CTO Manual Online cases: 11 , 14 , 48 , 67 , 105 , 127 , 135 , 136 , 148 PCI Manual Online cases: 28 , 32 , 33 , 41 , 52 , 59 , 60 , 72 , 83 , 84 , 85 , 88 , 91 , 96 , 97 , 100 Percutaneous coronary intervention (PCI) in the left main coronary artery…

16.1 Bifurcation algorithm ( Fig. 16.1 ) 16.1.1 Does the side branch need to be preserved? This depends on the size of the side branch (SB) (usually branches <2 mm in diameter do not need to be preserved) and the supplied myocardial territory. If a decision is made to preserve the SB, it must be decided whether to simply wire the SB to help preserve patency…

CTO Manual Online cases: 2 , 10 , 12 , 20 , 37 , 58 , 65 , 69 , 70 , 78 , 83 , 84 , 90 , 91 , 92 , 102 , 110 , 118 , 130 , 135 , 136 , 148 , 149 PCI Manual Online cases: 18 , 28 , 29 , 30 , 31 , 50 , 52…

14.1 Hemodynamic support: when and what device Maintaining adequate tissue perfusion is critical for survival. PCI may result in decreased cardiac output and tissue hypoperfusion or may be performed in the setting of decreased or absent perfusion (such as in cardiogenic shock or cardiac arrest). Although no randomized trials have demonstrated a decrease in in-hospital mortality or major complications with use of hemodynamic support devices ,…

13.1 When to do coronary intravascular imaging? Coronary intravascular imaging can be performed before, during, and after PCI to determine the need for coronary revascularization, and help plan and optimize the result of PCI, as described below. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are the currently available modalities for coronary intravascular imaging. Although some operators have advocated imaging of all coronary lesions undergoing PCI…

12.1 When should coronary physiology be used? 12.1.1 Before PCI 1. Determine significance of intermediate coronary lesions. Several studies have shown that PCI of lesions with adenosine fractional flow reserve (FFR)>0.80 (FFR>0.75 was used in earlier studies ) or lesions with nonhyperemic indices that do not show ischemia (such as instantaneous wave free ratio—iFR>0.89 ) can be safely deferred without increasing the incidence of adverse outcomes.…

11.1 Femoral access 11.1.1 Femoral access closure algorithm The following algorithm ( Fig. 11.1 ) reflects the experience and current practice of the authors; other vascular closure devices can be incorporated in the algorithm depending on local availability and expertise. Use of vascular closure devices is favored for shortening the time to ambulation and potentially reducing the risk of complications, although the latter remains controversial .…

Goal : To deliver and adequately expand a stent, completely covering the target lesion. 10.1 You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log in here

9.1 Goal To adequately prepare the target lesion to facilitate stent delivery and expansion. 9.2 When is lesion preparation needed? ( Fig. 9.1 ) Lesion preparation (in most cases with balloon angioplasty) should be performed in nearly all lesions because it: 1. Facilitates stent delivery and decreases the risk of stent loss. 2. Helps determine optimal stent diameter and length (especially when no intracoronary imaging is…

Goal : To advance a guidewire through and distal to the target coronary lesion in the most efficient way and without causing a complication and to provide an adequate platform to support balloon, stent and other equipment delivery. Similar to use of a guide catheter, wire insertion is essential for performing PCI and/or lesion assessment through coronary imaging or physiology. Obtaining optimal guide catheter support, as…

The following decisions need to be made after coronary angiography is performed. 1. Is coronary revascularization needed? Like every other procedure, coronary revascularization should be done when the anticipated benefits exceed the potential risks. Potential benefits are improving symptoms and improving prognosis. This is discussed separately for patients with stable angina ( Section 7.1 ) and for patients with acute coronary syndromes (ACS) ( Section 7.2…

Although adjunctive modalities (stress testing, noninvasive imaging including coronary computed angiography, coronary physiology, and intracoronary imaging) can help evaluate coronary anatomy, coronary angiography remains the most commonly used technique for assessing the presence and severity of coronary artery stenoses and for planning coronary revascularization (surgical or percutaneous). For coronary angiography to provide accurate information about coronary anatomy, it should be performed using meticulous technique, which can…

In Chapter 4 , Access, we discussed about how to obtain arterial access. In this chapter we describe the steps involved in advancing a catheter over a guidewire from the access site to the coronary ostia and engaging the coronary arteries. Neither diagnostic angiography nor PCI can be performed without engaging the coronary artery ostia. Although the steps involved in engaging the coronary arteries are simple…

4.1 Choosing access site Obtaining arterial access is required for performing diagnostic coronary angiography and percutaneous coronary intervention (PCI). There is continued controversy about optimal access site selection. Radial (proximal or distal) or ulnar access is associated with significantly fewer access site complications and greater patient satisfaction compared with femoral access , but engaging the coronary arteries can be more challenging and guide catheter support may…

In this chapter we discuss the following classes of medications that are commonly used in the cardiac catheterization laboratory: 1. Sedatives and analgesics 2. Vasodilators 3. Contrast media 4. Anticoagulants 5. Antiplatelet agents 6. Vasopressors and inotropes 7. Antiarrhythmics 3.1 Sedatives and analgesics 3.1.1 Goals Improve patient comfort. 3.1.2 How? Midazolam (Versed): 0.5–1 mg intravenous (IV)—can be repeated. Duration of action: 15–80 minutes. Fentanyl: 25–100 mcg…

Monitoring the patient should be continually performed from the beginning to the end of the case, so that potential complications are promptly identified and corrected. The following parameters are assessed ( Fig. 2.1 ). Open full size image Figure 2.1 What to monitor during cardiac catheterization. 2.1 Patient 1. Patient comfort level: patient discomfort can lead to movement, potentially leading to complications. It can also lead…

If you fail to plan you are planning to fail. Benjamin Franklin. Planning is essential for every procedure, including percutaneous coronary intervention (PCI). Thoughtful planning and appropriate preparation before performing PCI improves the safety, efficiency, outcome, and cost of the procedure. The following items should be checked, that correspond to each of the 14 steps of the procedure. While planning is in itself the first of…