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Vascular Access for Structural Heart Disease

Structural heart disease interventions require careful preprocedural planning. Imaging is the cornerstone for planning, particularly to determine whether the intervention is feasible and can be successful. The next critical step is to choose an approach that will maximize the chance of reaching the structural defect and provide enough support to deliver catheters and devices. This chapter discusses the vascular access for structural heart disease with emphasis…

Imaging in Structural Heart Disease

Transcatheter therapies for both congenital and noncongenital structural heart lesions continue to expand in both their scope and complexity. The evolution of percutaneous treatment options for structural heart disease (SHD) has also come with advances in the imaging techniques associated with successful outcomes. SHD intervention uniquely requires an understanding of anatomic relationships in three dimensions and soft-tissue visualization, necessitating the addition of echocardiography and more recently…

The Growing Specialty of Adult Structural Heart Disease

The field of structural cardiac and cardiovascular intervention is relatively new. Some of the component procedures have been part of the interventional armamentarium for many years, but have never been grouped into a unified field. The development of new catheter technology for shunt closure, valve repair, and valve replacement has created this new subspecialty within interventional cardiology. Historically, the pediatric interventional community has performed many of…

Overview of structural heart disease interventions

Key points Structural heart procedures include percutaneous valve replacement (or repair), left atrial appendage occlusion (or ligation), placement of devices across the intra-atrial or intraventricular septum, and placing plugs across spaces with perivalvular blood flow. Heart teams inclusive of interventional cardiologists and cardiac surgeons are central to structural procedures, particularly those involving valve replacement. Structural procedures require a unique integration of fluoroscopy and ultrasound guidance—often requiring…

Aortic, renal, subclavian, and carotid interventions

Key points Endovascular aneurysmal repair (EVAR) for abdominal aortic aneurysm (AAA) is a minimally invasive procedure that involves the placement of a bifurcated or tubular endoluminal stent graft over the AAA to exclude the aneurysm from arterial circulation suitable for patients at increased perioperative risk for open surgical repair (OSR). In patients with symptomatic atherosclerotic renal artery stenosis (RAS), renal artery stenting is reasonable for hemodynamically…

Iliofemoral peripheral vascular intervention

Key points Patients with symptomatic lower extremity peripheral artery disease often present with classical burning, cramping pain made worse with exertion and better with rest (known as “intermittent claudication”). The symptomatic location is typically one level below the area of arterial stenosis; however, multilevel stenoses are frequently encountered, especially in critical limb ischemia. Endovascular intervention for symptomatic claudication has a level I recommendation for iliac interventions…

Guides, wires, balloons, and stents for noncoronary interventions

Key points Peripheral interventions require a variety of equipment different from coronary interventions and specific for the noncoronary interventional complexity. Access site and equipment choices are driven by the specific procedure to be performed and require careful preprocedural planning. Most peripheral interventional techniques focus on balloon treatment with adjunctive atherectomy but rarely use stent placement (as opposed to coronary interventions) to maximize outcomes. Introduction Peripheral vascular…

Vascular access for noncardiac procedures

Key points Access for noncardiac procedures employs many of the same techniques as access for cardiac procedures with the choice of access site determined by patient-related factors and specific procedural needs. Antegrade femoral and tibiopedal access techniques have been developed for lower extremity percutaneous revascularization procedures. All operators should be familiar with the techniques for access described within this chapter, regardless of specialty. Introduction Endovascular intervention…

Complications of percutaneous coronary interventions

Key points Complications remain rare during interventional procedures and prediction tools have been developed to help operators appreciate potential risks before the procedure. Although avoidance of complications remains the primary goal, keen awareness must exist during the procedure to react quickly when complications arise to minimize its impact. Access site complications remain the most frequent complications of coronary interventional procedures. Cath lab staff and operators must…

Coils, plugs, covered stents, and snares

Key points Coils, plugs, covered stents, and snares are invaluable components of the interventional “toolbox” with a wide range of emergency and nonemergency applications. Coils, vascular plugs, and covered stents can be used effectively for the treatment of coronary or saphenous vein graft (SVG) aneurysms, pseudoaneurysms, and fistulas. Coils and/or covered stents are more commonly used in the management of coronary perforations. Vascular plugs have been…

PCI with left ventricular hemodynamic support

Key points Complex percutaneous coronary intervention (PCI) procedures have become more common as techniques for chronic total occlusions (CTOs), bifurcation, and left main lesions have been developed with improved outcomes. Complex PCI can create significant acute risk for hemodynamic collapse in the Cath lab and the placement of prophylactic left ventricular (LV) support can minimize the risk of such an event. Multiple percutaneous options for LV…

PCI in STEMI, NSTEMI, and shock

Key points Acute myocardial infarction (AMI) is best treated with timely revascularization using percutaneous coronary intervention (PCI). ST-segment elevation myocardial infarction (STEMI) systems of care are crucial in allowing patients with AMI to have the opportunity for timely care at a PCI-capable center. A focused history and electrocardiogram (ECG) interpretation are of great importance to rapidly diagnose STEMI and initiate activation of the cardiac catheterization laboratory.…

Chronic total occlusion interventions

Key points Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) has become safer and more successful with the advent of improved, dedicated equipment and an algorithmic approach. The principal indication for CTO PCI is to improve angina and quality of life. Terminology, equipment, and techniques specific to CTO PCI have been developed. Objective scores have been developed to give the operator insights into the likelihood…

Bifurcation PCI

Key points Percutaneous coronary intervention (PCI) of bifurcation lesions can be complex requiring several equipment types and intraprocedural decision making. Various classification systems exist for bifurcations to guide treatment decisions, but the Medina classification is most commonly used. There are a variety of well-known “two-stent” bifurcation strategies available which have specific technical steps to achieve procedural success. Intravascular imaging assists operators to guide and plan bifurcation…

Adjunctive tools: Atherectomy devices, laser, thrombectomy

Key points Intracoronary calcification creates significant challenges for interventional procedures due to suboptimal stent expansion and associated poor long-term clinical outcomes. Atherectomy tools are designed for modification of intracoronary calcification to allow balloon and stent expansion. Coronary thrombus presents a separate challenge and selective use of thrombectomy may improve outcomes. Other “niche” devices, including thrombectomy catheters and embolic protection filters are infrequently used but have benefit…

Intravascular lesion assessment: Physiology and imaging

Key points Angiographic determination of the significance for a given coronary lesion remains limited. Numerous physiologic indexes are now available that rely on coronary hyperemia (fractional flow reserve [FFR]) and nonhyperemic indexes [aka NHPR] (e.g., instantaneous wave-free pressure ratio [iFR], mean distal coronary divided by mean proximal aortic pressure [Pd/Pa], resting full-cycle ratio [RFR], diastolic hyperemia-free ratio [DFR]), which can all reliably assess the significance of…

Guide catheters, guide extenders, guidewires, balloons, and stents

Key points Guiding catheter selection remains one of the essential pieces enabling a successful coronary intervention procedure in the cath lab. Alternatives, such as using sheathless guides and guide catheter extensions, are now available to facilitate interventional procedures. Numerous coronary guidewires are available today for operators to choose from, including several workhorse wires, hydrophilic coated wires, and specialty wires that have niche applications. Coronary balloon catheters…

Interventional pharmacology

Key points Anticoagulant and antiplatelet medications are required for the safe percutaneous coronary intervention (PCI). Recent studies have demonstrated that shorter durations of dual antiplatelet therapy (DAPT) are safe. Vasodilators and vasopressors may often be necessary in some complicated or critical in-lab scenarios. This chapter will describe common medications used in the cardiac catheterization laboratory for interventional procedures. It is not intended to be all inclusive,…

Vascular access

Key points A significant source of complications from catheterization procedures continues to arise from the site of access. Ultrasound-guided access is the preferred method regardless of access site. There are several options for the best site of access, including the distal radial, radial, and femoral artery. Operators should adopt a consistent approach to vascular access to gain efficiency and minimize complications. Vascular access techniques for interventional…

The basics of percutaneous coronary interventions

Key points Percutaneous coronary intervention (PCI) procedures in today’s cath lab require assimilating numerous details regarding a patient’s clinical history, testing before catheterization with anatomic information provided from the diagnostic angiogram. PCI requires an understanding of anticoagulation therapy, guide catheters, guidewires, balloons, coronary physiology, and intravascular imaging procedures, before and after stent implantation. Appropriate selection of patients and coronary lesions for PCI, weighing the risk of…