non-cornoary intervention for the interventional cardiologist

Non-Coronary Interventionfor the

Interventional Cardiologist

Keith G OldroydDepartment of Cardiology

Western InfirmaryGlasgow

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


• Ilio-femoral

• Subclavian

• Renal

• Carotid

Indications for lower limb PTA

• Critical ischaemia - limb salvage

• Severe limiting claudication

• Complications following femoral arterial cannulation

Ilio-femoral disease

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

Renovascular Disease

• Patients undergoing coronary angiography– 15-20%

• Patients undergoing peripheral angiography– 30-40%

• Commonest cause of secondary hypertension– overall 4% of hypertensive population

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 RASBloch et al , Lancet 1999

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


• 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

Renal artery thrombusPre and post tPA

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


• 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%

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

CAROTID STENTING

Indications for Carotid Endarterectomy in Symptomatic Patients

• Recent ( < 6/12) non-disabling stroke/TIA

• Ipsilateral 70 to 99% stenosis

• Surgeon’s perioperative stroke rate must be < 6% (at least 50 consecutive cases over 2 years)

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

CAROTID STENTING

n Symptoms Death Stroke RR(%)

Yadav 1997 107 (126)

59% 1.6%

0

4.9

Wholey 1998 2048 65% 1.4%

1.3% 4.8

CAST-I 1999 99 Majority 0

0 3.0

Nancy 1998 164 (174)

35% 0

1.7% 2.0

Roubin 1999 44 1(RPB) 1 0

Waigand 1998 50 (53)

28% 1

1 6.5

CAVATAS - 1

Angioplasty CEA p

Death/major stroke

6.4% 5.9% NS

Death/any stroke 10% 9.9% NS

Cranial neuropathy

0 8.7% 0.001

Major haematoma

1.2% 6.7% 0.001

CAROTID WALL-STENT

Death/ipsilateral stroke

Stenting

(n=108)

CEA

(n=113)

30 days 10.2% 3.5%

1 year 12% 3.5%

Angioguard

SPIDER

The GuardWire Protection System

• GuardWire– 0.014” & 0.018” nitinol Guidewire

design– Low Entry & Exit Profile NOW

. 028”– Low pressure elastomeric

occlusion balloon (<2ATM)

• MicroSeal Inflation Adapter

– Low pressure inflation– Removable Hub

• Export– Aspiration catheter– Rail-like design

The GuardWire Protection System

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%

CAFE-USA RegistryTCD Sub-study

Control Protection p

Predilatation 32 12 0.001

Stent deployment 75 17 0.004

Post dilatation 27 5 0.002

Total 164 68 0.002

CAVATAS - II

• RCT

• Carotid wallstent vs CEA

• Mandatory distal protection

• Minimum 10 supervised stent procedures


• Transferable technical skills

• Team approach– interventional cardiologist– vascular/endovascular surgeon– interventional radiologist– neurologist– appropriate patient/lesion selection

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


• 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)

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)

Indications for Carotid Endarterectomy in Asymptomatic Patients

• Surgical risk < 3%– Proven - > 60% stenosis (ACAS)– Acceptable - as above in patient scheduled

for CABG– Uncertain - > 50% stenosis– N.B. ECST criteria for stenosis generally

assigns a higher stenosis than ACAS


• 30 day stroke rate in surgical arm of ACAS was 1.5%

• Surgical risk 3-5%– Proven - none– Acceptable

• Ipsilateral > 70%; contralateral 70-100%

– Uncertain• Ipsilateral stenosis > 70%• CABG required; bilateral stenosis > 70%• CABG required; unilateral stenosis > 70%


• 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 > 70%• CABG required; unilateral stenosis > 70%

CAROTID STENTING

Microvena Trap

CAROTID STENTING

n Symptoms Outcomes RR(%)

Comments

Yadav1997

107(126)

59% Death 1.6%Stroke 0

4.9 77% ineligiblefor NASCET

Wholey1998

2048 65% Death 1.4%Stroke 1.3%

4.8 Registry

CAST-I1999

99 Majority Death 0Stroke 0

3 Directpuncture

Nancy1998

164(174)

35% Death 0Stroke 1.7%

2.

Roubin1999

44 Death 1(RPB)

Stroke 10 Mayo Class IV

Waigand1998

50(53)

28% Death 1Stroke 1

6.5 No strokeduring CABG

non-cornoary intervention for the interventional cardiologist

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