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Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of Endovascular Interventions Director of Cardiovascular Research Metro Health Hospital, Wyoming, MI Clinical Assistant Professor of Medicine Michigan State University COM, E. Lansing, MI

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Page 1: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Calcification of BTK Arteries

J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories

Director of Endovascular Interventions

Director of Cardiovascular Research

Metro Health Hospital, Wyoming, MI

Clinical Assistant Professor of Medicine

Michigan State University COM, E. Lansing, MI

Page 2: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Disclosures

Consultant: • Abbott Vascular

• Bard Peripheral Vascular

• Boston Scientific

• Cardiovascular Systems, Inc.

• Cook Medical

• Medtronic

• Spectranetics

• Terumo Medical

Page 3: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

CLI and Calcification

• Pre-clinical factors that increase the suspicion of increased calcium presence

• Methods of calcific evaluations

• Intra-procedural measures that determine the depth of calcification

Page 4: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

CLI and Calcification

Pre-clinical factors that increase the suspicion of increased calcium presence:

CLI

DM

CKD

Smoking

HLP

HTN

Based on original work by JA Mustapha & Renu

Virmani

Page 5: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Myth vs Fact

• Fact: calcium deposit is two types

– Type one: intimal calcification

– Type two: medial calcification

• Myth: all calcium deposit is non structured and sporadic with the same densities.

Based on original work by JA Mustapha & Renu

Virmani

Page 6: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Fact: Medial calcification deposit in the medial wall is organized and structured in crescent shapes.

Based on original work by JA Mustapha & Renu Virmani

Page 7: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Fact: Intimal calcification deposit in the intima and plaque is disorganized and not structured

Scattered disorganized

Intimal calcification

Based on original work by JA Mustapha & Renu Virmani

Page 8: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Preclinical and clinical value of the two different calcium deposit types

• Suspicion of calcium presence/deposit should be high in patients with increased age, DM, CKD, and PVD/CLI

Page 9: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Preclinical and clinical value of the two different calcium deposit

There is higher association of medial calcification in patients with:

1- CLI RF IV - IV

2- CKD

3- Type 1 DM and long term Type 2 DM

Based on original work by JA Mustapha & Renu Virmani

Page 10: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Based on original work by JA Mustapha & Renu Virmani

Angio vs CT for calcium assessment

Page 11: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Crescent shape medial calcification

Medial calcification is similar to intimal calcification

with its variable densities..

Based on original work by JA Mustapha & Renu Virmani

Page 12: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

2D vs 3D Reconstruction CT (no contrast) of Calcified SFA

Based on original work by JA Mustapha & Renu Virmani

2D 3D

Page 13: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Popliteal

Intimal calcification

IVUS

Medial calcification

Acoustic shadowing: yellow arrows shows the

Drop out caused by the dense intimal calcification

Medial calcification not

causing acoustic shadowing

And the vessel wall is well

visualized

Crescent and organized

Disarrayed and

disorganized

Based on original work by JA Mustapha & Renu Virmani

IVUS limitations and benefits

Page 14: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Pre-clinical Subject

• 87 year old female

• Smoker

• Hx of MI, CHF, COPD

Calcium macro-evaluation

in an 87 y/o patient without h/o clinical PAD

Page 15: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Fluroscopic images

Based on original work by JA Mustapha & Renu Virmani

Page 16: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Faxitron x-ray

Page 17: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 18: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 19: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 20: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 21: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 22: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 23: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
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Page 25: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 26: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

LEFT POSTERIOR CADAVERIC TIBIAL ARTERY

ELECTRON MICROSCOPY

Page 27: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 28: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 29: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 30: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 31: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 32: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

What is so amazing

Is the amount of connective

Tissue between EACH layer

Of this hyperplastic tissue

On TOP of sever medial calcification

Page 33: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 34: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Take a look at this eccentric

Calcified plaque combined with

Layers of medial calcifications

AND

Dense connective tissues

Page 35: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of
Page 36: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

vs vs

Page 37: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

2D CT without contrast

Based on original work by JA Mustapha & Renu Virmani

Page 38: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

CT 3D reconstructed/pop combined medial and intimal calcification. Intimal to medial

Page 39: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

(Tibial) 3DCT reconstructed t concerning negative remodeling

and more medial calcification

Page 40: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Based on original work by JA Mustapha & Renu Virmani

Less medial calcification and more intimal calcification

Page 41: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Based on original work by JA Mustapha & Renu Virmani

Page 42: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Based on original work by JA Mustapha & Renu Virmani

Page 43: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Jenali Gap: An Ominous Sign

Associated with negative remodeling

A B C

Based on original work by JA Mustapha & Renu Virmani

Page 44: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Based on original work by JA Mustapha & Renu Virmani

Page 45: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Based on original work by JA Mustapha & Renu Virmani

Circumferential medial

Calcification causes

Severe high grade stenosis

In the distal tibials and

Pedal arteries.

Also causes complete

Luminal occlusion.

Page 46: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

1

2 3

4

MC

Based on original work by JA Mustapha & Renu Virmani

plaque calcification ( intimal ) tend to

Be more asymmetrical.

Page 47: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Calcium Micro-histology/histopathology

Page 48: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Based on original work by JA Mustapha & Renu Virmani

proximal mid distal

Pending publication

Page 49: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

R PROX AT

310-330

1

2

3

4

1

2

3

4

Ca(intimal)

Ca(media)

Necrotic core

Organized

thrombus

Based on original work by JA Mustapha & Renu Virmani

Page 50: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

R PROX AT

330-350

1

2

3

4

2

3

1

4

Ca(intimal)

Ca(media)

Necrotic core

Organized

thrombus

Based on original work by JA Mustapha & Renu Virmani

Page 51: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

CTOs comes in all different forms

Based on original work by JA Mustapha & Renu Virmani

Tibial-pedal trans-luminal obliteration in CLI patients

Page 52: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Thank You

J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories

Director of Endovascular Interventions

Director of Cardiovascular Research

Metro Health Hospital, Wyoming, MI

Clinical Assistant Professor of Medicine

Michigan State University, E. Lansing, MI

Page 53: Calcification of BTK Arteries - Login - NMSuite · Calcification of BTK Arteries J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of

Calcification of BTK Arteries

J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories

Director of Endovascular Interventions

Director of Cardiovascular Research

Metro Health Hospital, Wyoming, MI

Clinical Assistant Professor of Medicine

Michigan State University COM, E. Lansing, MI


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