Antonio Micari, MD,Director Laboratory of Invasive Cardiology Maria Eleonora Hospital, Palermo, Italy
Generalized atherosclerosis: result of cardiac and peripheral
revascularizzation
A Generalized A Generalized Disease……Disease………………
In presence of severe In presence of severe diffuse polivasculopathydiffuse polivasculopathy
First Step?First Step?First Step?First Step?•To know precisely the To know precisely the clinical statusclinical status of our patient.of our patient.•Considering the majority of patients Considering the majority of patients will die for will die for coronary disease.coronary disease.
•To know precisely the To know precisely the clinical statusclinical status of our patient.of our patient.•Considering the majority of patients Considering the majority of patients will die for will die for coronary disease.coronary disease.
In presence of severe diffuse In presence of severe diffuse polivasculopathy:polivasculopathy:
Most ImportantMost Important ClinicalClinical VariabesVariabes
Neurological symptomsNeurological symptoms: symptomatic vs asymptomatic / silent : symptomatic vs asymptomatic / silent cerebral ischemiacerebral ischemia
Carotid pathologyCarotid pathology: mono: mono--lateral vs bilaterallateral vs bilateral
Carotid plaque characteristicsCarotid plaque characteristics: low vs high embolization risk: low vs high embolization risk
Age, Diabetes, Controlled or Uncontrolled Blood Pressure Age, Diabetes, Controlled or Uncontrolled Blood Pressure
Renal functionRenal function: normal vs depressed: normal vs depressed
Peripheral arterial occlusive diseasePeripheral arterial occlusive disease: critical limb ischemia: critical limb ischemia
Anginal statusAnginal status: stable vs unstable: stable vs unstable
CADCAD: 1VD, 2VD, 3VD, Multi-VD, Left Main Stem, Re-operation: 1VD, 2VD, 3VD, Multi-VD, Left Main Stem, Re-operation
Left ventricular functionLeft ventricular function: normal vs depressed: normal vs depressed
NYHA classNYHA class: I, II, III, IV: I, II, III, IV
In presence of severe diffuse polivasculopathyIn presence of severe diffuse polivasculopathyFacing the Single PatientFacing the Single Patient
Which District First
Which District First
Single or Staged Procedures
Single or Staged Procedures
Gender: FemaleAge: 69 year
Risk factors: Active Smoker, HTN, IDDM
Clinical History: Bilateral intermittent claudicatio since 8 months
Main clinical Problem: Critical Limb Ischemia (Left Foot Calcaneal Ulcer, rest pain, Ankle pressure < 70 mmHg).
Duplex: Left popliteal occlusion (Fibro-lipid plaque). Collateral flow in the BTK arteries
Associated clinical conditions: Chronic renal failure (eGFR 43 ml/min/1.73 m2), β Thalassemia (Hb: 9.6)
Therapy: ASA, Lercadipine, Simvastatin
Chest Pain while Hospitalized !Chest Pain while Hospitalized !
CX and Om Lesion
LAD-Diag Lesion
Long RCA Lesion
Popliteal Occlusion
Clinical problemsClinical problems
• Do we need to re-vascularize the Limb?
• How we should re-vasularize the Limb?
• What about concomitant CAD (Syntax Score: 24)?
When we have to perform PCI/PTA we need a DAPT having:
1)Proven efficacy relatively independent from patient genetic backgroud
2)Good results in terms of long term outcomes
3)Is not harmful for patients with advanced age
0
5
10
15
0 30 60 90 180 270 360 450
HR 0.81(0.73-0.90)P=0.0004
Prasugrel
Clopidogrel
Days
Endp
oint
(%)
12.1
9.9
138 events
NNT = 46
Wiviott et al N Engl J Med. 2007
K-M estimate of first primary efficacyend-point (composite of CV death, MI or stroke)
K-M estimate of first primary efficacyend-point (composite of CV death, MI or stroke)
0
0.5
1
1.5
2
2.5
0 50 100 150 200 250 300 350 400 450
% o
f S
ubje
cts
HR 0.48 [0.36-0.64] P<0.0001
1 year: 1.06 vs 2.15%HR 0.48 [0.36-0.65], P<0.0001
2.35%
1.13%
52%
DAYS
CLOPIDOGREL
PRASUGREL
Wiviott SD et al. Lancet 2008
STENT Analysis Definite/Probable ST: Any Stent (N=12844)Definite/Probable ST: Any Stent (N=12844)
STENT Analysis Definite/Probable ST: Any Stent (N=12844)Definite/Probable ST: Any Stent (N=12844)
But remember limitations!!!!
Primary endpoint: CV death, MI or strokePrimary endpoint: CV death, MI or stroke
0
0
5
10
15
60 120 180 240 300 360
Days after randomization
K-M
est
ima
ted
rat
e (%
per
ye
ar)
HR: 0.84 (95% CI = 0.75–0.94), p=0.0025
9.02
10.65Clopidogrel
Ticagrelor
No. at risk
Clopidogrel
Ticagrelor
6,676
6,732
6,129
6,236
6,034
6,134
5,881 4,815
4,889
3,680
3,735
2,965
3,0485,972
K-M = Kaplan-Meier; HR = hazard ratio; CI = confidence interval
When we have to perform CLI PTA in a patient that will undergo CABG we should consider that Patient should go to surgery as soon as possible…this time is determined by the bleeding risk after last intake of DAPT
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6 7 >8
Ticagrelor
Clopidogrel
Major Fatal/Life-Threatening Bleeding by Days from Last Dose of Treatment to CABG
Major Fatal/Life-Threatening Bleeding by Days from Last Dose of Treatment to CABG
% P
atien
ts w
ith B
leed
ing
post
-CAB
G
Days
Bleeding differences favor ticagrelor >5 days post discontinuation
Courtesy of Sanjay Kaul
1) Predilation with an undersized balloon
2) Prolonged dilation with a Drug Coated Balloon
PTA of the Popliteal artery
Final result
Clinical outcome
•Discharged at home on day 4 (Serum creatinine Back to baseline)
•Medical therapy was tuned for CAD
•DAPT for 30 days
•Healed Ulcer after 3 weeks
6 Month Follow up6 Month Follow up
ConclusionsConclusions
1.CAD is frequent In PAD Patients
2.CAD Managment is crucial to allow good acute and long term results
3.The appropriate drug seletcion can reduce ischemic/bleeding risk
4.Use of stent should be limited to bail-out situations
Top Related