. Popliteal Occlusion

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)?

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

16. 2.5
2
1.5
1
0.5
0
DDeeffiinniittee//PPrroobbaabbllee SSTT:: AAnnyy SStteenntt ((NN==1122884444))
52%
STENT Analysis
0 50 100 150 200 250 300 350 400 450
% of Subjects
HR 0.48 [0.36-0.64]
P<0.0001
1 year: 1.06 vs 2.15%
HR 0.48 [0.36-0.65], P<0.0001
2.35%
1.13%
DAYS
CLOPIDOGREL
PRASUGREL
Wiviott SD et al. Lancet 2008
Definite/Probable But remember limitations!!!!

17. Primary endpoint: CCVV ddeeaatthh,, MMII oorr ssttrrookkee
15
10
5
0
0
10.65
60 120 180 240 300 360
Days after randomization
K-M estimated rate (% per year)
HR: 0.84 (95% CI = 0.75–0.94), p=0.0025
9.02
Clopidogrel
Ticagrelor
No. at risk
Ticagrelor
Clopidogrel
6,732
6,676
6,236
6,129
6,134
6,034
5,972 4,889
3,048
5,881 4,815
3,735
3,680
2,965
K-M = Kaplan-Meier; HR = hazard ratio; CI = confidence interval

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

22. Final result

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

24. 66 MMoonntthh FFoollllooww uupp

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