Ruolo della cardiologia interventistica nel paziente con patologia

Ruolo della cardiologia interventistica nel paziente con patologia extracoronarica complessa Dr. Giuseppe Sangiorgi, FESC, FSCAI Laboratorio di Emodinamica Università di Modena

Giuseppe Sangiorgi, MD Cardiac Cath Lab Modena Policlinic

L’idraulico dell’Extracoronarico • • • Quanti di voi hanno mai chiamato l’idraulico? Avete chiamato l’idraulico per il gabinetto ed è arrivato uno specialista solo in docce? Noi emodinamisti dovremmo saper riparare tutto?

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Chi vede il Paziente Affetto da Patologia Extracoronarica ? Medicina Interna Chirurgia MEDICINA DI BASE MEDICINA D’URGENZA Internista Cardiologo clinico Cardiologo interventista Angiologo Nefrologo 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

• 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 80 ies - 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. D 1 IMA L 2 Lumbar aa. D 3 D 4 D 5 D : diameter D 5 L : length A : angulation

Giorgio S. Rx. 32421 18102000 Selective injection of SMA fills back IMA up to the coil

Super-selective 3 rd left lumbar a. arteriography through Fast Traker 325 Selective 3 rd 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: 23 mm

Core. Valve PAVR Re. Valving 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 29 mm 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 2121995

PTA Carotide Comune Post PTA Post stent J&J 204 Remo S. Rx 11323 2221995

Bartolomeo G. Rx. 17685 2412007 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 2412007 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 80 ies 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 80 ies 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 l l 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

STROKE