Dr. Giuseppe Sangiorgi, FESC, FSCAIDr. Giuseppe Sangiorgi, FESC, FSCAI

Laboratorio di EmodinamicaLaboratorio di EmodinamicaUniversità di ModenaUniversità di Modena

Ruolo della cardiologia interventistica nel paziente con patologia extracoronarica complessa

Ruolo della cardiologia interventistica nel paziente con patologia extracoronarica complessa

Giuseppe Sangiorgi, MD

Cardiac Cath LabModena Policlinic

Giuseppe Sangiorgi, MD

Cardiac Cath LabModena Policlinic

L’idraulico dell’ExtracoronaricoL’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?

33

Chi vede il Paziente Affetto da Patologia Extracoronarica ?

MEDICINA DI BASEMEDICINA D’URGENZAInternistaCardiologo clinicoCardiologo interventistaAngiologoNefrologoNeurologo

Medicina Interna

Chirurgo GeneraleCardiochirurgoChirurgo VascolareNeurochirurgoRadiologia

Non-interventistaInterventistaNeuroradiologo

Chirurgia

My personal experience My personal experience

in developing an in developing an ““open cath-lab platformopen cath-lab platform””

In 15 MinutesIn 15 Minutes• How all this developed in the places How all this developed in the places

where I have been working up to now where I have been working up to now - and how this could develop in your place (I and how this could develop in your place (I

really hope your dreams comes true)really hope your dreams comes true)

• What you really need to make that happenWhat you really need to make that happen- and what could be helpful in these daysand what could be helpful in these days

• How this will develop in the futureHow this will develop in the future- and where we should work onand where we should work on

21 Years in 15 min21 Years in 15 min

19891989• University of Tor Vergata - RomeUniversity of Tor Vergata - Rome

- Coronary angiogramsCoronary angiograms- PTCAPTCA- Coronary angiogramsCoronary angiograms- PTCAPTCA- Coronary angiogramsCoronary angiograms- PTCAPTCA

• Max Sangiorgi: Max Sangiorgi: "Is there anything else I could "Is there anything else I could do?"do?"

• Senior Physician (Prof. Gioffrè): Senior Physician (Prof. Gioffrè): "Well, I have "Well, I have just got this balloon from Meditech. Some crazy just got this balloon from Meditech. Some crazy people have started to dilate pulmonary valves"people have started to dilate pulmonary valves"

Starting a pulmonary valvuloplasty Starting a pulmonary valvuloplasty program was pretty easy at that timeprogram was pretty easy at that time

• Doctor: Doctor: "Listen, you have a blocked heart valve! "Listen, you have a blocked heart valve! We are going to balloon it"We are going to balloon it"

• Patient: Patient: "Great, please go ahead""Great, please go ahead"

• No ethical committeeNo ethical committee• No regulatory issuesNo regulatory issues• No reimbursement issuesNo reimbursement issues• No paperwork at allNo paperwork at all

That's how we started to do That's how we started to do something else beside coronariessomething else beside coronaries

1989

If you are doing If you are doing coronaries only …coronaries only …

… … could you start a could you start a pulmonary valvuloplasty pulmonary valvuloplasty

program in your institution program in your institution today?today?

Of course!! No problemOf course!! No problem• You may just need …You may just need …

- some discussion with the general director of the hospitalsome discussion with the general director of the hospital- some discussion with CADMsome discussion with CADM- some discussion with administrationsome discussion with administration- some discussion with pharmacysome discussion with pharmacy- some discussion with clinical engineersome discussion with clinical engineer- a little bit more of discussion with the surgeons than we had a little bit more of discussion with the surgeons than we had

in the 80iesin the 80ies- a dedicated 3 day training organized by the medical device a dedicated 3 day training organized by the medical device

companycompany- a certificate from the scientific society of somethinga certificate from the scientific society of something- May be you will need IRB approval May be you will need IRB approval - and may be some other paper workand may be some other paper work

Needless to mention …Needless to mention …

… … that it is an absolute requirement that it is an absolute requirement that you already have done 100 that you already have done 100

cases (for the general director and cases (for the general director and CADM) with excellent outcome CADM) with excellent outcome beforebefore you start your program you start your program

19901990• PTCA in a 68 y/o patientPTCA in a 68 y/o patient• I punctured the right femoral I punctured the right femoral

- and failedand failed• I punctured the left femoralI punctured the left femoral

- and failedand failed• I punctured the right brachialI punctured the right brachial

- and failedand failed• I did not know about the radial approach I did not know about the radial approach

- and punctured the left brachialand punctured the left brachial- crossed a proximal stenosis of the left subclaviancrossed a proximal stenosis of the left subclavian- … … finally performed the PTCAfinally performed the PTCA

• "Would be nice to have that subclavian artery open""Would be nice to have that subclavian artery open"- The cath lab nurse run into the radiology department for a 5 mm The cath lab nurse run into the radiology department for a 5 mm

balloonballoon- I did my first peripheral angioplastyI did my first peripheral angioplasty- … … and finally learned what turf battle meansand finally learned what turf battle means

Next morning in the office Next morning in the office of the head of radiologyof the head of radiology

• Head of radiology (Prof. Giovanni Head of radiology (Prof. Giovanni Simonetti): Simonetti): "How could you as a cardiologist "How could you as a cardiologist do a peripheral angioplasty without do a peripheral angioplasty without permission?!?!permission?!?!What would you say if I as a radiologist would What would you say if I as a radiologist would start coronary angiography?"start coronary angiography?"

• My answer: My answer: "I would be more than happy to "I would be more than happy to train you"train you"

• Head of radiology: very angry with Head of radiology: very angry with cardiologists after 20 years cardiologists after 20 years

We moved on We moved on with other procedures with other procedures

which required big which required big balloonsballoons

… … like aortic valvuloplastylike aortic valvuloplasty

Angioplasty of coarctationAngioplasty of coarctation

1992

Thereafter, we pushed the balloon forward ....Thereafter, we pushed the balloon forward ....

Retrograde Mitral Valvuloplasty

1993

and transeptal mitral and transeptal mitral valvuloplasty with ugly balloonsvalvuloplasty with ugly balloons

1993

Later on Later on we did this with umbrellaswe did this with umbrellas

Rashkind-OkkluderRashkind-Okkluder

If you are familiar with...If you are familiar with...

• transseptal puncturetransseptal puncture

• the left atriumthe left atrium

• umbrellasumbrellas

So now you have some So now you have some contacts to the pediatric contacts to the pediatric

world, world,

so it is only a small step to so it is only a small step to become involved in VSD become involved in VSD

closureclosure

Congenital Muscular VSDCongenital Muscular VSD

San Donato 1998

Of course, you are still Of course, you are still involved in the sometimes involved in the sometimes

boring coronary workboring coronary work

So you will become So you will become involved in post-Myocardial involved in post-Myocardial

infarction VSD closureinfarction VSD closure

Post Myocardial Infarction VSDPost Myocardial Infarction VSD

Device released Final angio

By the way: By the way: Do not forget the coronary fistulasDo not forget the coronary fistulas

Only a small step to peripheral fistulasOnly a small step to peripheral fistulas

Pulmonary AV-FistulaPulmonary AV-Fistula

San Donato 2001

When you alreayd have When you alreayd have experience with really large experience with really large

sheaths...sheaths...

SPIRAL ANGIO CT

D3

D5

D4

IMALumbar aa.

Accessory renal a.

ANGIO DSA

Anatomical landmarks to be considered prior to EVG intervention

Renal a.

D5

D1

D : diameter L : length A : angulation

L2

D3

D5

D4

Giorgio S.Rx. 3242118\10\2000

Giorgio S.Rx. 3242118\10\2000

Selective injection of SMAfills back IMA up to the coilSelective injection of SMAfills back IMA up to the coil

Selective 3rd left lumbar a. arteriography

Selective 3rd left lumbar a. arteriography

Super-selective 3rd left lumbar a. arteriographythrough Fast Traker 325

Super-selective 3rd left lumbar a. arteriographythrough Fast Traker 325

Catheter treatment of Catheter treatment of congenital heart diseasecongenital heart disease

Non-congenital Non-congenital heart defectsheart defects

Other Other cardiovascular cardiovascular

diseasesdiseases

If you have learned transseptalsIf you have learned transseptalsand if you know where the left and if you know where the left

atrium is....atrium is....

Alain Cribier's Valve (PVT)Alain Cribier's Valve (PVT)

• Equine pericardiumEquine pericardium

• Balloon expandable Balloon expandable

stentstent

• One size: 23mm One size: 23mm

CoreValve PAVR CoreValve PAVR ReValvingReValving System System

• Nitinol frameNitinol frame- Self expandingSelf expanding

• Porcine pericardial valvePorcine 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 If you are dealing with stroke prevention like PFO and LAA prevention like PFO and LAA

closure you have some contacts closure you have some contacts to the world of neurologyto the world of neurology

And And Carotid Carotid Stenting?Stenting?

Siti più comuni di PTA

su vasi epiaortici

Siti più comuni di PTA

su vasi epiaortici

ACC corpoACC corpo

ACIACI

Tronco anonimoTronco anonimo

ACC ostialeACC ostiale

SucclaviaSucclavia

Critical left subclavian a. stenosis in a pt with CABG: LIMA to LAD

Critical left subclavian a. stenosis in a pt with CABG: LIMA to LAD

Post PTA + stentingPost PTA + stenting

Remo S.Rx 1132321\02\1995

Remo S.Rx 1132321\02\1995

PTA Carotide ComunePTA Carotide Comune

Post PTAPost PTA

Remo S.Rx 11323 22\02\1995

Remo S.Rx 11323 22\02\1995

Post stent J&J 204Post stent J&J 204

PTA Carotide ComunePTA Carotide Comune

Bartolomeo G.Rx. 1768524\01\2007

Bartolomeo G.Rx. 1768524\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. 1768524\01\2007

Bartolomeo G.Rx. 1768524\01\2007

Post CEAPost CEA

PTA + stent

retrogrado

della ACC

ostiale

via puntura

diretta dopo

esposizione

chirurgica

del vaso

PTA + stent

retrogrado

della ACC

ostiale

via puntura

diretta dopo

esposizione

chirurgica

del vaso

b

• The diameter of The diameter of the LAD is equal the LAD is equal to the diameter of to the diameter of the tibial arteriesthe tibial arteries

3 mesi dopo il trattamento

6 mesi dopo il trattamento

Basale 3 mesi dopo

PADunderdiagnosed and

undertreateddisease

• High prevalence and high morbidity (non-healing 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 We have been involved in all of thisin all of this

Can you become Can you become involved as well?involved as well?

Of course!! No problemOf course!! No problem• You may just need …You may just need …

- some discussion with the director of the hospitalsome discussion with the director of the hospital- some discussion with the administrationsome discussion with the administration- some discussion with the health care insurancessome discussion with the health care insurances- a little bit more of discussion with the surgeons than a little bit more of discussion with the surgeons than

we had in the 80ieswe had in the 80ies- a dedicated 3 day training organized by the medical a dedicated 3 day training organized by the medical

device companydevice company- a certificate from the scientific society of somethinga certificate from the scientific society of something- May be you will need IRB approval May be you will need IRB approval - and may be some other paper workand may be some other paper work

What do you What do you really need ?really need ?

You really needYou really need• Cath labCath lab• Echo and TEE and someone who helps Echo and TEE and someone who helps

you with thatyou with that

• … … and for some more complex and for some more complex procedures… anestesiologist, Vascular procedures… anestesiologist, Vascular surgeons, neurologists, cardiothoracic surgeons, neurologists, cardiothoracic surgeonssurgeons

You don't really needYou don't really need• Hybrid roomHybrid room

• CT CT

• MRIMRI

• 3 D Angio3 D Angio

• Although all this may be helpfulAlthough all this may be helpful

And of course all of the following is And of course all of the following is helpful in these dayshelpful in these days

• some discussion with the director of the hospitalsome discussion with the director of the hospital• some discussion with the administrationsome discussion with the administration• some discussion with the health care insurancessome discussion with the health care insurances• a little bit more of discussion with the surgeons than a little bit more of discussion with the surgeons than

we had in the 80ieswe had in the 80ies• a dedicated 3 day training organized by the medical a dedicated 3 day training organized by the medical

device companydevice company• a certificate from the scientific society of somethinga certificate from the scientific society of something• IRB approval IRB approval • and may be some other paper workand may be some other paper work

In 15 MinutesIn 15 Minutes• How all this I have been wish that could How all this I have been wish that could

developed in my place that now is Modenadeveloped in my place that now is Modena- and how this could develop in your placeand how this could develop in your place

• What you really need to make that happenWhat you really need to make that happen- and what could be helpful in these daysand what could be helpful in these days

• How this will develop in the futureHow this will develop in the future- and where we should work onand where we should work on

There will be much more catheter There will be much more catheter techniques available to treat all kind techniques available to treat all kind

of cardiovascular diseases of cardiovascular diseases

We should always tryWe should always try• to keep the doors opento keep the doors open• to stop over-regulationto stop over-regulation• to avoid turf battlesto avoid turf battles• and to train the radiologists and to train the radiologists

and vascular surgeons in and vascular surgeons in coronary angiographycoronary 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

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