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Aortic Vascular Interventions (Thoracic and Abdominal)

Key Points Acute aortic dissection is an uncommon but potentially catastrophic illness that occurs with an incidence of approximately 3.5 per 1 million person-years, with at least 8000 cases occurring annually in the United States. Aortic stent grafts are primarily used to reconstruct the compressed true lumen cranial to major aortic branches and to increase distal aortic flow. Proximal communications are sealed to direct flow into…

Device Therapy for Resistant Hypertension

Key Points Uncontrolled hypertension presents a significant health care problem with far-reaching public health and economic consequences. Novel therapies target neurohumoral modulation and mechanical alteration of vascular compliance to treat hypertension. Reduction of the sympathetic nervous output from the renal nerves has some supporting clinical data but remains experimental at the time of this publication. A variety of technologies can be used to modulate renal sympathetic…

Renal Artery Stenosis

Key Points Renal artery stenosis (RAS) is caused by a heterogeneous group of diseases with various causes, clinical manifestations, courses, treatments, and outcomes. Atherosclerotic renal artery sclerosis and fibromuscular dysplasia are the most common causes of renal artery sclerosis. Patients in whom atherosclerosis is progressive may have signs and symptoms of chronic ischemic renal disease, resulting in renovascular hypertension and renal dysfunction. However, the causal relationship…

Chronic Mesenteric Ischemia: Diagnosis and Intervention

Key Points Atherosclerotic stenoses commonly involve the major mesenteric arteries (celiac, superior mesenteric, and inferior mesenteric) but rarely cause symptomatic mesenteric ischemia because of the excellent collateral circulation that interconnects the visceral vascular beds. The classic presentation is postprandial abdominal pain with weight loss. Patients with functional bowel complaints rarely have significant weight loss. Patients with suspected chronic mesenteric ischemia (CMI) commonly have atherosclerosis involving other…

Upper Extremities and Aortic Arch

Key Points Arterial disease in one vascular bed is a harbinger of disease in other vascular beds. The differential diagnosis of diseases involving the upper extremity (UE) and aortic arch branch vessels is vast and requires extensive knowledge and a thorough history and physical examination. In patients with suspected arterial disease, blood pressure should be measured in both UEs, and if Takayasu arteritis is suspected, blood…

Lower Extremity Interventions

Key points Individuals at risk for lower extremity peripheral artery disease (PAD) should undergo a vascular review of symptoms to assess walking impairment, claudication, ischemic rest pain, and the presence of nonhealing wounds. Despite recent advances in noninvasive evaluation of lower extremity PAD, contrast angiography remains the gold standard for definitive evaluation. Contrast angiography provides detailed information about arterial anatomy and is recommended for evaluation of…

Diagnosis and Treatment of Coronary Microvascular Disease

Key Points Vascular physiology is grounded in the following basic equation: CO (flow) equals the pressure difference (Δ P ) divided by the resistance ( R ). Resultantly, coronary blood flow (CBF) is largely driven by supply/demand mismatches in myocardial oxygenation, requiring increased delivery of substrate to the myocardium. The coronary microcirculation is the primary regulator of myocardial perfusion and is largely dependent on vessel tone…

Regional Centers of Excellence for the Care of Patients With Acute Ischemic Heart Disease

Key Points Current clinical practice guidelines for the care of patients who present with ST-segment elevation myocardial infarction (STEMI) provide a class I recommendation that “all communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of emergency medical services (EMS) and hospital-based activities” (class I, level of evidence B). “Regional” care for patients with acute coronary syndromes…

Supported Percutaneous Intervention

Key Points Clinical characteristics of the elective high-risk patient include older age, history of myocardial infarction (MI), low ejection fraction, congestive heart failure (CHF), recent hemodynamic instability, renal insufficiency, and peripheral vascular disease. High-risk angiographic characteristics for the elective patient include left main coronary artery (LMCA) disease, last patent conduit, multivessel coronary artery disease, complex lesions (calcified, tortuous, bifurcation), decreased preprocedure thrombolysis in myocardial infarction (TIMI)…

Role of Adjunct Devices: Atherectomy, Cutting Balloon, and Laser

Key Points Rotational and orbital atherectomy facilitate stent implantation in undilatable, rigid, or heavily calcified lesions. Cutting or scoring balloons slip less often than conventional balloons and may be useful for treating restenotic or ostial lesions. Laser angioplasty uses a thermomechanical mechanism to prepare rigid or undilatable lesions for stent implantation. Atheroablative devices do not reduce restenosis. Atheroablative devices increase the risk of coronary perforation. The…

Restenosis

Key Points Restenosis is a pathologic response to injury that leads to narrowing of the vessel segment as a result of negative vascular remodeling and neointimal proliferation of vascular smooth muscle cells. Clinical and angiographic predictors of stent restenosis include diabetes, nonsmoking status, female sex, acute coronary syndrome, previous percutaneous coronary intervention (PCI), saphenous vein graft disease, small vessel diameter, long lesions, high angiographic complexity, ostial…

Role of the Cardiac Surgeon and the Heart Team

Key Points The role of the cardiac surgeon in the catheterization laboratory has traditionally been surgical backup for the interventional cardiologist. Such service is losing necessity as the development and mastery of new interventional procedures progress and correlate with the advancement of medical device technology. New minimally invasive interventional procedures are founded upon the historical open surgical approach and take a defined pathway from conception to…

Transradial Access for Cardiovascular Catheterization and Intervention

Key Points Access-site and nonaccess-site bleeding complications after percutaneous coronary intervention (PCI) are associated with poor outcome, including mortality. A transradial approach (TRA) for diagnostic angiography and PCI is associated with virtually no major access-site bleeding, early ambulation, and subsequent increase of net clinical benefit. After an initial short learning curve, the procedural success rates of TRA become similar to those of the transfemoral approach. TRA…

Access Management and Closure Devices

Key Points Access-site complications continue to be the most common adverse events after cardiovascular interventions, extending the patient’s hospital stay and increasing the associated procedural costs. Selection of the appropriate access site is frequently a key issue for the successful completion of coronary, peripheral vascular, or structural procedures. Selection depends on the target vessel or structural intervention, the operator’s skills, and the patient’s preferences. The ultrasound-guided…

Periprocedural Myocardial Infarction and Embolism-Protection Devices

Key Points Periprocedural myocardial necrosis remains a common complication of percutaneous coronary intervention (PCI). The 2012 Third Universal Definition document defines a myocardial infarction (MI) associated with PCI as elevation of troponin values above five times the 99th percentile of upper reference limit (URL) in patients with normal baseline values or a rise of troponin values above 20% if the baseline values are elevated and are…

Complications of Percutaneous Coronary Intervention

Key Points Although most complications are avoidable, when they occur, rapid recognition and corrective response are necessary to mitigate adverse consequences such as myocardial infarctions or death. Abrupt closure and intraprocedural stent thrombosis/acute stent thrombosis (<24 hours) are serious complications that can result in myocardial infarctions and death. Treating them requires rapid steps to restore perfusion, optimization of pharmacology, and careful evaluation to identify and treat…

The Thrombus-Containing Lesion

Key Points Thrombus plays a major role in the pathophysiology of acute and chronic ischemic coronary syndromes. Thrombus is a marker of active, unstable atherosclerotic plaques. Plaque rupture, plaque erosion, and calcified nodules are prominent histopathologic components causing coronary thrombosis. The necrotic core of the atherosclerotic plaque and its lipid content, especially the morphologic changes and dynamic movement of embedded cholesterol crystals, affect thrombus formation. The…

Bypass Graft Intervention

Key Points Early postoperative ischemia (<30 days) is frequently due to graft occlusion or stenosis, and percutaneous coronary intervention (PCI) is often feasible. Unstable angina or ST–segment–elevation myocardial infarction (STEMI) years after coronary artery bypass grafting (CABG) is most often due to a saphenous vein graft (SVG) lesion; in such cases, native vessel PCI is preferred whenever possible. Embolic protection reduces the risk of atheroembolic myocardial…

Intervention for Coronary Chronic Total Occlusions

Key Points Chronic total occlusion (CTO) is a common feature in patients with coronary artery disease (CAD) and is a frequent reason for not proceeding with percutaneous coronary intervention (PCI). Observational data suggests that ischemic reduction from successful CTO PCI improves symptoms, ejection fraction (EF), and long-term clinical survival compared with failure of CTO PCI. Available randomized trial data are limited and have several limitations. Clinically,…

Complex and Multivessel Percutaneous Coronary Intervention

Key Points Myocardial revascularization, which aims to relieve the negative prognostic impact of coronary artery disease left untreated, has emerged as a strategy to improve prognosis and quality of life in patients with multivessel disease (MVD). Over the past four decades, percutaneous coronary intervention (PCI) has evolved into a safe and reproducible procedure that, using an armamentarium of cutting-edge devices, has extended the possibility of noninvasive…