My Approach to Complex BTK Disease New York 2014
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1 My Approach to Complex BTK Disease New York 2014 Raj Dave, MD, FACC, FSCAI Chairman, Division Of Cardiology Director, Catheterization Laboratories Chief Medical Executive, Holy Spirit Cardiovascular Institute Holy Spirit Hospital Camp Hill, PA
2 Interventinonal Cardiologist and PVD It is essential part of your practice: Global Cardiovascular Disease care rather than just CAD PAD will lead to undetected CAD diagnosis and vice versa, Saves LIVES PV Intervention is just like Coronary, Just Amplified!! My personal Volume: 550 PV Intervention/year, 350 Coronary intervention/year!!!!
3 Disclosure Abbott, Maquet, Bayer, CSI, : Training, Research TriReme, Angioscore: Advisory Board
4 CLI Treatment Goals Establish Straight-line Flow to The Foot Pressure and Oxygen content to the affected segment Localized wound care and? Hyperbaric Oxygen
5 CLI Revascularization Availability of target vessel Wound or Gangrene ( Healing, complete limb salvage vs limit the amputation, level) Wound: Size, Timing, Diabetes, Infection Post PCI vessel quality: Restenosis/ occlusion likelihood, Time frame?(? Provide Total vs one)
6 Is the straight-line flow through one vessel enough? Most CLI patients are Diabetics Small vessel disease at foot level is Universal Arcuate artery and its branches Despite having restored one vessel the healing is very slow in these cases
7 Traditional Standard of Care : Is it really the best? CLI: Straight Single vessel runoff is sufficient Vs Open All you can? POBA vs?plaque Modification,? DES,?DEB as routine In patient with Wound/Ulcer: Follow up, Reintervention Attention tovenous Insufficiency, Perforators in mixed disorder
8 Newer Techniques Retrograde, Reverse CART Transpedal loop reconstruction and use as collateral from retrograde access into second vessel
9 BTK-Coronary CTO Similarities Careful Study of Target & Foot Vessels is important in Complex case Attention to Collaterals ( prevent Collateral perforations, their use as a conduit) and course of the artery to increase success
10 Angiography Clarification of AT to DP course PT to Plantar course LAO 30 Left BTK RAO 30 LT BTK
11 Standard Retrograde 75 yo male with restpain and non healing ulcer
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13 Retrograde Access into AT, Armada 1.5mm balloon as support And wire crossing into 5f Catheter from Antegrade Sheath
14 Orbital Atherectomy
15 Pta and SE Stents Why Stent the Popliteal?, Unlike popular Belief the fracture rate With Next generation SE e.g SUPERA very low fracture
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18 Plantar Loop Case 60 year old male Rest pain of left foot and multiple toe ulcers Prior History of Recurrent CLI
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21 Attempt made to cross AT occlusion from Top Failed Retrograde wire also Failed Reverse CART with Successful passage
22 After PTA with Armada 2.5 and 3.0 balloon Plus 3.0x38 Expedition DES in Prox AT
23 Why DES? Should we do Second Vessel? Notice the Proximal occlusion of AT at the beginning of the procedure- Likely the site for Recurrent Occlusion, DES will stabilize this site Notice a small dissection in Distal AT despite two prolonged inflations: Reduces the reliability of patency Lost distal Peroneal Inadequate Anticoagulation, thrombus from sheath
24 In a staged fashion Corsair and Fielder FC Via Plantar loop
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26 Caution When the wire is being Snared, leave support catheter In Plantar Loop to prevent Shearing effect and intense Spasm ( IA Nitro) After Antegrade wire threaded Pull the whole assembly from retrograde side
27 Note Notice that artery that looked Like PT is not actually PT
28 3x38 Expedition DES In Proximal PT To maintain access Into PT
29 75yof with rest pain And cellulitis A case of transcollateral Access
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32 Angiography and failed antegrade attempt
33 Armada 3.0 balloon dilated From antegrade wire and then Advancing Fielder FC and Corsair from below
34 Retrograde Balloon dilation
35 Now Antegrade wire crosses into Lateral Plantar artery
36
37 Conclusions Careful Angiography to understand anatomy Consider Angiosome but if possible complete Revascularization Challenging areas use DES Follow up critical, don t be ashamed to inform patient about reintervention upfront
Patients suffering from critical limb ischemia (CLI)
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