I am no good at debates!
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- Patrick Welch
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1 Disclosure Statement of Financial Interest Imaging Strategy for Claudication: Ultrasound Alone is Not Adequate to Select Patients for Endovascular Intervention 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 Consulting Fees/Honoraria Company Boston Scientific, Medtronic, Abbott, Covidien, Bard Peripheral Vascular, Spectranetics, Volcano Research Support WL Gore John R. Laird Professor of Medicine Medical Director of the Vascular Center UC Davis Medical Center Scientific Advisory board/stock options Angioslide, Reflow Medical, Endoluminal Sciences, Syntervention, PQ Bypass, Shockwave Medical Board Member VIVA Physicians Additional Disclosure Try as I might, I can t think of anything intelligent to say. I am no good at debates! 1
2 Additional Disclosure It s not good to have to debate Dennis Bandyk regarding anything related to duplex ultrasound! Laird Bandyk The Lebron James of Vascular Ultrasound DUS Advantages: non-invasive, comprehensive, no contrast, great for surveillance after interventinos Following Duplex of Iliac Arteries Never Again! Disadvantages: operator dependent, calcification, iliac disease, timeconsuming, unpleasant for patients 2
3 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 + + ANATOMIC PATTERN OF DISEASE: Level of Disease LENGTH Severity of Disease OF OCCLUSION DELINEATE STENOSIS VS Disease OCCLUSION Progression + + CALCIFICATION Revascularization ECCENTRICITY Planning + + STENTS Surveillance ANATOMIC VARIATIONS Sensitivity and specificity of CTA in patients with PAD 3
4 CTA displays Subtracted Curved Planar Reformation (CPR) I don t even know what those words mean. Shaded Surface Display Maximum Intensity Pixel (MIP) 4
5 Nitinol Stents for the SFA Choosing the Right Device for the Lesion Laser and Atherectomy Devices Limitation: Calcification Acoustic Shadowing 5
6 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 coronal reconstruction bone and ca ++ subtracted bone subtraction Source Data Iodine Subtracted Calcium Subtracted 6
7 Procedural Planning Choosing the best access site Ipsilateral, contralateral, or bilateral Aortoiliac Interventions Radial/brachial Vessel sizing Assessing tortuosity Covered vs. bare metal Self-expanding vs. balloon expandable Procedure Planning Which Access? Assessing Tortuosity 7
8 Choosing the Best Approach to the CTO No proximal stump Chronic Occlusion of Right Limb of Aortobifemoral bypass graft 8
9 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
Device Evolution. Atherectomy: Where Do We Stand After 12 Years Since FDA Clearance. Where Do We Stand? 4/18/2015
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