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Dr. Giuseppe Sangiorgi, FESC, FSCAI Laboratorio di Emodinamica
Ruolo della cardiologia interventistica nel paziente con patologia extracoronarica complessa Dr. Giuseppe Sangiorgi, FESC, FSCAI Laboratorio di Emodinamica Università di Modena
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Giuseppe Sangiorgi, MD Cardiac Cath Lab Modena Policlinic
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L’idraulico dell’Extracoronarico
Quanti di voi hanno mai chiamato l’idraulico? Avete chiamato l’idraulico per il gabinetto ed è arrivato uno specialista solo in docce? Noi emodinamisti dovremmo saper riparare tutto?
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Chi vede il Paziente Affetto da Patologia Extracoronarica ?
Medicina Interna Chirurgia Chirurgo Generale Cardiochirurgo Chirurgo Vascolare Neurochirurgo Radiologia Non-interventista Interventista Neuroradiologo MEDICINA DI BASE MEDICINA D’URGENZA Internista Cardiologo clinico Cardiologo interventista Angiologo Nefrologo Neurologo
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My personal experience in developing an “open cath-lab platform”
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In 15 Minutes How 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 happen and what could be helpful in these days How this will develop in the future and where we should work on
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21 Years in 15 min
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1989 University of Tor Vergata - Rome Coronary angiograms PTCA
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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"
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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" Patient: "Great, please go ahead" No ethical committee No regulatory issues No reimbursement issues No paperwork at all
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That's how we started to do something else beside coronaries
1989
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If you are doing coronaries only …
… could you start a pulmonary valvuloplasty program in your institution today?
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Of course!! No problem 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
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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
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1990 PTCA in a 68 y/o patient I punctured the right femoral
and failed I punctured the left femoral I punctured the right brachial I 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" 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
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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
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We moved on with other procedures which required big balloons
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… like aortic valvuloplasty
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Angioplasty of coarctation
1992
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Thereafter, we pushed the balloon forward ....
Retrograde Mitral Valvuloplasty 1993
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and transeptal mitral valvuloplasty with ugly balloons
1993
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Later on we did this with umbrellas
Rashkind-Okkluder
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If you are familiar with...
transseptal puncture the left atrium umbrellas
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So now you have some contacts to the pediatric world,
so it is only a small step to become involved in VSD closure
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Congenital Muscular VSD
San Donato 1998
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So you will become involved in post-Myocardial infarction VSD closure
Of course, you are still involved in the sometimes boring coronary work So you will become involved in post-Myocardial infarction VSD closure
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Post Myocardial Infarction VSD
Device released Final angio
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Do not forget the coronary fistulas
By the way: Do not forget the coronary fistulas
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Only a small step to peripheral fistulas
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Pulmonary AV-Fistula San Donato 2001
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When you alreayd have experience with really large sheaths...
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Anatomical landmarks to be considered prior to EVG intervention
ANGIO DSA SPIRAL ANGIO CT Renal a. D1 Accessory renal a. IMA L2 Lumbar aa. D3 D4 D3 D4 D5 D5 D5 D : diameter L : length A : angulation
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Selective injection of SMA fills back IMA up to the coil
Giorgio S. Rx 18\10\2000 Selective injection of SMA fills back IMA up to the coil
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Super-selective 3rd left lumbar a. arteriography
through Fast Traker 325 Selective 3rd left lumbar a. arteriography
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Catheter treatment of congenital heart disease
Other cardiovascular diseases Non-congenital heart defects
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If you have learned transseptals and if you know where the left atrium is....
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Alain Cribier's Valve (PVT)
Equine pericardium Balloon expandable stent One size: 23mm
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CoreValve PAVR ReValving System
Nitinol frame Self expanding Porcine pericardial valve Low radial force Orients the system Constrained area Avoids coronaries High radial force Secure anchoring 26 and 29mm diameter
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If you are dealing with stroke prevention like PFO and LAA closure you have some contacts to the world of neurology
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And Carotid Stenting?
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Succlavia ACI ACC ostiale ACC corpo Tronco anonimo
Siti più comuni di PTA su vasi epiaortici ACC corpo
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Critical left subclavian a.
stenosis in a pt with CABG: LIMA to LAD Post PTA + stenting
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PTA Carotide Comune Remo S. Rx 11323 21\02\1995
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PTA Carotide Comune Post PTA Post stent J&J 204 Remo S. Rx 11323
22\02\1995
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Bartolomeo G. Rx 24\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 Post direct JOMED P 38 stenting
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Bartolomeo G. Rx 24\01\2007 Post CEA
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PTA + stent retrogrado della ACC ostiale via puntura diretta dopo esposizione chirurgica del vaso
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The diameter of the LAD is equal to the diameter of the tibial arteries
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3 mesi dopo il trattamento
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6 mesi dopo il trattamento
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Basale 3 mesi dopo
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PAD underdiagnosed and undertreated disease
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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 The Prevention of Atherothrombotic Disease Network Arch Intern Med 2003;63:884–92.
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Tctmd.com
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tctmd
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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.
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ABI and Survival From tctmd
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We have been involved in all of this
Can you become involved as well?
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Of course!! No problem 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
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What do you really need ?
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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
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You don't really need Hybrid room CT MRI 3 D Angio
Although all this may be helpful
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And of course all of the following is helpful in these days
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 IRB approval and may be some other paper work
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In 15 Minutes How 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 happen and what could be helpful in these days How this will develop in the future and where we should work on
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There will be much more catheter techniques available to treat all kind of cardiovascular diseases
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We should always try to keep the doors open to stop over-regulation
to avoid turf battles and to train the radiologists and vascular surgeons in coronary angiography
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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 L’intero 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
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STROKE
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