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Managementof Peripheral Artery Disease in the elderly: from patients selection to access tricks Gianluca Rigatelli, MD, PhD, EBIR, FACP, FACC, FESC, FSCAI Vice-Director, Cardiovascula

Managementof Peripheral Artery Disease

in the elderly: from patients selection to

access tricks

Gianluca Rigatelli, MD, PhD, EBIR, FACP, FACC, FESC, FSCAI

Vice-Director, Cardiovascular Diagnosis and Endoluminal Interventions Unit

Director, Congenital Heart Disease Interventions, Co-Director Peripheral Artery Disease Interventions, S.Maria della Misericordia Rovigo General Hospital, Rovigo, Italy

VHA scientific meeting, 12°October 2014

• Femoral/popliteal: 80-90%

• Tibial/peroneal: 50%

40-• Aorto-iliac: 30%

Harrison’s Principles of Int Med

Distrectual PAD

AMI

ANGINA

ICTUS TIA

Hypertension Renal failure

DISTRICT Clinical syndrome

Critical and acute limb ischemia

Diabetic Foot

PAD INCIDENCE

0 10 20 30 40 50 60

55-59 60-64 65-69 70-74 75-79 80-84 85-89

Age group (y)

Figure adapted from Creager M, ed Management of Peripheral Arterial Disease Medical, Surgical and Interventional Aspects 2000

1 Meijer WT et al Arterioscler Thromb Vasc Biol 1998; 18: 185-192

2.Criqui MH et al Circulation 1985; 71: 510-515

Diagnosing PAD , even if asymptomatic ,

may be useful in preventing AMI and Stroke,

ESPECIALLY IN AGED PATIENTS

WHY IT IS IMPORTANT TO DIAGNOSE

PAD IN THE ELDERLY?

50% cardiovascular events

surgical (BP aorto-femoral, aorto iliac, femoro-

popliteal or embolectomy)

Endovascular Treatment

REVASCULARIZATION OF

PAD (IIb-III-IV)

Surgery

SURGERY RESULTS

60-80% patency at 5 years with saphein graft

60% limb savage at 5 years

LIMITATIONS High mortality rate and AMI rate in aged pts

Mortality 2-6%

Not always you can reintervene

Long hospital staying Complications (AMI)

ENDOVASCULAR THERAPY

Angioplasty/ stent Thromboaspiration Subintimal PTA Stent-graft

ADVANTAGES

FEASIBLE in aged pts

Mortality < 1%

Redo PTA Multisite treatment Short hospital staying

How to select aged patients for peripheral angioplasty?

Clinic First : Fontaine CLASSIFICATION

1.5%

TASC A: Iliac Femoropopliteal

TASC B:

Anatomy Second: classification TASC II

TASC Working Group J Vasc Surg 2000;31(1Suppl):S1-S296.

> 3 cm

TASC C:

> 5 cm

Third: personal assessment

-Need for anaestesiologic support

-life expectance: less/more than 6 month

Fourth: selecting the approach

LOOK AT:

-Obesity: is antegrade approach feasible?

-Obesity: can the pt breath supine if a

popliteal approach is needed?

-Arm decubit: can the pt

extend the arm if I need

a brachial approach?

OK: your aged pt is ready to go

What I should take care of?

Take care:

1-of the schedule of the procedure: aged pt are prone to dehidratation and become tired very quickly Put the elderly first in the program!

2-of hidratation of the pt: good hydratation

means good chance to complete the procedure

3-of pain: elderly people suffer from chronic

arthrosic pain that often make the procedure

badly tollerated Use analgesic protocol!

OK: your aged pt is ready to go

What I should take care of?

Take care:

4-of diabetes Aged pts are very often diabetic:

check blood sugar and don’t let them to much without eating!

5- of renal function Aged patients have very

often poor GFR: don’t use more than 100 cc of contrast

6-of pain: pure contrast into the leg is very

painfull Use 50/50% water/contrast mixture!

Popliteal antegrade/retrograde (ADVANCED) femoral occlusion

Femoral Crossover Technique 1

Femoral Crossover Technique 2

 HUGE LIMITATION INTREATING DISTAL FEMORAL , POPLITEAL AND BTK

DISEASE

Antegrade ipsilateral Technique 2

Advantages:

Drawbacks:

 DIRECT ACCESS TO THE ARTERY

 STRAIGHT ROUTE TO THE LESION

 A 0.14-0.18 INCH WIRE CAN BE USED

 SOMETIMES DIFFICULT TO DO >>> USE fluoro or US guide

 ATTENTION TO ANTIPLATELET DRUGS

IF YOU ARE NOT SURE ABOUT THE PUNCTURE

Pedideal Puncture technique 1

Pedideal Puncture Technique 2

 NEED FOR micropuncture set

 ATTENTION when the pedideal is the unique artery of the foot

Popliteal Puncture technique 1

Popliteal Puncture Technique 2

 NEED FOR micropuncture set

 NEED for US guide

 NEED of femoral punture to seal the artery with a balloon inflation (inflation of a

5 or 4 diameter baloon for 5 minutes)

Femoral crossover Technique 2

Advantages:

Drawbacks:

 SIMPLE TO DO (even when there is no pulse) >>> fluoro or US guide

 DIRECT ACCESS TO THE ARTERY

 STRAIGHT ROUTE TO THE LESION

 A 0.14-0.18 INCH WIRE CAN BE USED

 NEED OF A T LEAST 7F 23 CM SHEATH

 SOMETIMES DIFFICULT TRACK IN OCCLUSIVE DISEASE

 SOMETIMES NEED OF CONTROLATERAL ACCESS FOR INJECTING (OSTIAL DISEASE)

Radio-brachial Technique 1

Radio-brachial Technique 2

Advantages:

Drawbacks:

 SIMPLE TO DO ( FOR CORONARY GUYS

 AVOID MAJOR ACCESS SITE BLEEDING

 SAFER ROUTE FROM ABOVE FOR OCCLUSIVE DISEASE

 DIFFICULT ACCESS TO THE LESION SITE IF AORTICH ARCH TYPE 2 OR 3

 NEED OF 90 CM LONG 4 TO 7F SHEATH (Shuttle or Flexor Cook, Biotronik, Terumo)

 NEED OF HIGH SUPPORT WIRE (EASY ACCESS IN CASE OF VESSEL

covered stent size

Vassilev D,Rigatelli G et al Poland J Cardiol in PRESS

Special case: carotid artery angioplasty and

stenting

Advantages: - Simple route for RCA and LCA if

approach from right and left radial

-size matter!

1) radial access in the usual site as per PCI

2) 5F short sheath

3) Mammary artery + Terumo 035 inch to the RCA or

Simmond/Amplatz +Terumo to the LCA

4) Catheter in the external carotid artery

5) Exchange wire for a Stiff ,035 inch (Amplatz , Supracor, etc) 6) Advance a 6 F 70 or 90 cm long guiding sheath (Cook,

Terumo, Biotronik)

7) Perform neuroprotection and stenting

1) Direct engagement

2) Looping technique

3) Multiple wire technique

Bilateral CAS, Cardaioli P, Rigatelli G, et al Minerva Cardioangiologica 2013

A) Aged patients are the typical patients you

may face with managing peripheral artery

disease

B) You need to carefully select patients based

upon: clinic, anatomy, global assessment, need

of specific approach

C) Good access site selection and technique is mandatory to succeed in peripheral angioplasty

in aged patients

D) Radio-brachial access is emerging as the

preferred approach in PAD patients in the

elderly

Let’s keep our elderly pts alive!