I am no good at debates! 1 4/17/2015 Additional Disclosure Its - - PowerPoint PPT Presentation

4/17/2015 1

Imaging Strategy for Claudication: Ultrasound Alone is Not Adequate to Select Patients for Endovascular Intervention Imaging Strategy for Claudication: Ultrasound Alone is Not Adequate to Select Patients for Endovascular Intervention

John R. Laird Professor of Medicine Medical Director of the Vascular Center UC Davis Medical Center

Disclosure Statement of Financial Interest

Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.

• Affiliation/Financial Relationship

Company

• Consulting Fees/Honoraria

Boston Scientific, Medtronic, Abbott, Covidien, Bard Peripheral Vascular, Spectranetics, Volcano

• Research Support

WL Gore

• Scientific Advisory board/stock options

Angioslide, Reflow Medical, Endoluminal Sciences, Syntervention, PQ Bypass, Shockwave Medical

Board Member VIVA Physicians

Additional Disclosure

I am no good at debates!

Try as I might, I can’t think of anything intelligent to say….

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Additional Disclosure

It’s not good to have to debate Dennis Bandyk regarding anything related to duplex ultrasound!

The Lebron James of Vascular Ultrasound

Bandyk Laird

DUS

Advantages: non-invasive, comprehensive, no contrast, great for surveillance after interventinos Disadvantages: operator dependent, calcification, iliac disease, time- consuming, unpleasant for patients

Following Duplex of Iliac Arteries

Never Again!

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Why Ultrasound is Not Enough!

Interventions are getting more and more complex, and additional information is required:

– More precise vessel sizing – Better plaque/lesion characterization (to guide device selection) – More complete evaluation of the extent/severity of calcification – Better visualization of infrapopliteal arteries – Better roadmap to guide choice of access site

Planning for Infrainguinal Interventions

Multiple potential access sites:

– Contralateral crossover – Antegrade femoral – Radial/Brachial – Retrograde popliteal – Retrograde SFA – Pedal and tibial access

Physiologic Anatomic

NIFS

(ABI/PVR)

Duplex CTA MRA Presence of Disease + + Level of Disease + + + + Severity of Disease + + + Disease Progression + + Revascularization Planning

+ +

Surveillance + + +

ANATOMIC PATTERN OF DISEASE: LENGTH OF OCCLUSION DELINEATE STENOSIS VS OCCLUSION CALCIFICATION ECCENTRICITY STENTS ANATOMIC VARIATIONS

Courtesy of John Rundback

Sensitivity and specificity of CTA in patients with PAD

Courtesy of John Rundback

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CTA displays

Shaded Surface Display Maximum Intensity Pixel (MIP) Subtracted Curved Planar Reformation (CPR)

Courtesy of John Rundback

I don’t even know what those words mean….

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Choosing the Right Device for the Lesion Choosing the Right Device for the Lesion

Nitinol Stents for the SFA

Laser and Atherectomy Devices Limitation: Calcification

Acoustic Shadowing

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Baseline Final

What about vascular calcification in the infrainginal arteries?

• The most frequently cited limitation of peripheral

CTA

• Solutions:
• Source image evaluation
• Reconstruction filters (3rd party workstations)
• Curved planar reformats
• Dual energy acquisition

Courtesy of John Rundback

Source Data Iodine Subtracted Calcium Subtracted

Courtesy of John Rundback

coronal reconstruction bone and ca++ subtracted bone subtraction

Courtesy of John Rundback

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Aortoiliac Interventions Aortoiliac Interventions

Procedural Planning

Choosing the best access site

– Ipsilateral, contralateral, or bilateral – Radial/brachial

Vessel sizing Assessing tortuosity Covered vs. bare metal Self-expanding vs. balloon expandable

Assessing Tortuosity Procedure Planning – Which Access?

4/17/2015 8 Choosing the Best Approach to the CTO No proximal stump Chronic Occlusion

• f Right

Limb of Aorto- bifemoral bypass graft

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Summary

Optimal imaging is crucial for the selection

• f patients for endovascular therapies and

to help with procedural planning The increasing complexity of our interventions for patients with claudication and CLI mandates that we have good imaging In many cases, Duplex alone is not sufficient