Ruolo della cardiologia interventistica
nel paziente con patologia
extracoronarica complessa
Dr. Giuseppe Sangiorgi, FESC, FSCAI
Laboratorio di Emodinamica
Università di Modena
THE
LETE
P
M
O
C
GUIDE
Building
Interacting withan
Interventional
Cardiologist’s
Endovascular
Practice
Giuseppe
MD
Gary MSangiorgi,
Ansel MD
Cardiac Cath Lab
Riverside
Methodist
Modena Policlinic
GaryColumbus,
M Ansel MDOhio
FACC
The Body Plumber
L’idraulico dell’Extracoronarico
•
How many of you have used a
Quanti di voi hanno
plumber?
mai
chiamato
Did you
look for a bathroom
plumber?
l’idraulico?
Your doctor
should act as a
• Avete
chiamato
whole
house plumber?
l’idraulico
per il
gabinetto ed è
arrivato uno
specialista solo in
docce?
• Noi emodinamisti
dovremmo saper
3
Chi vede il Paziente Affetto da
Patologia Extracoronarica ?
Medicina Interna
Chirurgia
MEDICINA DI BASE
MEDICINA D’URGENZA
Internista
Cardiologo clinico
Cardiologo interventista
Angiologo
Nefrologo
Neurologo
Chirurgo Generale
Cardiochirurgo
Chirurgo Vascolare
Neurochirurgo
Radiologia
Non-interventista
Interventista
Neuroradiologo
My personal experience
in developing an
“open cath-lab
platform”
In 15 Minutes
• How all this developed in the places
where I have been working up to now
- and how this could develop in your place
(I really hope your dreams comes true)
• What you really need to make that
happen
- and what could be helpful in these days
• How this will develop in the future
- and where we should work on
21 Years in 15 min
1989
• University of Tor Vergata - Rome
-
Coronary angiograms
PTCA
Coronary angiograms
PTCA
Coronary angiograms
PTCA
• Max Sangiorgi: "Is there anything else I could
do?"
• Senior Physician (Prof. Gioffrè): "Well, I have
just got this balloon from Meditech. Some crazy
people have started to dilate pulmonary valves"
Starting a pulmonary valvuloplasty
program was pretty easy at that time
• Doctor: "Listen, you have a blocked heart valve!
We are going to balloon it"
• Patient: "Great, please go ahead"
•
•
•
•
No ethical committee
No regulatory issues
No reimbursement issues
No paperwork at all
That's how we started to do
something else beside coronaries
1989
If you are doing
coronaries only …
… could you start a
pulmonary valvuloplasty
program in your institution
today?
Of course!! No problem
• You may just need …
- some discussion with the general director of the
hospital
- some discussion with CADM
- some discussion with administration
- some discussion with pharmacy
- some discussion with clinical engineer
- a little bit more of discussion with the surgeons
than we had in the 80ies
- a dedicated 3 day training organized by the
medical device company
- a certificate from the scientific society of
something
- May be you will need IRB approval
- and may be some other paper work
Needless to mention …
… that it is an absolute requirement
that you already have done 100
cases (for the general director and
CADM) with excellent outcome
before you start your program
1990
• PTCA in a 68 y/o patient
• I punctured the right femoral
- and failed
• I punctured the left femoral
- and failed
• I punctured the right brachial
- and failed
• I did not know about the radial approach
- and punctured the left brachial
- crossed a proximal stenosis of the left subclavian
- … finally performed the PTCA
• "Would be nice to have that subclavian artery open"
- The cath lab nurse run into the radiology department for a 5
mm balloon
- I did my first peripheral angioplasty
- … and finally learned what turf battle means
Next morning in the office
of the head of radiology
• Head of radiology (Prof. Giovanni
Simonetti): "How could you as a
cardiologist do a peripheral angioplasty
without permission?!?!
What would you say if I as a radiologist
would start coronary angiography?"
• My answer: "I would be more than happy
to train you"
• Head of radiology: very angry with
cardiologists after 20 years
We moved on
with other procedures
which required big
balloons
… like aortic valvuloplasty
Angioplasty of coarctation
1992
Thereafter, we pushed the balloon forward ....
Retrograde Mitral Valvuloplasty
1993
and transeptal mitral
valvuloplasty with ugly balloons
1993
Later on
we did this with umbrellas
Rashkind-Okkluder
If you are familiar with...
• transseptal puncture
• the left atrium
• umbrellas
So now you have some
contacts to the pediatric
world,
so it is only a small step to
become involved in VSD
closure
Congenital Muscular VSD
San Donato 1998
Of course, you are still
involved in the sometimes
boring coronary work
So you will become
involved in post-Myocardial
infarction VSD closure
Post Myocardial Infarction VSD
Device released
Final angio
By the way:
Do not forget the coronary fistulas
Only a small step to peripheral fistulas
Pulmonary AV-Fistula
San Donato 2001
When you alreayd have
experience with really large
sheaths...
Anatomical landmarks to be considered
prior to EVG intervention
ANGIO DSA
SPIRAL ANGIO CT
Renal a.
Accessory
renal a.
D1
IMA
L2
Lumbar aa.
D3
D4
D3
D4
D5
D5
D : diameter
D5
L : length
A : angulation
Giorgio S.
Rx. 32421
18\10\2000
Selective injection of SMA
fills back IMA up to the coil
Super-selective 3rd left
lumbar a. arteriography
through Fast Traker 325
Selective 3rd left
lumbar a. arteriography
Catheter treatment of
congenital heart disease
Non-congenital
heart defects
Other
cardiovascular
diseases
If you have learned transseptals
and if you know where the left
atrium is....
Alain Cribier's Valve (PVT)
• Equine pericardium
• Balloon expandable
stent
• One size: 23mm
CoreValve PAVR ReValving System
• Nitinol frame
- Self expanding
• Porcine pericardial valve
• Low radial force
- Orients the system
• Constrained area
- Avoids coronaries
• High radial force
- Secure anchoring
• 26 and 29mm diameter
If you are dealing with stroke
prevention like PFO and LAA
closure you have some contacts
to the world of neurology
And
Carotid
Stenting?
Succlavia
ACI
ACC ostiale
Tronco anonimo
Siti più comuni di PTA
su vasi epiaortici
ACC corpo
Critical left subclavian a.
stenosis in a pt with CABG:
LIMA to LAD
Post PTA + stenting
PTA Carotide Comune
Remo S.
Rx 11323
21\02\1995
PTA Carotide Comune
Post PTA
Post stent J&J 204
Remo S.
Rx 11323
22\02\1995
Bartolomeo G.
Rx. 17685
24\01\2007
Association of critical left CCA ostial
and distal calcified stenosis at
bifurcation.
Strategy : exposure of CCA, direct
stenting of ostial and CEA at
bifurcation.
Post direct JOMED P 38 stenting
Bartolomeo G.
Rx. 17685
24\01\2007
Post CEA
PTA + stent
retrogrado
della ACC
ostiale
via puntura
diretta dopo
esposizione
chirurgica
del vaso
• The diameter of
the LAD is equal
to the diameter of
the tibial arteries
3 mesi dopo il trattamento
6 mesi dopo il trattamento
Basale
3 mesi dopo
PAD
underdiagnosed and
undertreated
disease
• High prevalence and high morbidity (nonhealing wounds, gangrene, and amputation)
lead to the publication of a “call to action” to
physicians to increase detection of and
treatment for PAD
Arch Intern Med 2003;63:884–92.
Sensitivity and specificity
• Resting ABI value <0.9 approaches 95%
sensitivity in detecting angiogram positive
disease, and it is associated with the presence of
50% or greater stenosis in 1 or more major
vessels.
• It is almost 100% specific in excluding healthy
individuals.
ABI and Survival
We have been involved
in all of this
Can you become
involved as well?
Of course!! No problem
• You may just need …
- some discussion with the director of the hospital
- some discussion with the administration
- some discussion with the health care
insurances
- a little bit more of discussion with the surgeons
than we had in the 80ies
- a dedicated 3 day training organized by the
medical device company
- a certificate from the scientific society of
something
- May be you will need IRB approval
- and may be some other paper work
What do you
really need ?
You really need
• Cath lab
• Echo and TEE and someone who helps
you with that
• … and for some more complex
procedures… anestesiologist, Vascular
surgeons, neurologists, cardiothoracic
surgeons
You don't really need
•
•
•
•
Hybrid room
CT
MRI
3 D Angio
• Although all this may be helpful
And of course all of the following is
helpful in these days
•
•
•
•
•
•
•
•
some discussion with the director of the hospital
some discussion with the administration
some discussion with the health care insurances
a little bit more of discussion with the surgeons
than we had in the 80ies
a dedicated 3 day training organized by the
medical device company
a certificate from the scientific society of
something
IRB approval
and may be some other paper work
In 15 Minutes
• How all this I have been wish that
could developed in my place that now
is Modena
- and how this could develop in your place
• What you really need to make that
happen
- and what could be helpful in these days
• How this will develop in the future
- and where we should work on
There will be much more catheter
techniques available to treat all kind
of cardiovascular diseases
We should always try
• to keep the doors open
• to stop over-regulation
• to avoid turf battles
• and to train the radiologists
and vascular surgeons in
coronary angiography
Conclusioni




Il trattamento percutaneo delle diverse patologie
periferiche si è rapidamente sviluppato ed è in
rapida evoluzione
Molte applicazioni interventistiche periferiche
hanno tratto enorme vantaggio dalla traslazione
della tecnologia coronarica
L’intero campo ha avuto ed avrà enormi benefici
dalla partecipazione di un maggior numero di
colleghi cardiologi
Come cardiologi, la partecipazione in questo
programma di sviluppo è imperativa