Presentation is loading. Please wait.

Presentation is loading. Please wait.

Dr. Giuseppe Sangiorgi, FESC, FSCAI Laboratorio di Emodinamica Università di Modena Ruolo della cardiologia interventistica nel paziente con patologia.

Similar presentations


Presentation on theme: "Dr. Giuseppe Sangiorgi, FESC, FSCAI Laboratorio di Emodinamica Università di Modena Ruolo della cardiologia interventistica nel paziente con patologia."— Presentation transcript:

1 Dr. Giuseppe Sangiorgi, FESC, FSCAI Laboratorio di Emodinamica Università di Modena Ruolo della cardiologia interventistica nel paziente con patologia extracoronarica complessa

2 Giuseppe Sangiorgi, MD Cardiac Cath Lab Modena Policlinic Giuseppe Sangiorgi, MD Cardiac Cath Lab Modena Policlinic

3 Lidraulico dellExtracoronarico Quanti di voi hanno mai chiamato lidraulico? Avete chiamato lidraulico per il gabinetto ed è arrivato uno specialista solo in docce? Noi emodinamisti dovremmo saper riparare tutto?

4 3

5

6 Chi vede il Paziente Affetto da Patologia Extracoronarica ? MEDICINA DI BASE MEDICINA DURGENZA Internista Cardiologo clinico Cardiologo interventista Angiologo Nefrologo Neurologo Medicina Interna Chirurgo Generale Cardiochirurgo Chirurgo Vascolare Neurochirurgo Radiologia Non-interventista Interventista Neuroradiologo Chirurgia

7

8 My personal experience in developing anopen cath-lab platform

9 In 15 Minutes How all this developed in the places where I have been working up to nowHow all this developed in the places where I have been working up to now -and how this could develop in your place (I really hope your dreams comes true) What you really need to make that happenWhat you really need to make that happen -and what could be helpful in these days How this will develop in the futureHow this will develop in the future -and where we should work on

10 21 Years in 15 min

11 1989 University of Tor Vergata - RomeUniversity of Tor Vergata - Rome -Coronary angiograms -PTCA -Coronary angiograms -PTCA -Coronary angiograms -PTCA

12 Max Sangiorgi: "Is there anything else I could do?"Max Sangiorgi: "Is there anything else I could do?" Senior Physician (Prof. Gioffrè): "Well, I have just got this balloon from Meditech. Some crazy people have started to dilate pulmonary valves"Senior Physician (Prof. Gioffrè): "Well, I have just got this balloon from Meditech. Some crazy people have started to dilate pulmonary valves"

13 Starting a pulmonary valvuloplasty program was pretty easy at that time Doctor: "Listen, you have a blocked heart valve! We are going to balloon it"Doctor: "Listen, you have a blocked heart valve! We are going to balloon it" Patient: "Great, please go ahead"Patient: "Great, please go ahead" No ethical committeeNo ethical committee No regulatory issuesNo regulatory issues No reimbursement issuesNo reimbursement issues No paperwork at allNo paperwork at all

14 That's how we started to do something else beside coronaries 1989

15 If you are doing coronaries only … … could you start a pulmonary valvuloplasty program in your institution today?

16 Of course!! No problem You may just need …You may just need … -some discussion with the general director of the hospital -some discussion with CADM -some discussion with administration -some discussion with pharmacy -some discussion with clinical engineer -a little bit more of discussion with the surgeons than we had in the 80ies -a dedicated 3 day training organized by the medical device company -a certificate from the scientific society of something -May be you will need IRB approval -and may be some other paper work

17 Needless to mention … … that it is an absolute requirement that you already have done 100 cases (for the general director and CADM) with excellent outcome before you start your program

18 1990 PTCA in a 68 y/o patientPTCA in a 68 y/o patient I punctured the right femoralI punctured the right femoral -and failed I punctured the left femoralI punctured the left femoral -and failed I punctured the right brachialI punctured the right brachial -and failed I did not know about the radial approachI did not know about the radial approach -and punctured the left brachial -crossed a proximal stenosis of the left subclavian -… finally performed the PTCA "Would be nice to have that subclavian artery open""Would be nice to have that subclavian artery open" -The cath lab nurse run into the radiology department for a 5 mm balloon -I did my first peripheral angioplasty -… and finally learned what turf battle means

19 Next morning in the office of the head of radiology Head of radiology (Prof. Giovanni Simonetti): "How could you as a cardiologist do a peripheral angioplasty without permission?!?! What would you say if I as a radiologist would start coronary angiography?" My answer: "I would be more than happy to train you" Head of radiology: very angry with cardiologists after 20 years

20 We moved on with other procedures which required big balloons

21 … like aortic valvuloplasty

22 Angioplasty of coarctation 1992

23 Thereafter, we pushed the balloon forward.... Retrograde Mitral Valvuloplasty 1993

24 and transeptal mitral valvuloplasty with ugly balloons 1993

25 Later on we did this with umbrellas Rashkind-Okkluder

26 If you are familiar with... transseptal puncturetransseptal puncture the left atriumthe left atrium umbrellasumbrellas

27

28 So now you have some contacts to the pediatric world, so it is only a small step to become involved in VSD closure

29 Congenital Muscular VSD San Donato 1998

30 Of course, you are still involved in the sometimes boring coronary work So you will become involved in post-Myocardial infarction VSD closure

31 Post Myocardial Infarction VSD Device released Final angio

32 By the way: Do not forget the coronary fistulas

33 Only a small step to peripheral fistulas

34 Pulmonary AV-Fistula San Donato 2001

35 When you alreayd have experience with really large sheaths...

36 SPIRAL ANGIO CT D3 D5 D4 IMA Lumbar aa. Accessory renal a. ANGIO DSA Anatomical landmarks to be considered prior to EVG intervention Renal a. D5 D1 D : diameter L : length A : angulation L2 D3 D5 D4

37

38

39

40

41

42

43

44

45 Giorgio S. Rx \10\2000 Giorgio S. Rx \10\2000 Selective injection of SMA fills back IMA up to the coil Selective injection of SMA fills back IMA up to the coil

46 Selective 3rd left lumbar a. arteriography Selective 3rd left lumbar a. arteriography Super-selective 3rd left lumbar a. arteriography through Fast Traker 325 Super-selective 3rd left lumbar a. arteriography through Fast Traker 325

47 Catheter treatment of congenital heart disease Non-congenital heart defects Other cardiovascular diseases

48 If you have learned transseptals and if you know where the left atrium is....

49

50

51 Alain Cribier's Valve (PVT) Equine pericardiumEquine pericardium Balloon expandable stentBalloon expandable stent One size: 23mmOne size: 23mm

52 CoreValve PAVR ReValving System Nitinol frameNitinol frame -Self expanding Porcine pericardial valvePorcine pericardial valve Low radial force -Orients the system Constrained area -Avoids coronaries High radial force -Secure anchoring 26 and 29mm diameter

53 If you are dealing with stroke prevention like PFO and LAA closure you have some contacts to the world of neurology

54 And Carotid Stenting?

55 Siti più comuni di PTA su vasi epiaortici Siti più comuni di PTA su vasi epiaortici ACC corpo ACI Tronco anonimo ACC ostiale Succlavia

56

57 Critical left subclavian a. stenosis in a pt with CABG: LIMA to LAD Critical left subclavian a. stenosis in a pt with CABG: LIMA to LAD Post PTA + stenting

58 Remo S. Rx \02\1995 Remo S. Rx \02\1995 PTA Carotide Comune

59 Post PTA Remo S. Rx \02\1995 Remo S. Rx \02\1995 Post stent J&J 204 PTA Carotide Comune

60 Bartolomeo G. Rx \01\2007 Bartolomeo G. Rx \01\2007 Association of critical left CCA ostial and distal calcified stenosis at bifurcation. Strategy : exposure of CCA, direct stenting of ostial and CEA at bifurcation. Post direct JOMED P 38 stenting

61 Bartolomeo G. Rx \01\2007 Bartolomeo G. Rx \01\2007 Post CEA

62 PTA + stent retrogrado della ACC ostiale via puntura diretta dopo esposizione chirurgica del vaso PTA + stent retrogrado della ACC ostiale via puntura diretta dopo esposizione chirurgica del vaso

63

64 a b The diameter of the LAD is equal to the diameter of the tibial arteriesThe diameter of the LAD is equal to the diameter of the tibial arteries

65

66 3 mesi dopo il trattamento

67 6 mesi dopo il trattamento

68

69 Basale3 mesi dopo

70 PAD underdiagnosed and undertreated disease

71 High prevalence and high morbidity (non- healing wounds, gangrene, and amputation) lead to the publication of a call to action to physicians to increase detection of and treatment for PAD Arch Intern Med 2003;63:884–92.

72

73

74

75

76

77 Sensitivity and specificity Resting ABI value <0.9 approaches 95% sensitivity in detecting angiogram positive disease, and it is associated with the presence of 50% or greater stenosis in 1 or more major vessels. It is almost 100% specific in excluding healthy individuals.

78 ABI and Survival

79 We have been involved in all of this Can you become involved as well?

80 Of course!! No problem You may just need …You may just need … -some discussion with the director of the hospital -some discussion with the administration -some discussion with the health care insurances -a little bit more of discussion with the surgeons than we had in the 80ies -a dedicated 3 day training organized by the medical device company -a certificate from the scientific society of something -May be you will need IRB approval -and may be some other paper work

81 What do you really need ?

82 You really need Cath lab Echo and TEE and someone who helps you with that … and for some more complex procedures… anestesiologist, Vascular surgeons, neurologists, cardiothoracic surgeons

83 You don't really need Hybrid roomHybrid room CTCT MRIMRI 3 D Angio3 D Angio Although all this may be helpfulAlthough all this may be helpful

84 And of course all of the following is helpful in these days some discussion with the director of the hospitalsome discussion with the director of the hospital some discussion with the administrationsome discussion with the administration some discussion with the health care insurancessome discussion with the health care insurances a little bit more of discussion with the surgeons than we had in the 80iesa little bit more of discussion with the surgeons than we had in the 80ies a dedicated 3 day training organized by the medical device companya dedicated 3 day training organized by the medical device company a certificate from the scientific society of somethinga certificate from the scientific society of something IRB approvalIRB approval and may be some other paper workand may be some other paper work

85 In 15 Minutes How all this I have been wish that could developed in my place that now is ModenaHow all this I have been wish that could developed in my place that now is Modena -and how this could develop in your place What you really need to make that happenWhat you really need to make that happen -and what could be helpful in these days How this will develop in the futureHow this will develop in the future -and where we should work on

86 There will be much more catheter techniques available to treat all kind of cardiovascular diseases

87

88 We should always try to keep the doors opento keep the doors open to stop over-regulationto stop over-regulation to avoid turf battlesto avoid turf battles and to train the radiologists and vascular surgeons in coronary angiographyand to train the radiologists and vascular surgeons in coronary angiography

89 Conclusioni Il trattamento percutaneo delle diverse patologie periferiche si è rapidamente sviluppato ed è in rapida evoluzione Molte applicazioni interventistiche periferiche hanno tratto enorme vantaggio dalla traslazione della tecnologia coronarica Lintero campo ha avuto ed avrà enormi benefici dalla partecipazione di un maggior numero di colleghi cardiologi Come cardiologi, la partecipazione in questo programma di sviluppo è imperativa Il trattamento percutaneo delle diverse patologie periferiche si è rapidamente sviluppato ed è in rapida evoluzione Molte applicazioni interventistiche periferiche hanno tratto enorme vantaggio dalla traslazione della tecnologia coronarica Lintero campo ha avuto ed avrà enormi benefici dalla partecipazione di un maggior numero di colleghi cardiologi Come cardiologi, la partecipazione in questo programma di sviluppo è imperativa

90

91

92 STROKE

93


Download ppt "Dr. Giuseppe Sangiorgi, FESC, FSCAI Laboratorio di Emodinamica Università di Modena Ruolo della cardiologia interventistica nel paziente con patologia."

Similar presentations


Ads by Google