Non-Coronary Intervention for the Interventional Cardiologist

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Non-Coronary Interventionfor theInterventional
Cardiologist

• Keith G Oldroyd
• Department of Cardiology
• Western Infirmary
• Glasgow

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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

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Total Body Revascularisation

• Ilio-femoral
• Subclavian
• Renal
• Carotid

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Indications for lower limb PTA

• Critical ischaemia - limb salvage
• Severe limiting claudication
• Complications following femoral arterial
  cannulation

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Ilio-femoral disease
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Ilio-femoral disease
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Ilio-femoral disease
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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

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Renovascular Disease

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

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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
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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
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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

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Renal artery thrombusPre and post tPA
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Renovascular Disease
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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

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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

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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

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CAROTID STENTING
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Indications for Carotid Endarterectomy in
Symptomatic Patients

• Recent ( lt 6/12) non-disabling stroke/TIA
• Ipsilateral 70 to 99 stenosis
• Surgeons perioperative stroke rate must be lt 6
  (at least 50 consecutive cases over 2 years)

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Indications for Carotid Stenting

• Increased surgical risk
• Medical comorbidity
• Advanced age
• Contralateral occlusion
• Patient refuses surgery
• Randomised trial

• Anatomically difficult lesions
• Restenosis
• post-irradiation
• Too low
• Too high

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CAROTID STENTING
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CAVATAS - 1
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CAROTID WALL-STENT
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Angioguard
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SPIDER
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The GuardWire? Protection System

• GuardWire?
• 0.014 0.018 nitinol Guidewire design
• Low Entry Exit Profile NOW . 028
• Low pressure elastomeric occlusion balloon
  (lt2ATM)
• MicroSeal? Inflation Adapter
• Low pressure inflation
• Removable Hub
• Export?
• Aspiration catheter
• Rail-like design

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The GuardWire? Protection System
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The GuardWire? Protection System
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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

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CAFE-USA RegistryTCD Sub-study
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CAVATAS - II

• RCT
• Carotid wallstent vs CEA
• Mandatory distal protection
• Minimum 10 supervised stent procedures

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Total Body Revascularisation

• Transferable technical skills
• Team approach
• interventional cardiologist
• vascular/endovascular surgeon
• interventional radiologist
• neurologist
• appropriate patient/lesion selection

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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
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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)
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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)
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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)
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Indications for Carotid Endarterectomy in
Asymptomatic Patients

• Surgical risk lt 3
• Proven - gt 60 stenosis (ACAS)
• Acceptable - as above in patient scheduled for
  CABG
• Uncertain - gt 50 stenosis
• N.B. ECST criteria for stenosis generally assigns
  a higher stenosis than ACAS

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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 gt 70 contralateral 70-100
• Uncertain
• Ipsilateral stenosis gt 70
• CABG required bilateral stenosis gt 70
• CABG required unilateral stenosis gt 70

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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 gt 70
• CABG required unilateral stenosis gt 70

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CAROTID STENTING
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CAROTID STENTING
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Microvena Trap
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CAROTID STENTING