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Renal Artery Intervention : Catheter-Based Therapy for Renal Artery Stenosis

Open full size image Introduction A key principle governing renal artery stenting (RAS) is that clinical benefit will result from relieving a significant renal artery stenosis causing renal hypoperfusion. Published meta-analyses suggest that a very high RAS technical success rate (>95%) is accompanied by a surprisingly modest and inconsistent clinical improvement ( Figure 20-1 ). The discordance between the high technical success rate for RAS and…

Upper Extremity Intervention

Open full size image Introduction Atherosclerotic upper extremity obstructive disease is predominantly secondary to subclavian or innominate artery stenosis (SAS or IAS). The diagnosis is usually suspected when a significant (often ≥15 mm Hg) systolic brachial blood pressure discrepancy (SBBP) is detected between the two arms. Applying this threshold, the prevalence of SAS in the general population is estimated at approximately 2% and increases with advancing age. In…

Intervention for Lower Extremity Arterial Disease

Open full size image Clinical Assessment Peripheral artery disease (PAD) is caused by a number of pathologies affecting the arteries of the lower extremities. The most common cause in industrialized countries is atherosclerosis, but the interventionalist needs to be aware of other pathologies that may be best treated by noninterventional approaches. The history and physical exam can distinguish most causes of peripheral artery disease and determine…

Optical Coherence Tomography

Open full size image Introduction Optical coherence tomography (OCT) is a tomographic imaging technology first described for use in ophthalmology that has been adapted for real-time intravascular imaging. The resolution of OCT is significantly higher than other currently available intravascular imaging modalities, allowing for detailed characterization of the morphological features of coronary arteries, coronary plaques, and intracoronary stents. OCT is analogous to intravascular ultrasound (IVUS) with…

Intravascular Ultrasound Imaging

Open full size image Background and Limitations of Angiography Contrast angiography has been the gold standard of coronary artery imaging for over six decades. However, it is important to understand that angiograms only delineate the coronary lumen with no direct imaging or examination of the arterial wall. With the growing interest in vascular biology and understanding of the metabolically active atherosclerotic plaque, intravascular ultrasound (IVUS) imaging…

Fractional Flow Reserve

Open full size image Introduction Coronary blood flow and pressure measurements across a stenotic coronary artery provide information on the ischemic potential of a specific lesion at the time of catheterization. Physiologic assessment of coronary artery stenosis by fractional flow reserve (FFR) has become the gold standard for invasive assessment of myocardial ischemia. Its integration into the catheterization procedure as an adjunct to coronary angiography has…

Management of Thrombotic Lesions

Open full size image Introduction Acute myocardial infarction is caused by thrombotic occlusion of a native coronary artery. While partial occlusion usually presents as a non ST-elevation myocardial infarction (NSTEMI), it is expected that complete occlusion will result in ST-elevation myocardial infarction (STEMI). Acute myocardial infarction can also occur as a result of thrombotic occlusion of a saphenous vein graft. Saphenous vein graft occlusion may be…

Treatment of In-Stent Restenosis

Open full size image Introduction The development of percutaneous coronary intervention (PCI) with stent implantation has revolutionized the practice of cardiology over the course of the past decades. However, despite considerable technological advancements, in-stent restenosis (ISR) remains the most common cause of treatment failure after PCI. Moreover the high efficacy with contemporary devices—primarily drug-eluting stents (DES)—has facilitated the expansion of PCI to broader and increasingly more…

Calcified Lesions

Open full size image Introduction Calcified coronary lesions present an important challenge to interventional cardiologists. Because of the rigidity and noncompliance of a heavily calcified coronary artery segment, heavy calcification was a risk factor for traditional balloon angioplasty failure and remains associated with major adverse cardiac events after stenting lesions with moderate/heavy calcification in patients with acute coronary syndromes and decreased success for chronic total occlusion…

Bypass Graft Interventions

Open full size image Dr. Brilakis: Research support from the Department of Veterans Affairs (PI of the Drug Eluting Stents in Saphenous Vein Graft Angioplasty—DIVA trial and Merit grant—I01-CX000787-01) and from the National Institutes of Health (1R01HL102442-01A1); consulting fees/speaker honoraria from St. Jude Medical, Boston Scientific, Asahi, Abbott Vascular, Somahlution, Elsevier, and Terumo; research support from Guerbet and InfraRedx; spouse is an employee of Medtronic. Dr.…

Bifurcations

Open full size image Introduction A bifurcation coronary lesion is a stenosis involving or adjacent to the origin of an arterial side branch ≥2 mm in diameter. The stenosis can involve the large branch (main branch, MB), the smaller branch (side branch, SB), or both. Coronary bifurcation lesions have been the subject of several classifications. However, attempts to classify bifurcation lesions suffer all the limitations of coronary…

Chronic Total Coronary Occlusions: Rationale, Technique, and Clinical Outcomes

Open full size image Introduction Despite remarkable advances in the procedural and clinical outcomes of percutaneous revascularization, chronically occluded coronary arteries represent persistent technical challenges and unresolved clinical dilemmas in interventional cardiology. Although a coronary chronic total occlusion (CTO) is identified in approximately one in every three to five diagnostic cardiac catheterizations, revascularization is attempted in fewer than 10% of instances and overall accounts for less…

Percutaneous Coronary Intervention for Unprotected Left Main Disease

Open full size image Philippe Généreux has received speaker fees from Abbott Vascular and is a consultant for Cardiovascular System, Inc. Introduction Left main (LM) coronary artery disease, defined by a visually estimated diameter stenosis of at least 50%, is present in approximately 3% to 5% of patients undergoing coronary angiography. Without revascularization, mortality is as high as 50% within 3 years of follow-up. Current treatment…

Contrast Selection

Open full size image Introduction Iodinated contrast media (CM) are widely used in interventional cardiology. Efficacy is predicated on the capacity to opacify intravascular structures; however, when selecting a CM, other important properties should be considered. Most notably, chemical properties such as ionicity, osmolality, and viscosity, as well as the potential for adverse effects, should be incorporated in the decision for CM selection. This chapter aims…

Radiation Safety in the Cardiac Catheterization Laboratory

Open full size image Introduction Over the past few decades, major technological improvements in Cardiac Catheterization Laboratory (CCL) equipment have enabled acquisition of images with better quality at a potentially lower radiation dose. Concurrently, the number and complexity of angiographic procedures have been increasing, creating the risk of greater radiation exposure to angiographers, patients, and lab personnel. Angiographers have a responsibility to assure appropriate and safe…

Hemodynamic Support During High-Risk PCI

Open full size image Introduction Coronary balloon angioplasty (PTCA), introduced in 1977, was initially limited to treatment of focal, noncalcified, proximal, concentric coronary lesions. Initially case selection was confined to patients with normal left ventricular function and single vessel coronary artery disease. Complex lesions (eccentric, bifurcation, chronic total occlusion) and patients with multivessel coronary disease simply could not be technically approached. Dramatic advances in guidewire technology,…

Pharmacotherapy in the Modern Interventional Suite

Open full size image The major aims of pharmacotherapy during percutaneous coronary intervention (PCI) and invasive cardiac procedures are to avoid the adverse consequences related to iatrogenic plaque rupture during balloon angioplasty and stent deployment, to reduce the hazards of thrombus formation on the intracoronary PCI equipment, and to mitigate myocardial ischemia and all periprocedural complications. The informed, effective, and judicious use of drugs in the…

Vascular Access and Closure

Open full size image Arterial access for common coronary and vascular procedures can be obtained via the common femoral artery, radial, ulnar, or brachial arteries. More recently, the subclavian artery and direct aortic access are being used for transcatheter aortic valve replacement procedures. Arterial access site complications are common in interventional procedures, and knowledge of the anatomy, optimal access techniques, and optimal techniques to obtain hemostasis…

Guidelines and Appropriateness Criteria for Interventional Cardiology

Open full size image Introduction Quality of care has been a major focus of medical care since the Institute of Medicine focused attention on the unacceptable degree of variability in care and concern about patient safety and effectiveness. In its classic monograph, Crossing the Quality Chasm, the institute identified six aims to improve the quality of health care in the United States. It stressed that health…

The Birth of Interventional Cardiology

Open full size image The Innovator of Angioplasty There are few who are acknowledged as true pioneers in medicine, but Andreas Grüntzig was surely one ( Figure 1-1 ). He quite simply not only coined the term interventional cardiology, he was interventional cardiology. For many evenings, he, his wife Michaela, and Walter and Maria Schlumpf sat at the Grüntzig's kitchen table fabricating balloon catheters. These catheters…