Author''s Accepted Manuscript

Author's Accepted Manuscript Increasing Role of Interventional Cardiologists for Peripheral Vascular Disease Tonga Nfor MD, MSPH, Suhail Allaqaband MD, FACC, FCCP, FSCAI, Tanvir Bajwa MD, FACC, FSCAI www.elsevier.com/locate/buildenv PII: DOI: Reference: S0146-2806(14)00037-1 http://dx.doi.org/10.1016/j.cpcardiol.2014.05.003 YMCD276 To appear in: Curr Probl Cardiol Cite this article as: Tonga Nfor MD, MSPH, Suhail Allaqaband MD, FACC, FCCP, FSCAI, Tanvir Bajwa MD, FACC, FSCAI, Increasing Role of Interventional Cardiologists for Peripheral Vascular Disease, Curr Probl Cardiol, http://dx.doi.org/ 10.1016/j.cpcardiol.2014.05.003 This is a PDF file of an unedited manuscript that has been accepted for publication As a service to our customers we are providing this early version of the manuscript The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain Increasing Role of Interventional Cardiologists for Peripheral Vascular Disease Tonga Nfor, MD, MSPH, Suhail Allaqaband, MD, FACC, FCCP, FSCAI, and Tanvir Bajwa, MD, FACC, FSCAI Aurora Cardiovascular Services, Aurora Sinai/Aurora St Luke’s Medical Centers, University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin Brief Title: Nfor et al – Role of interventional cardiologist in PVD Financial Support: None Disclosure Statement: Nothing to disclose Address for Correspondence: Tanvir Bajwa, MD, FACC, FSCAI Aurora Cardiovascular Services 2801 W Kinnickinnic River Parkway, #840 Milwaukee, WI 53215 (414) 649-3909 (414) 649-3551 (fax) publishing2@aurora.org  PAGE Table of Contents Foreword Biographical Sketches Introduction Interventional cardiologist as the vascular expert Aortic Aneurysms and Dissection Abdominal Aortic Aneurysm Thoracic and Thoracoabdominal Aortic Aneurysms Aortic Dissection Carotid and Vertebral Artery Disease Percutaneous Treatment of Carotid Artery Disease Vertebral Artery Disease Subclavian and Brachiocephalic Artery Disease Renal Artery Disease Disease of the Celiac and Mesenteric Arteries Lower Extremity Arterial Disease Revascularization for Critical Limb Ischemia Endovascular Treatment of Acute Limb Ischemia Endovascular Treatment of Suprainguinal Disease Endovascular Treatment of Femoropopliteal Disease New Drug-Eluting Technologies for Femoropopliteal Disease Endovascular Treatment of Infrapopliteal Disease Adjuvant Therapies for Calcified Lesions and Chronic Total Occlusions PAGE Percutaneous Treatments for Venous Occlusive Disease Deep Venous Thrombosis of Lower Extremities Catheter-directed Thrombolysis Pharmacomechanical Thrombolysis May-Thurner Syndrome Inferior Vena Cava Filters Veno-Occlusive Disease of Upper Extremities Renal Denervation Therapy for Resistant Hypertension Conclusion References PAGE Abstract Improvements in the design of endovascular devices and technical skill of interventionalists have opened new possibilities for patients with a wide range of peripheral vascular diseases (PVD) In lower extremity peripheral artery disease, percutaneous treatments have become the predominant revascularization strategy for simple and complex lesions Newer generations of stents and drug-coated balloons have demonstrated strong potential in treatment of femoropopliteal and infrainguinal diseases One of the most dramatic advances in the recent past has been endovascular repair of thoracic and abdominal aortic aneurysms, which has become the preferred approach in lieu of open surgical repair Contemporary trials have established the safety and effectiveness of carotid stenting in selected patients with severe stenosis Endovascular treatments for venous occlusive disease have long been underutilized, but their effectiveness is being increasingly recognized This review will cover new endovascular procedures performed by interventional cardiologists for PVD PAGE Glossary of Abbreviations AAA = abdominal aortic aneurysm CAS = carotid artery stenting CDT = catheter-directed thrombolysis CEA = carotid endarterectomy CI = confidence interval DCB = drug-coated balloon DES = drug-eluting stents EVAR = endovascular abdominal aneurysm repair HR = hazard ratio IVC = inferior vena cava OR = odds ratio PAD = peripheral artery disease PTFE = polytetrafluoroethylene PTS = post-thrombotic syndrome PVD = peripheral vascular disease SVC = superior vena cava TASC = Trans-Atlantic Inter-Society Consensus TEVAR = thoracic endovascular aneurysm repair PAGE Introduction Peripheral vascular disease (PVD) is a heterogeneous group of disorders that affect the extracardiac circulatory system including arteries, veins and lymphatics Arterial atherosclerotic disease makes up the bulk of PVD disorders, but venous disorders of the lower extremities can cause significant morbidity Venous disorders manifest as veno-occlusive disease most commonly from thrombosis or extrinsic compression, or as venous insufficiency with stasis in the lower extremities On the arterial side, PVD can involve arteries in the lower or upper extremities, aorta and carotid, renal and mesenteric arteries Current nomenclature approved by professional societies is peripheral artery disease (PAD) for a disease of the lower and upper extremities exclusively However, in routine clinical practice, PAD is still used loosely to also include diseases of the aorta and carotid, renal and mesenteric arteries.1 The prevalence of PAD is high among adult patients and increases with age In general medical practice using routine ankle-brachial index screening, PAD was found in 19.8% of men and 16.8% of women 65 years or older.2 A key principle in the care of patients with atherosclerotic PAD in any one vascular territory is to approach this as a marker of systemic atherosclerosis Large multinational registries have demonstrated that 50-60% of patients with established PAD also have cerebrovascular or coronary disease.3,4 Patients with PAD have twice the risk of all-cause mortality and other major adverse cardiac events as those with matched Framingham risk scores but no PAD.5 The management of patients with PVD requires a comprehensive approach that goes beyond correcting the local anatomical abnormality of the vessel to include aggressive treatment for atherosclerosis to prevent cardiovascular mortality and morbidity, relieving pain and preserving functional status as well as preventing tissue or limb loss This often requires a multidisciplinary approach involving providers in different specialties Different experts with training in interventional cardiology, interventional radiology or vascular surgery perform invasive procedures to treat PVD The physician that manages PVD is required to have a broad understanding of atherosclerotic disease and the cardiovascular or cerebrovascular mortality and morbidity associated with it Long-term patient follow-up and treatment is essential to prolong survival and maintain quality of life PAGE Interventional Cardiologist as the Vascular Expert Sample case: A 79-year-old man with coronary artery disease, PAD, critical aortic valve stenosis and left ventricular ejection fraction of 30% was transferred from an outside hospital to our institution with non-ST-segment elevation myocardial infarction, cardiogenic shock and pulmonary edema He had already been turned down by two surgeons for surgical aortic valve replacement He was taken to the catheterization laboratory with the intention of percutaneous coronary revascularization, aortic valvuloplasty and intra-aortic balloon pump to bail him out of shock Coronary angiography showed acute subtotal occlusion of mid-left anterior descending artery The intra-aortic balloon pump required an Fr sheath and valvuloplasty required a 12 Fr sheath, both of which could not be placed due to severe bilateral iliac stenosis The common iliac arteries were revascularized with kissing stents The intra-aortic balloon pump was then placed from the left common femoral artery and the left anterior descending artert was successfully stented via a sheath in the right common femoral artery Then the sheath in the right common femoral artery was upsized to 12 Fr and aortic valvuloplasty was performed Hemodynamics stabilized, pressors and inotropes were weaned off and the patient was extubated after 24 hours He underwent successful transcatheter aortic valve replacement via femoral approach a week later and was discharged home Interventional cardiologists have become more involved in managing PVD as medical therapies, invasive techniques and devices improve Unlike other specialties, the interventional cardiologist’s background in internal medicine and general cardiology provides expertise in both the medical and invasive management of PVD that is uncommon for other specialties As the population ages and patients develop more advanced cardiac and peripheral disease, interventional cardiologists have adapted their ability in manipulating large sheaths and devices for procedures like transcatheter aortic valve replacements, placement of intra-aortic balloon pumps and percutaneous left ventricular assist devices, and endovascular repair of aortic or thoracic aneurysms In an analysis of admissions for PAD in the United States between 1996 and 2005, open surgical procedures decreased by 6.6% per year while endovascular procedures increased by 4.8% per year (Fig 1).6 This corresponded with a decrease in acute admissions for PAD by 4.3% per year and major amputations by 6.4% per year during the same period Endovascular procedures for PVD are performed by interventional radiologists, vascular PAGE surgeons and interventional cardiologists with the role of the latter constantly increasing Data from the National Inpatient Sample showed that the number of endovascular procedures done for PVD by interventional radiologists decreased six-fold between 1998 and 2005, the share done by vascular surgeons doubled and by interventional cardiologists tripled.7 More recent Medicare data, including both inpatient and outpatient lower extremity endovascular interventions, show interventional cardiologists leading the pack with 37.6% of procedures, followed by vascular surgeons with 36.7%, interventional radiologists with 24.4% and others 1.3%.8 This paper presents an up-to-date review of techniques, devices and outcomes from endovascular interventions for PVD that are performed by interventional cardiologists Endovascular treatments for diseases of the aorta, carotid, renal, mesenteric, upper and lower arteries as well as venous occlusive disease will be discussed Aortic Aneurysms and Dissection Aortic aneurysm and aortic dissection have similar risk factors as atherosclerotic disease in other arterial territories; however, uncontrolled hypertension and genetic predisposition may play a disproportionately stronger role in pathogenesis The identification of genes associated with aortic aneurysms and dissection is a fast-growing area of research Medical treatment involves controlling blood pressure and heart rate, use of statins and antiplatelet therapy When repair of the aortic aneurysm is indicated, endovascular repair is fast growing as the preferred alternative to open surgical repair Abdominal Aortic Aneurysm The prevalence of abdominal aortic aneurysm (AAA) in the general population is about 1.3% in men and 0.1% in women 45 to 55 years old, increasing to 12.5% in men and 5.2% in women older than 75 years.9 Patients with AAA are usually asymptomatic, and the rationale for repair is to avoid rupture since 64% of patients with ruptured AAA die before reaching the hospital.10 Repair of stable AAA is recommended when the maximum diameter exceeds cm Several trials have shown that endovascular repair of abdominal aortic aneurysm (EVAR) confers lower shortterm mortality and morbidity than open surgical repair but long-term survival beyond two years after repair is similar (Table 1).11-15 This is because most patients are elderly and long-term survival after repair of AAA is driven more by comorbidities than aorta-specific complications