XVII Congresso Regionale A.R.C.A Holiday Inn ROMA 22 settembre 2017 TREATMENT OF ERECTILE DYSFUNCTION: THE ROLE OF INTERVENTIONAL CARDIOLOGY

Transcription

1 XVII Congresso Regionale A.R.C.A Holiday Inn ROMA 22 settembre 2017 TREATMENT OF ERECTILE DYSFUNCTION: THE ROLE OF INTERVENTIONAL CARDIOLOGY

2 CONFLICTS OF FINANCIAL INTERESTS

3 ERECTILE DYSFUNCTION IT S A BIG DEAL!! ED negatively impacts quality of life: Self esteem, depression Relationship with partner

4 MYTHS SURROUNDING ED

5 DEFINITION AND PREVALENCE

6 ARTERIAL ANATOMY AND PATHOPHYSIOLOGY

7 THUS FOR A TOTALLY NATURAL ERECTIONS YOU NEED

8 ETIOLOGY OF ERECTILE DYSFUNCTION A PROBLEM BETWEEN THE EARS, THE LEGS OR THE COUPLE? 6% 5% 3% 1% Vascular (atherosclerotic, venous leakage) Diabetes Medication (bblockers, Cimetidine) 15% 40% Pelvic Surgery, Radiation, Trauma Neurological Causes 30% Endocrine Problems Other (Respiratory Diseases, Psychiatric Conditions, Hematologic Diseases, Systemic Diseases)

9 8-ZONE CLASSIFICATION SYSTEM OF PELVIC ANGIOGRAM Anteroposterior Projection Lateral Projection Zone 4 Zone 5 (Zone 1) (Zone 2) (Zone 5A) (Zone 5B) (Zone 3) Zone 5 (Zone 6) (Zone 4) (Zone 5) (Zone 4A) Proximal IPA (Zone 4B) Distal IPA Wang TD, et al. J Am Coll Cardiol 2013;62:B160.

10 ATHEROSCLEROTIC LESIONS DISTRIBUTION IN 476 PELVIC CT Wang TD, et al. J Am Coll Cardiol 2013;62:B160.

11 INTERNATIONAL INDEX OF ERECTILE FUNCTION (IIEF SCORE) Gold Standard for measuring efficacy for ED Primary efficacy measure for 50 + trials Viagra, Cialis, Levitra, etc. Consists of 15 Questions that are divided into 5 Domains Erectile Function (6) Sexual Desire Satisfaction Overall Satisfaction Orgasmic Intercourse

12 IEF SCORE IN PATIENTS AFFECTED BY ERECTILE DYSFUNCTION Severe 10% None 53% [NOME CATEG ORIA] [PER Moderate 10% Low 17%

13 LINK BETWEEN ERECTILE DYSFUNCTION AND CARDIOVASCULAR DISEASE Risk Factors Age, DM, HTN Alchool, tobacco Endothelial Dysfunction + Atherosclerosis Up to 46% of men with CAD have ED and more than 85% with CHF 75% of men with CAD have problem achieving erection and 67% maintining it ED predates the onset of symptomatic CVD by ~ 3 years Gazzaruso et al. Circulation 2004;110: 22; Rosen et al. J Urol 1991;145:759 Montorsi et al., European Heart Journal 2006; 27, 2632

14 STEEP GRADIENT OF THERAPY FOR ED (FROM UROLOGIST S PRESENTATIONS 72 PPT SEARCH ON GOOGLE )? No PDE-5 Inhibitor Oral Therapy ~ 50% Discontinuation Rate Penile Injection Intraurethral Suppository Vacuum Constriction Device Sildenafil (Viagra, Pfizer) Vardenafil (Levitra, Bayer) Tadalafil (Cialis, Lilly) mention of PCI treatment for vasculogenic causes which are indeed more than 40% of cases!! Penile Prosthesis

15 THE ZEN TRIAL 383 pts screened 30 treated (93% screening failure) 63 to little or to diseased 56 venous leak 19 pts 27 unilat. S 11 pts 29 bilat. S Restenosis rate at 12 mo >40% Rogers JH et al. JACC 2012; 60:

16 Perfect-1 Study 2014 EuroIntervention. All rights reserved. Durable Improvement 55% (11/20) EuroIntervention 2014;10: Safety and six-month durability of angioplasty for isolated penile artery stenoses in patients with erectile dysfunction: a first-in-man study

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19 PERFECT-LUTS Study 12 Months Results

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22 PERSONAL EXPERIENCE Baseline Characteristics (n=24 out of 56 pts screened) Clinical Variables Values Clinical Variables Values Age, years Lesions per pt, n (%) BMI, Kg/m Internal Pudendal A. prox, n (%) 12 (44) Fat Mass, % 17.8 Internal Pudendal A. dist, n (%) 15 (56) Waiste/Heigth Ratio 0.55 % Stenosis pre-, n (%) AMI, n (%) 4 (17) % Stenosis post-, n (%) 5+2 Diabetes, n (%) 9 (37) RVD Internal Pudendal A, mm Hyperlipidemia, n,(%) 14 (58) Lesion Length, mm Current Smoker, (n,%) 3 (12.5) Procedural Success, n (%) 23 (96) Family History CAD, n (%) 8 (33) Perforation, n (%) 1 (4) Basal Score IIEF ED Mild (13-24), n (%) ED Moderate (7-12), n (%) ED Severe (0-6), n (%) (8) 12 (50) 10 (42) IIEF Score at 3 mos > 20 n (%) (range 1-8 mos) Clinical Success, n (%) Fat Mass: Low; Normal 11-22; High>22; Waist/Heigth Ratio: Low<0.43, Normal , High , Obesity , Pathologic Obesity >0.63. Clinical Success: ΔIIEF-5 4 or IIEF (66) 20 (83)

23 CASE EXAMPLE POBA + PEB 2.0x20

24 POSSIBLE COMPLICATIONS DURING INTERNAL PUDENDAL ARTERY PCI CTO Int. Pudenda a. Sion Black engaging Int. Pudenda a.

25 PELVIC VASCULATURE IS COMPLEX!! 80% 15% 4.9% P-3: Internal Pudendal artery Origin from main hypogastric trunk, branches of it, inferior gluteal a., and in 10-12% cases as accessory IP S-1: Superior gluteal artery I-2: Inferior gluteal artery Yamaki et al. Kur Med J 1998; (45) Pereira JA et al. Acta Med Port 2013 (3):

26 CHALLENGES IN PERCUTANEOUS TREATMENT OF ERECTILE DYSFUNCTION

27 CONCLUSIONS

28 PCI FOR ERECTILE DYSFUNCTION? JUST DO IT!! (in Selected Cases)