Basic principles of peripheral interventions

1. Basic principles of peripheral interventions Giuseppe Biondi Zoccai University of Turin, Turin, Italy gbiondizoccai@gmail.com Educational Fellowship Course In PCI For Young Interventionalists Session 2 - How do I treat: Case based discussion 22 October 2009 – 16:35-16:47

2. DISCLOSURE • I am giving a lecture at a Fellows’ Course

3. LEARNING GOALS • Why peripheral interventions are important for everybody • General approach • What is similar and what is different between coronary and peripheral arteries • District-specific tips & tricks

4. LEARNING GOALS • Why peripheral interventions are important for everybody • General approach • What is similar and what is different between coronary and peripheral arteries • District-specific tips & tricks

5. 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

6. LEARNING GOALS • Why peripheral interventions are important for everybody • General approach • What is similar and what is different between coronary and peripheral arteries • District-specific tips & tricks

7. A GLOBAL MANAGEMENT APPROACH IS A MUST

8. TAKE CARE AT PREPPING

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

10. IMAGING WITH DSA IS A MUST FOR ALL VESSELS < 5.0 MM

11. MINIMIZE RADIATION RISK 2 MONTHS AFTER PROCEDURE 6 MONTHS AFTER PROCEDURE 2 YEARS AFTER PROCEDURE

12. LEARNING GOALS • Why peripheral interventions are important for everybody • General approach • What is similar and what is different between coronary and peripheral arteries • District-specific tips & tricks

13. COMMON ACCESS SITES FOR PERIPHERAL=FOR CORONARY Garcia et al, Catheter Cardiovasc Interv 2009;74:27-36

14. LESS COMMON ACCESS SITES FOR PERIPHERAL≠FOR CORONARY Garcia et al, Catheter Cardiovasc Interv 2009;74:27-36

15. DEVICE TYPES ARE ALSO BROADLY SIMILAR • Sheaths • Shuttle sheaths • Guidewires • Balloons • Stents • Filters • Thrombectomy catheters

16. BUT DEVICE SIZES AND FEATURES ARE VERY 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) • Filters • Thrombectomy catheters (4-6 Fr)

17. 5.0-9.0 6.0-9.0 4.0-7.0 4.0-6.0 5.0-7.0 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 MATTERS! 2.0-4.0

18. LEARNING GOALS • Why peripheral interventions are important for everybody • General approach • What is similar and what is different between coronary and peripheral arteries • District-specific tips & tricks

19. RENAL ARTERY STENOSIS

20. RENAL ARTERY STENOSIS

21. LOWER-LIMB INTERVENTIONS:TASC II 2007 vs. TASC 2000

22. IMPORTANCE OF SUBINTIMAL ANGIOPLASTY FOR LOWER-LIMB PTA

23. BTK PTA: TOOLS OF THE TRADE Biondi-Zoccai et al, J Endovasc Ther 2009

24. ENDOVASCULAR ANEURYSM REPAIR

25. CAROTID ARTERY STENOSIS

26. CAROTID ARTERY STENOSIS

27. CAROTID ARTERY STENOSIS McDonald et al, Stroke 2009

28. What about stroke? McDonald et al, Stroke 2009

29. TAKE HOME MESSAGES

30. TAKE 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

31. ThankyouforyourattentionForanycorrespondence: gbiondizoccai@gmail.comForthese and furtherslides on thesetopicsfeel free tovisit the metcardio.org website:http://www.metcardio.org/slides.html

32. ABSTRACT 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.

33. MULTIPLE CHOICE QUESTIONS • 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.