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Non-Coronary Intervention for the Interventional Cardiologist

This guide explores total body revascularization and interventions for ilio-femoral, subclavian, renal, and carotid diseases, providing insights into conditions like renovascular disease and "flash" pulmonary edema. Learn about indications for renal stenting, carotid stenting, and relevant clinical trials for optimal patient management.

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Non-Coronary Intervention for the Interventional Cardiologist

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  1. Non-Coronary Interventionfor theInterventional Cardiologist Keith G Oldroyd Department of Cardiology Western Infirmary Glasgow

  2. Total Body Revascularisation • CHD and PVD frequently co-exist • CHD commonest cause of morbidity and mortality in patients with PVD • PVD has a negative impact on the management of ACS and CHF • Potential for combined diagnostic and revascularisation procedures

  3. Total Body Revascularisation • Ilio-femoral • Subclavian • Renal • Carotid

  4. Indications for lower limb PTA • Critical ischaemia - limb salvage • Severe limiting claudication • Complications following femoral arterial cannulation

  5. Ilio-femoral disease

  6. Ilio-femoral disease

  7. Ilio-femoral disease

  8. Subclavian Disease • Subclavian steal • hypoperfusion of LIMA • Vertebrobasilar symptoms • Carotid to subclavian bypass • Stenting • Ochsner - 27 patients; 100% success • 22 (95%) asymptomatic or improved at 28 months

  9. Renovascular Disease • Patients undergoing coronary angiography • 15-20% • Patients undergoing peripheral angiography • 30-40% • Commonest cause of secondary hypertension • overall 4% of hypertensive population

  10. Renovascular Diseaseand “Flash” Pulmonary Oedema • 55 patients with renovascular hypertension + uraemia • 23% had recurrent pulmonary oedema • Predictors of pulmonary oedema • No BP Renal function • Yes CHD Bilateral RAS Bloch et al , Lancet 1999

  11. Renovascular Diseaseand “Flash” Pulmonary Oedema • 41% patients with bilateral RAS had history of pulmonary oedema • 12% patients with unilateral RAS had pulmonary oedema • 77% with bilateral RAS had no further episodes following PTA/stenting • 1 of 3 treated patients with unilateral RAS remained free of pulmonary oedema • Evidence of stent restenosis or thrombus if pulmonary oedema recurred Bloch et al , Lancet 1999

  12. Renovascular Disease • 60 year old female • Admitted 3x in 2years with severe pulmonary oedema • PMH - hypertension; R ureteric calculus; hydronephrosis • Rx - lisinopril, frusemide • Echo - LV hypertrophy; normal LVEF

  13. Renal artery thrombusPre and post tPA

  14. Renovascular Disease

  15. Renovascular DiseaseIndications for renal stenting Bilateral disease or unilateral disease with single kidney + • deteriorating renal function • previous failed trial of ACEI • ? refractory severe hypertension • ? unstable angina • ? congestive heart failure

  16. Renovascular Disease • Ochsner Clinic • 149 stents in 133 arteries in 100 consecutive patients • Procedural success 99% • Normalisation of BP 76% • Complications • SAT (1) • Transient contrast nephropathy (2) • Angiographic restenosis 19%

  17. ASTRAL RCT Stenting plus best medical therapy vs best medical therapy MRA now allowed for diagnosis Split function GFR – kidney with most severe stenosis may still provide majority of function

  18. CAROTID STENTING

  19. Indications for Carotid Endarterectomy in Symptomatic Patients • Recent ( < 6/12) non-disabling stroke/TIA • Ipsilateral 70 to 99% stenosis • Surgeon’s perioperative stroke rate must be < 6% (at least 50 consecutive cases over 2 years)

  20. Increased surgical risk Medical comorbidity Advanced age Contralateral occlusion Patient refuses surgery Randomised trial Anatomically difficult lesions Restenosis post-irradiation Too low Too high Indications for Carotid Stenting

  21. CAROTID STENTING

  22. CAVATAS - 1

  23. CAROTID WALL-STENT

  24. Angioguard

  25. SPIDER

  26. GuardWire 0.014” & 0.018” nitinol Guidewire design Low Entry & Exit Profile NOW . 028” Low pressure elastomeric occlusion balloon (<2ATM) MicroSeal Inflation Adapter Low pressure inflation Removable Hub Export Aspiration catheter Rail-like design The GuardWire Protection System

  27. The GuardWire Protection System

  28. The GuardWire Protection System

  29. CAFE-USA RegistryPercusurge in Carotid Stenting • 212 patients • 99% procedural success • 8% required “staged” protection • Visual embolic material in every case • Mean 12 min of balloon occlusion • 30 day - mortality: 1.4% stroke: 2.4%

  30. CAFE-USA RegistryTCD Sub-study

  31. CAVATAS - II • RCT • Carotid wallstent vs CEA • Mandatory distal protection • Minimum 10 supervised stent procedures

  32. Total Body Revascularisation • Transferable technical skills • Team approach • interventional cardiologist • vascular/endovascular surgeon • interventional radiologist • neurologist • appropriate patient/lesion selection

  33. Atherosclerotic Renovascular Disease • Case reports of flash pulmonary oedema with ARVD. • 6% renal allograft recipients develop ARVD • 11 patients with ARVD • 9 bilateral • 2 unilateral • Revascularisation improved BP, renal function and eliminated heart failure Pickering et al 1988

  34. Renovascular Disease • 29 patients; 32 arteries stented • Procedural success 100% • 6m follow-up • BP improved in 50% • renal function • improved 33% • stabilised 29% Taylor et al, (WIG/Gartnavel)

  35. Renovascular Disease • 29 patients; 32 arteries stented • Procedural success 100% • 6m follow-up • BP improved in 50% • renal function • improved 33% • stabilised 29% Taylor et al, (WIG/Gartnavel)

  36. Atherosclerotic Renovascular Disease • Complications 24% • pseudoaneurysm • dissection • renal failure • atheroembolisation • renal artery perforation • Follow up angiography • restenosis rate 16% at 6m Taylor et al, (WIG/Gartnavel)

  37. Indications for Carotid Endarterectomy in Asymptomatic Patients • Surgical risk < 3% • Proven - > 60% stenosis (ACAS) • Acceptable - as above in patient scheduled for CABG • Uncertain - > 50% stenosis • N.B. ECST criteria for stenosis generally assigns a higher stenosis than ACAS

  38. Indications for Carotid Endarterectomy in Asymptomatic Patients • 30 day stroke rate in surgical arm of ACAS was 1.5% • Surgical risk 3-5% • Proven - none • Acceptable • Ipsilateral > 70%; contralateral 70-100% • Uncertain • Ipsilateral stenosis > 70% • CABG required; bilateral stenosis > 70% • CABG required; unilateral stenosis > 70%

  39. Indications for Carotid Endarterectomy in Asymptomatic Patients • 30 day stroke rate in surgical arm of ACAS was 1.5% • Surgical risk 5-10% • Proven - none • Acceptable - none • Uncertain • CABG required; bilateral stenosis > 70% • CABG required; unilateral stenosis > 70%

  40. CAROTID STENTING

  41. CAROTID STENTING

  42. Microvena Trap

  43. CAROTID STENTING

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