My Approach to Complex BTK Disease New York

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
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!!!!
Disclosure
•  Abbott, Maquet, Bayer, CSI, :
Training, Research
•  TriReme, Angioscore: Advisory
Board
CLI Treatment Goals
•  Establish Straight-line Flow to The
Foot
•  Pressure and Oxygen content to the
affected segment
•  Localized wound care and ?
Hyperbaric Oxygen
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)
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
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
Newer Techniques
•  Retrograde, Reverse CART
•  Transpedal loop reconstruction and
use as collateral from retrograde
access into second vessel
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
Angiography
•  Clarification of AT to DP course
•  PT to Plantar course
LAO
30 Left
BTK
RAO 30
LT BTK
Standard Retrograde
•  75 yo male with restpain and non
healing ulcer
Retrograde Access into AT, Armada 1.5mm balloon as support
And wire crossing into 5f Catheter from Antegrade Sheath
Orbital Atherectomy
Pta and SE
Stents
Why Stent the Popliteal?, Unlike popular Belief the fracture rate
With Next generation SE e.g SUPERA very low fracture
Plantar Loop Case
•  60 year old male
•  Rest pain of left foot and multiple
toe ulcers
•  Prior History of Recurrent CLI
Attempt made to cross
AT occlusion from Top
Failed
Retrograde wire also
Failed
Reverse CART with
Successful passage
After PTA with Armada
2.5 and 3.0 balloon
Plus 3.0x38 Expedition
DES in Prox AT
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
In a staged fashion
Corsair and Fielder
FC Via Plantar loop
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
Note
Notice that artery that looked
Like PT is not actually PT
3x38 Expedition DES
In Proximal PT
To maintain access
Into PT
75yof with rest pain
And cellulitis
A case of transcollateral
Access
Angiography and failed antegrade attempt
Armada 3.0 balloon dilated
From antegrade wire and then
Advancing Fielder FC and Corsair
from below
Retrograde Balloon dilation
Now Antegrade wire crosses into Lateral Plantar artery
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