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

Biondi-Zoccai: Peripheral interventions – metcardio.org DISCLOSURE I am giving a lecture at a Fellows’ Course

Biondi-Zoccai: Peripheral interventions – metcardio.org 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

Biondi-Zoccai: Peripheral interventions – metcardio.org 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

Biondi-Zoccai: Peripheral interventions – metcardio.org 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

Biondi-Zoccai: Peripheral interventions – metcardio.org 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

Biondi-Zoccai: Peripheral interventions – metcardio.org A GLOBAL MANAGEMENT APPROACH IS A MUST

Biondi-Zoccai: Peripheral interventions – metcardio.org TAKE CARE AT PREPPING

Biondi-Zoccai: Peripheral interventions – metcardio.org ALWAYS BEGIN YOUR TRAINING AND YOUR SINGLE PROCEDURE WITH A GOOD QUALITY ANGIO

Biondi-Zoccai: Peripheral interventions – metcardio.org IMAGING WITH DSA IS A MUST FOR ALL VESSELS < 5.0 MM

Biondi-Zoccai: Peripheral interventions – metcardio.org MINIMIZE RADIATION RISK 2 MONTHS AFTER PROCEDURE 6 MONTHS AFTER PROCEDURE 2 YEARS AFTER PROCEDURE

Biondi-Zoccai: Peripheral interventions – metcardio.org 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

Biondi-Zoccai: Peripheral interventions – metcardio.org Garcia et al, Catheter Cardiovasc Interv 2009;74:27-36 COMMON ACCESS SITES FOR PERIPHERAL=FOR CORONARY

Biondi-Zoccai: Peripheral interventions – metcardio.org Garcia et al, Catheter Cardiovasc Interv 2009;74:27-36 LESS COMMON ACCESS SITES FOR PERIPHERAL≠FOR CORONARY

Biondi-Zoccai: Peripheral interventions – metcardio.org DEVICE TYPES ARE ALSO BROADLY SIMILAR Sheaths Shuttle sheaths Guidewires Balloons Stents Filters Thrombectomy catheters

Biondi-Zoccai: Peripheral interventions – metcardio.org 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 ( mm) Stents (balloon-, self-expandable) Filters Thrombectomy catheters (4-6 Fr)

Biondi-Zoccai: Peripheral interventions – metcardio.org SIZE MATTERS!

Biondi-Zoccai: Peripheral interventions – metcardio.org 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

Biondi-Zoccai: Peripheral interventions – metcardio.org RENAL ARTERY STENOSIS

Biondi-Zoccai: Peripheral interventions – metcardio.org RENAL ARTERY STENOSIS

Biondi-Zoccai: Peripheral interventions – metcardio.org LOWER-LIMB INTERVENTIONS: TASC II 2007 vs. TASC 2000

Biondi-Zoccai: Peripheral interventions – metcardio.org IMPORTANCE OF SUBINTIMAL ANGIOPLASTY FOR LOWER-LIMB PTA

Biondi-Zoccai: Peripheral interventions – metcardio.org BTK PTA: TOOLS OF THE TRADE Biondi-Zoccai et al, J Endovasc Ther 2009

Biondi-Zoccai: Peripheral interventions – metcardio.org ENDOVASCULAR ANEURYSM REPAIR

Biondi-Zoccai: Peripheral interventions – metcardio.org CAROTID ARTERY STENOSIS

Biondi-Zoccai: Peripheral interventions – metcardio.org CAROTID ARTERY STENOSIS

Biondi-Zoccai: Peripheral interventions – metcardio.org CAROTID ARTERY STENOSIS McDonald et al, Stroke 2009

Biondi-Zoccai: Peripheral interventions – metcardio.org McDonald et al, Stroke 2009 What about stroke?

Biondi-Zoccai: Peripheral interventions – metcardio.org TAKE HOME MESSAGES

Biondi-Zoccai: Peripheral interventions – metcardio.org 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

Biondi-Zoccai: Peripheral interventions – metcardio.org Thank you for your attention For any correspondence: For these and further slides on these topics feel free to visit the metcardio.org website:

Biondi-Zoccai: Peripheral interventions – metcardio.org 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.

Biondi-Zoccai: Peripheral interventions – metcardio.org 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.