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

4/17/2015 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. Imaging Strategy for Imaging Strategy for Affiliation/Financial Relationship Company � Claudication: Ultrasound Alone is Claudication: Ultrasound Alone is Not Adequate to Select Patients Not Adequate to Select Patients Consulting Fees/Honoraria Boston Scientific, Medtronic, Abbott, Covidien, � Bard Peripheral Vascular, Spectranetics, Volcano for Endovascular Intervention for Endovascular Intervention Research Support WL Gore � John R. Laird Professor of Medicine Scientific Advisory board/stock options Angioslide, Reflow Medical, Medical Director of the Vascular Center � Endoluminal Sciences, UC Davis Medical Center Syntervention, PQ Bypass, Shockwave Medical Board Member VIVA Physicians Try as I might, I can’t think of Additional Disclosure anything intelligent to say…. I am no good at debates! 1

4/17/2015 Additional Disclosure It’s not good to have to debate Bandyk Dennis Bandyk regarding anything related to duplex Laird ultrasound! The Lebron James of Vascular Ultrasound DUS Following Duplex of Iliac Arteries � Advantages: non-invasive, Never comprehensive, no contrast, great for Again! surveillance after interventinos � Disadvantages: operator dependent, calcification, iliac disease, time- consuming, unpleasant for patients 2

4/17/2015 Planning for Infrainguinal Why Ultrasound is Not Enough! Interventions � Interventions are getting more and more � Multiple potential access sites: complex, and additional information is required: – Contralateral crossover – More precise vessel sizing – Antegrade femoral – Better plaque/lesion characterization (to guide – Radial/Brachial device selection) – More complete evaluation of the extent/severity of – Retrograde popliteal calcification – Retrograde SFA – Better visualization of infrapopliteal arteries – Pedal and tibial access – Better roadmap to guide choice of access site Sensitivity and specificity of CTA in Physiologic Anatomic patients with PAD NIFS Duplex CTA MRA (ABI/PVR) Presence of Disease + + ANATOMIC PATTERN OF DISEASE: Level of Disease + + + + � LENGTH OF OCCLUSION Severity of Disease + + + � DELINEATE STENOSIS VS Disease Progression + + OCCLUSION � CALCIFICATION Revascularization + + � ECCENTRICITY Planning � STENTS Surveillance + + + � ANATOMIC VARIATIONS Courtesy of John Rundback Courtesy of John Rundback 3

4/17/2015 Curved Planar CTA displays Reformation Subtracted (CPR) I don’t even know what those words mean…. Shaded Surface Display Maximum Intensity Pixel (MIP) Courtesy of John Rundback 4

4/17/2015 Nitinol Stents for the SFA Choosing the Right Choosing the Right Device for the Lesion Device for the Lesion Laser and Atherectomy Devices Limitation: Calcification Acoustic Shadowing 5

4/17/2015 What about vascular calcification in the infrainginal arteries? • The most frequently cited limitation of peripheral CTA • Solutions: • Source image evaluation • Reconstruction filters (3 rd party workstations) • Curved planar reformats • Dual energy acquisition Baseline Final Courtesy of John Rundback coronal reconstruction bone and ca ++ subtracted bone subtraction Source Data Iodine Subtracted Calcium Subtracted Courtesy of John Rundback Courtesy of John Rundback 6

4/17/2015 Procedural Planning � Choosing the best access site – Ipsilateral, contralateral, or bilateral – Radial/brachial Aortoiliac Interventions Aortoiliac Interventions � Vessel sizing � Assessing tortuosity � Covered vs. bare metal � Self-expanding vs. balloon expandable Procedure Planning – Which Access? Assessing Tortuosity 7

4/17/2015 Choosing the Best Approach to the CTO No proximal stump Chronic Occlusion of Right Limb of Aorto- bifemoral bypass graft 8

4/17/2015 Summary � Optimal imaging is crucial for the selection of 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 9