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