B P3 C21 Coronary Angiography and Intravascular Imaging Flashcards
Class 1 indications for CA in SIHD
Patients with SIHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia.
Patients with SIHD who develop symptoms and signs of HF
Patients whose clinical characteristics and results of noninvasive testing indicate a high likelihood of severe IHD
Patients with presumed SIHD who have unacceptable ischemic symptoms despite optimal medical therapy
Class I indications for CA in UA and NSTEMI
- An urgent/immediate invasive strategy (diagnostic angiography with revascularization if appropriate) is indicated in patients with NSTE- ACS who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures). (LOE: A)
- An early invasive strategy (diagnostic angiography with revascularization if appropriate) is indicated in initially stabilized patients with NSTE-ACS (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events. (LOE: B)
Class I indications for CA in STEMI
- Immediate angiography and PCI when indicated should be performed in resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows STEMI. (LOE: B)
- Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration. (LOE: A)
- Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from first medical contact. (LOE: B)
- Primary PCI should be performed in patients with STEMI and cardiogenic shock or acute severe HF, irrespective of time delay from MI onset. (LOE: B)
Risk Factors That Support Early Invasive Evaluation of Patients Presenting with ACS
Significant troponin increase
Diagnostic ST or T wave changes
GRACE score >140
Diabetes mellitus
Reduced LV function (ejection fraction <40%)
Early postinfarction angina
Recent PCI
Prior CABG
Intermediate to high GRACE risk score
During injection of contrast media into the right coronary artery (RCA), one should take care to avoid deep cannulation of the RCA and injection of contrast media directly into the _____________ because this can result in ______________
Conus branch
Ventircular fibrillation
There are ___ absolute contraindications to coronary angiography listed in the clinical practice guidelines. However, specific conditions should be taken into account when weighing risks and benefits of the procedure.
No
Relative contraindications that should be taken into account are _____.
Known anaphylactoid reaction to contrast media
Moderate to severe kidney impairment
Decompensated heart failure and pulmonary edema that prevent the patient from lying down during the procedure
Uncontrolled hypertension
Active infection
Coagulopathy
Gastrointestinal bleeding
Pregnancy
Complications during coronary angiography are rare, occurring in approximately ___% of patients, with serious complications such as cerebrovascular accident (CVA), or stroke, or myocardial infarction (MI) accounting for less than _____% of all patients. Mortality rate is lower than 0.1%
2%
1%
Although rare, the most common complications of coronary angiography are _____.
Allergic reactions to contrast
Vascular complications
Worsening of kidney function
The risk of a vascular complication increases with the _____.
Diameter of the sheath used
Age of the patient
Degree of local calcifications
Embolic events are rare but can occur and may involve the coronary arteries, central nervous system, or peripheral arteries. _____ arteries can increase the likelihood of embolization.
Highly calcific axillary or subclavian
In addition, _____ have been reported as risk factors for periprocedural stroke
Advanced age
Diabetes mellitus
Emergency coronary angiography
Prior stroke
Renal failure
Congestive heart failure (CHF)
Use of ________ access rather than femoral access has significantly reduced the rate of vascular and bleeding complications
Radial
CI-AKI is defined as an acute deterioration of renal function, defined as an increase in creatinine of ________ or more or ___________ compared with baseline. It generally develops ______________ after administration of an intravascular contrast agent in the absence of other identifiable causes
0.5mg/dl
25% or greater
24 to 72 hours
Risk of CI-AKI depends largely on ____________________
Components of Mehran risk score
Baseline renal function (eGFR value below 60 mL/min are at high risk of CI-AKI)
CHF (5 points),
Hypotension (IABP)(5 points),
Age > 75 years (4 points),
eGFR (2-4 points), DM (3 points), Anemia (3 points),
Contrast volume (1 point/100cc)
Prevention of CI AKI
Periprocedural hydration with crystalloids, 1-1.5 mL/kg/hr 3-12 hours before and 12-24 hours after the procedure of hydration volume adjusted as per LVEDP
Prefer IOCM/LOCM
Minimize volume of CM
Periprocedural statin treatment (rosuvastatin?)
Radiation injury may be deterministic (i.e.-_______________), which can present weeks after exposure, or _______________, which is genetically determined and not dosedependent.
Dose-dependent
Stochastic
Deterministic injury may result in skin injury, hair loss, and lens injury. However, the most common location of radiation-induced lesions in cardiac catheterization is the skin of the _____, and common patterns include erythema, telangiectasia, and plaques
Back
Exposure to radiation can be minimized in several ways:
(1) Reduced FT and acquisition time
(2) Use of multiple angles rather than a single working camera position
(3) Reduced fluoroscopy dose
(4) Avoidance of high magnification
(5) Use of collimator beams and filters
(6) Avoidance of high angulation
(7) Reduction in the flat-panel image detector as much as possible
For exposures of absorbed radiation greater than 5 Gy, patients should be advised to watch for areas of _____; for those greater than 10 Gy, a _____t should be consulted to calculate the peak dose in 2 to 4 weeks; greater than 15 Gy is regarded as a _____. Similarly, in the event that FT exceeds 60 minutes, physicians must be vigilant for late radiation effects.
> 5 Gy: Erythema
> 10 Gy: Medical physicist consult
> 15 Gy: Hospital risk management event
Access site for femoral artery insertion
Landmark
Common femoral artery (CFA) is punctured with a base-metal needle approximately 1 cm below the inguinal line with a 45- to 60-degree angulation
Head of the femur
Usually, a 6 French (6F) sheath (French units: F = ____ mm) is used for coronary angiography and coronary interventions
1F = 0.33 mm
The _____ is performed by applying pressure on both the ulnar and the radial artery of one wrist to occlude them while the patient keeps the hand elevated with the fist clenched for approximately 30 seconds.
Once opened, the hand appears pale. The compression on the ulnar artery is then removed while pressure is maintained on the radial artery.If the ulnar artery supply to the hand is adequate, the color quickly returns to the hand and the test is normal. Conversely, if color does not return, the ulnar artery supply is insufficient, meaning that the radial artery supports the entire circulation of the hand. In this case the radial artery should not be punctured, because this may compromise the blood flow to the hand
Modified Allen test
This rule (Modified Allen Test) may be bypassed if an oximeter is placed in the thumb during radial artery occlusion, and resurgence of pulsation and oxygenation is documented after its initial disappearance _____.
“Barbeau method”
Radial access - ideal puncture site is ___________ to the radial styloid with the wrist slightly hyperextended
Medications to prevent SPASM
Medications to prevent THROMBOSIS
1 to 2 cm proximal
Nitroglycerin (100 to 200 μg) or Verapamil (2.5 mg)
Weight-adjusted unfractionated heparin (UFH), 40 to 70 U/kg up to 5000 U
The standard length for adult left-heart catheterization by both the radial and the femoral approach is ______________, while ___________ is suitable for brachial access.
100 cm (40 inches)
80 cm
Judkins catheters can be used both for the femoral and for the right/left radial approach.
Preformed left Judkins (JL) presents a primary curve of _______ degrees and a secondary curve of ____________; ______________ engages the ostium of the left coronary artery (LCA)
______________ most often used to engage the LCA
Right Judkins (JR) presents a primary curve of __________ and secondary curve of _____________; requires a ________________ to engage the ostium of the RCA from any vascular approach; may be used for _____ grafts
A. 90 degrees, 180 degrees, automatically
B. JL 4.0
C. 90 degrees, 30 degrees, clockwise rotation, SVG and IMA
________________________ easier coronary engagement in specific settings, such as short left main ostium, separate ostium of circumflex (Cx)–left anterior descending (LAD) artery branches, and RCA with anterior-high origin
Right Amplatz (AR) catheter allows engagement of RCAs with inferior orientation
Amplatz okay with SVG
Left Amplatz (AL) catheter
SVGs from the aorta to the distal RCA or PDA originate from the right anterolateral aspect of the aorta approximately ____________ superior to the sinotubular ridge
SVGs to the LAD artery (or diagonal branches) originate from the anterior portion of the aorta approximately _______ superior to the sinotubular ridge
SVGs to the obtuse marginal branches arise from the left anterolateral aspect of the aorta __________ superior to the sinotubular ridge
A. 5 cm (2 inches), LOWEST
B. 7 cm
C. 9 to 10 cm
The left IMA (LIMA) can be cannulated with a specially designed _____ catheter. The catheter is advanced into the aortic arch distal to the origin of the left subclavian artery, then rotated counterclockwise and gently withdrawn with the tip pointing in a cranial direction, allowing entry into the left subclavian artery. The right anterior oblique (RAO) or anteroposterior (AP) projections can be used to visualize the IMA
J-tip IMA catheter
For the ______, first the innominate artery is entered with the guidewire in the LAO projection, then the IMA catheter is advanced to a point distal to the expected origin of the RIMA. The catheter is withdrawn slowly in the LAO view and rotated to cannulate the RIMA.
Right IMA (RIMA)
To cannulate the GEA, first a special catheter called the ____________ is inserted into the common hepatic artery.
Next, a hydrophilic-coated guidewire is advanced to the gastroduodenal artery and then to the right GEA.
“Cobra” catheter
_____ grafts represent the most popular arterial grafts after the LIMA and RIMA. Similar to SVGs, radial grafts require a double anastomosis, one on the aorta and one on the coronary vessel. Because of potential early spasm, RA grafts were abandoned in the 1970s and 1980s. In the 1990s, however, this procedure was rediscovered, and with specific surgical techniques and pharmacologic prophylaxis, it has safely been used with good short- and long-term results
Radial artery (RA) grafts
Left ventriculography provides important information about _____.
Volumes,
Global and segmental function
Anatomic abnormalities such as ventricular septal defect, ventricular thrombus
Valvular dysfunction.
Incomplete ventricular opacification with hand-injection of up to _____ cc of contrast through a JR catheter has been become popular as a method to verify an already known normal LV function based on earlier noninvasive studies.
10 cc
Since the physiologic high pressure developed during each cycle in the left ventricle, the operator should inject a rather high volume of contrast agent in a rather short time for an effective opacification. Accordingly, _____are the best option since the single end-hole catheter could be unstable during the high-pressure injection, thus increasing the risk of arrhythmias or inadequate ventricle opacification.
6F to 8F catheters with multiple lateral holes
The pigtail catheter, including multiple side holes and a “pigtail-like” end-configuration, is frequently used for several reasons.
First, the pigtail catheter easily crosses the aortic valve, either directly or by prolapsing across the valve leaflets.
Second, the loop shape keeps the end-hole of the catheter away from the cardiac wall, thus decreasing the risk of endocardium trauma, intramyocardial ventricular staining, and arrhythmias.
Third, the simultaneous delivery of the contrast agent along the numerous side holes allows a correct opacification of the left ventricle and a further stabilization of the catheter.
Settings and suggested projections for Left ventriculography
Settings:
Flow rate 10-15 mL/sec
Total contrast volume 30-45 mL Pressure limit 750-1200 psi
0- to 0.5-second rise
Suggested projection:
30-degree right anterior oblique and 0-degree cranial angulation
Structures:
Global LV function
Segmental wall motion (AB, AL, Apical, Diaphragmatic, IB)
MV
60-degree left anterior oblique and 25-degree cranial angulation
Structures:
SWMA (L, PL, Apical, septal, basal septal)
IVS
AV
Settings and suggested projections for Right ventriculography
Settings:
Flow rate 8-10 mL/sec
Total contrast volume 20-30 mL Pressure limit 750 psi
Suggested projections:
30-degree right anterior oblique and 0-degree cranial angulation
Structures:
Global LV function
SWM (RV ydsplasia)
Anteroposterior view
Structures: CHD evaluation
Complications related to left ventriculography are as follows:
(1) Cardiac arrhythmias (both supraventricular and ventricular) often requiring dynamic repositioning
(2) Microembolization
(3) Intramyocardial contrast staining
(4) Contrast associated issues, including nephropathy or high volume load in end-stage heart failure or dialysis patients
Trivial (+1): A minimal jet with a brief and incomplete atrial opacification during systole, rapidly clearing during each cycle without atrial enlargement
Mild (+2): A ____________ opacification of the left atrium with each cycle, clearing with the subsequent beats. The atrium is less opacified than the left ventricle, usually with preserved dimensions.
Moderate (+3): A __________ opacification of the left atrium, ________ intensity to ventricular opacification. There is delayed atrial clearing
Severe (+4): A complete and immediate opacification of the left atrium, even ________ than the ventricle. The left atrium is typically severely enlarged and opacification of ______________ may be visible.
A. Moderate
B. Complete, equal
C. Denser; pulmonary veins
Dos Santos first described aortography in 1929 by a direct abdominal aorta puncture. Ascending aortography, as practiced by Sones, is indicated to assess the following:
(1) aortic valve regurgitation
(2) dimensions
(3) aortic coarctation
(4) sub- or supravalve aortic stenosis
(5) shunts
(6) identification of bypass grafts
The typical set up for aortic injection is ____.
FR 15 to 20 mL/sec
Volume of the contrast agent 30 to 45 mL
Rate of rising 0 to 0.5 s
Pressure limit 750 to 1000 psi
Aortic regurgitation may be trivial, mild, moderate, or severe depend- ing on ventricular opacification after the third cycle following contrast injection.
Trivial or grade 1 (1+): minimal regurgitation jet with a brief and incomplete left ventricle opacification during diastole and fast clearance of the contrast agent.
Mild or grade 2 (+2): regurgitation jet causing a moderate ventricular opacification, which less dense than in the ascending aorta and is cleared within one to two cardiac cycles.
Moderate or grade 3 (+3): regurgitation jet causing complete ventric- ular opacification within two cycles, as dense as in the ascending aorta and with delayed clearing from the ventricle over several cycles,often associated with dilated left ventricle.
Severe or grade 4 (+4): complete and immediate opacification of the left ventricle,denser than observed in the ascending aorta.
AORTOGRAPHY
The standard approach of ___________________ allows the best view of ascending aorta, aortic arch, the innominate artery, and the left subclavian and carotid arteries
____________ is preferred for aortic valve evaluation and related interventions.T
A. LAO 30-degree projection
B. LAO 30-degree projection
Right ventriculography is indicated to assess _____. However, it is not valuable for assessing tricuspid regurgitation due to the presence of the catheter across that valve. A multiple-hole pigtail might be used
(1) Right-to- left ventricular shunts
(2) Right ventricle dimensions or dysplasia
(3) Abnormalities of the RV outflow tract (RVOT)
(4) Pulmonary stenosis or global and segmental ventricular function
Typically,20 to 30 mL of contrast material is injected at 8 to 10 mL/sec (but if the ventricle is severely dilated,the volume could be increased up to 40 to 50 mL at 12 to 18 mL/sec).
Ionic high-osmolality ICAs were the first class of ICA used. However, the high-osmolality and calcium-chelating proprieties often resulted in _____.
(1) Heart rhythm disorders (sinus bradycardia, atrioventricular blocks, QRS prolongation, long QT, ST-T, giant T-wave inversion, and extremely rarely, VT and VF)
(2) Altered LV contractility
In large cohort studies,the incidence of all types of adverse reactions to contrast was approximately 12% with a high-osmolality agent, compared with only 3% with a low-osmolality ICA. For this reason, _____ are now considered the safest ICAs to use for vascular diagnostic procedures.
LOCA and IOCA
Manual contrast injection:
For the RCA, ____________ is usually injected to optimally visualize the entire vessel, with a maximal pressure of ____________
For the LCA, a volume of _________ is injected at a pressure of ______________
A. 4 to 6 mL/sec; 450 psi
B. 6 to 8 mL/sec; 450 to 600 psi.
____- reactions can present with a variety of clinical symptoms, ranging from itching to skin rash, local edema, asthma, and full-blown anaphylactoid reaction. The pathophysiologic mechanisms hinge on the activation of different components of the immune system. _____ reactions have a similar clinical presentation as the classic allergic response but are independent of immune system activation. Allergic-like reactions revolve around a physiologic response to contrast (e.g., nausea, vom- iting, vasovagal reaction, hypertension, flushing)
Allergic reactions
Allergic - like reactions
In elective patients at risk for allergic reactions, in particular those with a history of anaphylactic reaction, prophylactic treatment must include _____.
(1) Prednisone, 50 mg by mouth (PO)
(2) Hydrocortisone, 200 mg intravenous (IV) at 13 hours, 7 hours, and 1 hour before ICA injection, + Diphenhydramine, 50 mg IV, intramuscularly (IM), or PO, 1 hour before ICA administration
(3) Methylprednisolone, 32 mg PO, 12 hours and 2 hours before ICA injection, plus an antihistamine can also be used
Reactions to contrast agents may be more difficult to manage in patients receiving _____ therapy. Recurrence rates may approach 50% on repeat exposure to contrast agents, and prophylactic use of H1 and H2 histamine receptor–blocking agents and aspirin therapy has been recommended.
Beta blocker
Classification of Delayed Adverse Reactions After Injection of Intravascular Contrast Agents
Most frequent:
Urticaria
Persistent rash
Maculopapular exanthema
Exanthema pustulosis
Urticaria or pruritus
Angioedema or pruritus
Pruritus alone
Rare:
Severe cutaneous reactions in patients with systemic lupus erythematosus (SLE)
Cutaneous reactions in sun-exposed areas of body
Inflammation and swelling of salivary glands (parotitis or mumps)
Acute polyarthropathy
Nausea or vomiting
Fever
Drowsiness
Headache
Severe hypotension*
Cardiopulmonary arrest*
The LAD artery runs along the ________________________ and provides circulation for the anterior and anterolateral wall of the left ventricle with ______________ and the anterior two-thirds of the interventricular septum with the ________________
Types of LAD
I - _________________
II - ________________
III - ________________
A. Anterior interventricular sulcus, diagonal vessels, septal branches
B.
Type 1 if it does not reach the LV apex
Type 2 if it reaches the LV apex
Type 3 if it reaches and wraps around the LV apex,
The Cx artery courses along the ______________________ and provides branches for the left atrium, occasionally giving rise to the sinoatrial (SA) branch (40% of cases).
The Cx also supplies the LV lateral and posterior walls with branches called ___________________
A. Left atrioventricular (AV) groove
B. Obtuse marginal (OM) branches
The RCA originates from the right sinus of Valsalva and courses across the right AV groove.
The proximal branches provided by the RCA are atrial branches for the right atrium, the SA node in _________, and the branch to the __________ that supplies the right ventricular outflow tract.
Branches - PDA, PL
Coronary Dominance
Left - _____ %
Right - _____ %
Codominance - _____ %
A. 60% of cases (Cx - 40%)
B. Conus
C. 80, 10, 10
Standard angiographic projection
RCA - Vessel engagement projection, Ostium and RCA along AV sulcus
LAO 45
Standard angiographic projection
RCA - PDA, PL branches, and RCA after crux
LAO10-30, CRAN 30
Standard angiographic projection
RCA - PDA ostium, PDA septal branches, right ventricular branches, acute margin branches
RAO
Standard angiographic projection
LCA - LMCA engagement projection
AP, CAUD 10
Standard angiographic projection
LCA - “Spider projection”: LMCA and proximal segment of LAD, Cx, and ramus (if present)
LAO 20-45, CAUD 30-45
Standard angiographic projection
LCA - Mid- and distal LAD and its branches, Cx PDA, and Cx PL branches if present
LAO 20-45, CRAN 30-60
Standard angiographic projection
LCA - All LAD and branches, Cx and OM branches
RAO 15-30, CAUD 10-30
Standard angiographic projection
LCA - Mid- and distal LAD and branches, mid-Cx and branches
RAO 15-30, CRAN 10-30
Classification of Coronary Anomalies Based on Ischemia
Absence of ischemia:
Most anomalies (split RCA, ectopic RCA from right cusp; ectopic RCA from left cusp)
Episodic ischemia:
Anomalous origin of a coronary artery from the opposite sinus (ACAOS)
Coronary artery fistulas
Myocardial bridge
Typical ischemia:
Anomalous left coronary artery from the pulmonary artery (ALCAPA)
Coronary ostial atresia or severe stenosis
Coronary ostial hypoplasia or atresia can occur as an isolated lesion or as a concomitant anomaly with other CAAs. The life expectancy of patients with coronary ostial hypoplasia or atresia depends on the presence of _____ circulation from other vessels that can supply the distal coronary bed.
Collateral
Anomalous origin of coronary arteries is a common type of CAA. Coronary arteries with ectopic origin - wrong sinus or different structure
LCA arising from the right aortic sinus usually follows one of these four courses: prepulmonic, retroaortic, interarterial, or transseptal. Which course is associated with SCD during or shortly after exercise in young individuals?
Management?
A. Interatrial course (same with RCA from L coronary sinus); CABG
The _____ course of an anomalous LCA from the right sinus is associated with SCD during or shortly after exercise in young individuals. The hemodynamic mechanism underlying the risk of SCD remains unclear. Some authors hypothesize that distention of the aortic root and the pulmonary trunk during exercise or stress might exacerbate the preexisting angulation of the anomalous coronary artery, resulting in compression of the coronary artery lumen. In other cases the vessel might have an aberrant course within the aortic wall that favors compression of the coronary artery.
Similarly, origin of the RCA from the left aortic sinus with an interarterial course is associated with myocardial ischemia and SCD.
Interarterial
A benign variation of the RCA origin is represented by the _____origin. This variation has no hemodynamic significance but might result in a challenging cannulation.
High anterior
Anomalous pulmonary origin of any coronary artery (APOCA) is a very rare occurrence. If all three coronary arteries arise from the ___, prognosis is poor; patients with this anomaly usually die within the first month of life
PA
______________________, was reported for the first time in 1956 and represents the most common APOCA
AKA ____________________
Management - preferred treatment for APOCA is CABG or unroofing and re-implantation (with or without a patch).
A. Anomalous origin of the LCA from PA (ALCAPA)
B. Bland-White-Garland syndrome,
___________________ is the most common form of congenital coronary absence, with a rate of 0.41% to 0.67%.
Lack of an LMCA
In the absence of LMCA, the LAD and Cx arteries simply arise directly from the left sinus of Valsalva with separate origins. This anomaly is considered a benign condition and is an occasional finding during coronary angiography
_________________ is defined as the maldevelopment of at least one of the major epicardial arteries or its branches. One, two, or all three coronary territories can be involved. Hypoplastic coronary arteries usually have a small diameter and a shortened course. A luminal diameter of ________________ in a major epicardial vessel, with no nearby compensatory branches,
A. Hypoplasia of a coronary artery
B. less than 1.5 mm
CAF are abnormal direct communication between one or more coronary arteries with another major vessel or a chamber
Most common origin of CAF ________________
Most common drainage chamber of CAF ______________
Gold standard in the diagnosis ______________
A. RCA in 33% to 55%, the LAD in 35% to 49%, and the Cx in 17% to 18% of cases
B. Right ventricle (40%), right atrium (26%), PA (17%), coronary sinus (7%), and superior vena cava (1%) - LOW PRESSURE STRUCTURES
C. Coronary Angiography
______________ consists of a segment of an epicardial artery that descends into the myocardium for a variable distance
Epicardial artery involved? ____________
Typical finidngs on angio _____________
Treatment ___________ may be considered
A. Myocardial bridging
B. LAD
C. As it runs in the myocardium, during systole the arterial segment is constricted by the muscle fibers and appears as a narrowing on the angiogram. However, these segments are usually easily identifiable because the narrowing disappears during diastole
D. Beta Blockers
Coronary spasm is a ____________________ of a coronary artery caused by the constriction of the smooth muscle cells in the vessel wall
Causes:
Prinzmetal Angina - prolonged spasm with ECG changes
Provocative tests and give effects:
IV ergonovine maleate
IV acetylcholine
Hyperventilation
A. Dynamic reversible focal restriction or occlusion
B. Cigarette smoking, cocaine use, alcohol, intracoronary irradiation, and administration of catecholamines
C.
IV ergonovine maleate - focal spasm with chest pain
IV acetylecholine - in the presence of endothelial dysfunction, cells cannot produce NO in response to ACh, resulting in local vasoconstriction (vasodilator talaga siya)
Hyperventilation - spasm but less sensitive
Stenoses are defined as _____.
Minimal if the narrowing is visually < 50%,
Moderate between 50% and 70%,
Severe with diameter reduction > 70%
AHA/ACC Lesion Classification: Type A
Length < 10 mm
Discrete
Concentric readily accessible
< 45 degree angle
Smooth contour
Little or no calcification
Less than totally occluded
No ostial
No major side branch involvement
Absence of thrombus
AHA/ACC Lesion Classification: Type B
Length 10-20 mm
Eccentric
Moderate tortuosity pf proximal segment
45 to 90 degree angle
Irregular contour
Presence of any thrombus grade
Moderate or heavy calcification
Total occlusion < 3 months old
Ostial lesion
Bifurcation lesion requiring 2 guidewires
B1 if only 1 characteristic present
B2 if 2 or more characteristic present
AHA/ACC Lesion Classification: Type C
Length > 20 mm
Diffuse
Excessive tortuosity of proximal segment
> 90 degree angle
Total occlusion > 3 mo old and/or bridging collaterals inability to protect major side branches
Degenerated vein graft with friable lesions
Type A lesions have a procedural success rate of ______ and a low complication rate
Type B lesions have a _____ success rate with a 10% rate of complications
Type C lesions have only a _____ success rate and a 21% rate of complications
A. 92%
B. 72%
C. 61%
Identify TIMI Flow rate
Contrast reaches the distal vessel but at reduced rate of filling or clearing compared with other coronary arteries (partial perfusion)
A. Type 2
TIMI 0 Flow - No penetration of contrast beyond the stenosis (100% stenosis, occlusion)
TIMI 1 Flow - Penetration of contrast beyond the stenosis but no perfusion of the distal vessel (99% stenosis, subtotal occlusion)
TIMI 2 Flow - Contrast reaches the distal vessel but at reduced rate of filling or clearing compared with other coronary arteries (partial perfusion)
TIMI 3 Flow - Contrast reached the distal vessel and clear at the same rate as the other coronary arteries
TIMI Flow rate
TIMI 0 Flow - No penetration of contrast beyond the stenosis (100% stenosis, occlusion)
TIMI 1 Flow - Penetration of contrast beyond the stenosis but no perfusion of the distal vessel (99% stenosis, subtotal occlusion)
TIMI 2 Flow - Contrast reaches the distal vessel but at reduced rate of filling or clearing compared with other coronary arteries (partial perfusion)
TIMI 3 Flow - Contrast reached the distal vessel and clear at the same rate as the other coronary arteries
_____ blood vessels are anastomotic connections between two segments of the same artery or between different native coronary arteries. They function as natural bypasses and represent an alternative source of blood supply for a coronary territory
Collateral blood vessels
______________ is the growth of preexisting arterioles that transform into functional collateral arteries; promoted by the pressure gradient across the stenosis
______________ involves the de novo formation of vessels starting from primitive postcapillary venules
2 types: _______________
Classification/Grading of Collaterals: ________________
A. Arteriogenesis
B. Angiogenesis
C. Intracoronary and Intercoronary collaterals
D. Rentrop Grade
Grade 0 - no filling
Grade 1 - minor filling, no retrograde
Grade 2 - partial retrograde
Grade 3 - complete retrograde
0- No filling of collateral circulation
1- Minor filling of collateral vessels with no retrograde visualization of the epicardial vessel
2 - Partial retrograde opacification by the collateral vessels of the epicardial artery
3- Complete retrograde opacification by the collateral vessels of the epicardial vessel
Chronic total occlusion (CTO) is the complete or almost-complete blockage of a coronary artery for ____________
Scoring system ______________, has been developed to predict the probability of successful guidewire CTO crossing within 30 minutes
Predictors (5)
A. 30 or more days
B. JCTO score
C.
Previously failed lesion
Blunt stump type
Vessel bending
Presence of calcification
occlusion length of 20 mm or more
The gold standard for the evaluation of calcific lesions is _____.
CTCA
CAC score that describe as High risk of having at least one significant coronary stenosis (>90%). Significant risk of having a cardiovascular event within the next 10 years.
CAC > 400
0 - nonidentified
1- 10 - minimal
11 - 100 - mild
101 - 400 - moderate
>400 - extensive
As an alternative to CTCA, IVUS has been shown to have significantly higher sensitivity to detect coronary calcification than standard angiography, especially for milder calcifications. Presence of a calcific arc greater than ___ degrees by IVUS is considered a severe calcification.
180 degrees
Presence of a calcific arc greater than ____________ by IVUS is considered a severe calcification
A. 180 degrees
Myocardial blush score
Grade 0: No myocardial blush or contrast density
Grade 1: Minimal myocardial blush or contrast density
Grade 2: Moderate myocardial blush but less than that obtained from the ipsilateral non–infarct-related coronary artery
Grade 3: Normal myocardial blush or contrast density comparable to that obtained during angiography of a contralateral or ipsilateral non–infarct-related artery
Presence of thrombus is usually associated with _____ observed during ACSs.
Plaque rupture
However, patients with generalized prothrombotic states can develop thrombus in the absence of plaque rupture.
Rentrop Classification of Coronary Collateral
Grade 0: No filling of collateral circulation
Grade 1: Minor filling of collateral vessels with no retrograde visualization of the epicardial vessel
Grade 2: Partial retrograde opacification by the collateral vessels of the epicardial artery
Grade 3: Complete retrograde opacification by the collateral vessels of the epicardial vessel
Coronary Artery Calcium (CAC) score
0 - Nonidentified: Negative test: very low risk of having a cardiovascular event in the next 10 years (<5%).
1-10 - Minimal: Minimal atherosclerosis is present. Findings are consistent with a low risk of having a cardiovascular event in the next 10 years (<10%).
11-100 - Mild: Mild coronary atherosclerosis is present. Mild or minimal coronary stenosis is likely.
101-400 - Moderate: Moderate calcium is detected in the coronary arteries. There is a moderate risk of having a cardiovascular event within 10 years.
> 400 - Extensive: High risk of having at least one significant coronary stenosis (>90%). Significant risk of having a cardiovascular event within the next 10 years.
Identify TIMI flow grade for Thrombotic Lesions
_________ Images suggestive but not diagnostic for thrombus: reduced contrast density, haziness, and irregular lesion contour
_________ recent total occlusion, which can involve some collateralization but usually does not involve extensive collateralization and tends to have a “beak” shape and a hazy edge or appearance of distinct thrombus
Grade 0 - no cineangiographic characteristics of thrombus present
Grade 1 - images suggestive but not diagnostic for thrombus: reduced contrast density, haziness, and irregular lesion contour;
Grade 2 - small thrombus present that is onehalf or less the vessel diameter
Grade 3 - moderate-size thrombus present with greatest linear dimension more than onehalf the vessel diameter but less than two vessel diameters
Grade 4 - large thrombus present with a dimension that is two vessel diameters or greater
Grade 5 - recent total occlusion, which can involve some collateralization but usually does not involve extensive collateralization and tends to have a “beak” shape and a hazy edge or appearance of distinct thrombus
Grade 6 - CTO, which usually involves extensive collateralization, tends to have a distinct, blunt cutoff or edge and will generally clot to the nearest proximal side branch.
Bifurcation lesions are difficult to assess and treat because they may require intervention not only on the main vessel but also on the side branch as well.
Classification system for bifurcation lesions: ________________________
Identify 3 distinct segments
Medina Classification
Main artery in the segment proximal to the bifurcation
Main artery in the segment distal to the bifurcation
Side branch
0 - no significant CAD
1 - significant stenosis
Coronary artery dissection can be a life-threatening complication during PCI or a spontaneous event. Iatrogenic dissections can be caused by the _____.
Advancement of the guidewire into the coronary artery
or
Plaque fracture after intracoronary balloon inflation
Identify type of Coronary Dissection:
Presence of contrast outside the coronary lumen (“extraluminal cap”) with persistence of contrast after dye has cleared from the lumen
Types not requiring treatment: ____ and ____
Major dissections: ____ and _____ (associated with morbidity or mortality)
Management: ___________________
A.
Type A - Minor radiolucent areas within the coronary lumen during contrast injection with no persistence of the contrast after dye has cleared from the lumen
Type B - Dissections are parallel tract or double lumen separated by a radiolucent area during contrast injection with minimal or no persistence after dye clearance
Type C - Presence of contrast outside the coronary lumen (“extraluminal cap”) with persistence of contrast after dye has cleared from the lumen
Type D - Spiral (“barbershop pole”) luminal filling defects frequently with excessive contrast staining in the dissected false lumen
Type E - Dissection appears as new, persistent filling defects within the coronary lumen
Type F - Dissection that leads to total occlusion of the coronary lumen without distal antegrade flow
B. A, B
C. C, F
D. Stent deployment
Causes of SCAD
Steroid hormones
Within 2 weeks post partum (marked changes inhormones)
FMD (intramural hematomas, 86%)
_____ IVUS catheters include transducers emitting sound waves at frequencies of 20 to 60 MHz, which provide high penetration (5 to 10 mm) for accurate assessment of vessel size and plaque burden. However, the low resolution (70 to 200 μ; 100-μ micron axial resolution parallel to radius and 200-μ lateral resolution perpendicular to radius) of gray-scale IVUS results in imperfect plaque characterization
Contemporary IVUS
_____ IVUS (VH-IVUS) overcomes the drawback of gray-scale IVUS and allows detailed interpretation of plaque morphology in the different stages of phenotypic plaque evolution, namely, pathologic intimal thicken- ing, fibrotic plaque, thick- and thin-cap fibroatheroma, and fibrocalcific plaque.This also clearly demonstrates necrotic core, dense calcium, and areas of plaque rupture
Virtual histology IVUS
OCT provides better definition of the vascular endothelium and fibrous cap of atheromas
IVUS has ____________________________ that ensures a more detailed characterization of the atheroma core.
Higher vessel wall penetration
ACC/AHA recommends IVUS use for assessment of indeterminate lesions in the _____ coronary arteries to determine the need for revascularization.
IVUS is also recommended for _____.
LMCA (class IIa, level of evidence B)
Non-LMCA (IIb, B)
Optimization of stent implantation, particularly in the LMCA (IIa, B)
After PCI, IVUS is recommended for the investigation of stent failure to determine the mechanism of both _____.
In-stent restenosis (IIa, C)
Stent thrombosis (IIb, C)
A gap between the stent struts and the vessel wall indicates malapposition; the greater the distance between the stent strut and the vessel wall, the worse the malapposition. Stent _____ are correlated with long-term adverse outcomes, including stent thrombosis
Underexpansion and malapposition
ACC/AHA Class IIa recommendations in the use of IVUS for DIAGNOSIS:
IVUS is a reasonable option to assess angiographically indeterminant ___________ CAD
IVUS and coronary angiography are within reason 4 to 6 weeks and 1-year post cardiac transplantation to rule out donor CAD, detect rapidly progressive cardiac allograft vasculopathy, and provide prognostic information
IVUS is a reasonable option to determine the mechanism of ___________________
A. Left Main
B. Stent restenosis
ACC AHA Class IIB
IVUS may be reasonable in assessing non–left main coronary arteries possessing angiographically intermediate coronary stenoses (i.e., 50% to 70% diameter stenosis)
IVUS may be reasonable for the determination of the mechanism of stent thrombosis
ESC Class IIA
IVUS should be considered to assess the severity of unprotected left main lesions
IVUS should be considered to detect stent-related mechanical problems leading to restenosis
General criteria for significant obstructive dis- ease include minimum lumen area less than _____ mm2 in the LMCA or less than _____ mm2 in the proximal LAD and other major vessel
LMCA < 6 mm2
Proximal LAD and other major vessel < 4 mm2
Thin-cap fibroatheroma on VH-IVUS is diagnosed in the presence of a greater than ___-degree arc of necrotic core abutting the lumen in three consecutive slice
> 30 degree arc of necrotic core
ACC/AHA Class IIB recommendation in the use of IVUS for INTERVENTION:
IVUS may be considered for the guidance of coronary stent implantation, especially in cases of _______________________ stenting
Left main coronary artery (LMCA)
ESC Class IIA
IVUS or OCT should be considered in selected patients to optimize stent implantation
IVUS should be considered to optimize treatment of unprotected left main lesions
Identify the trial
IVUS was used in 39% of cases and was associated with longer stents, larger stent diameters, and higher inflation pressures in 74% of IVUS-guided cases.
ADAPT-DES Trial (Assessment of Dual Antiplatelet Therapy with Drug-Eluting Stents)
Identify the trial
Study that compared patients undergoing IVUS-guided versus non-IVUS-guided PCI. Both short- and long-term outcomes were significantly reduced with IVUS use.
consecutive, unselected patients treated with sirolimus-eluting stents (SES), 631 patients (42%) underwent IVUS-guided stenting, and 873 (58%) had only angiographic guidance; assessed 30-day, 1-year, and 2-year rates of death/myocardial infarction (MI), major adverse cardiac events (cardiac death, MI, or target vessel revascularization), and definite/probable stent thrombosis in 548 propensity-score matched patient pairs.
The MATRIX (Comprehensive Assessment of Sirolimus-Eluting Stents in Complex Lesions)
Patients in the IVUS group had significantly less death/MI at 30 days (1.5% vs. 4.6%, p < 0.01), 1 year (3.3% vs. 6.5%, p < 0.01), and 2 years (5.0% vs. 8.8%, p < 0.01). Patients in the IVUS group had significantly less major adverse cardiac events at 30 days (2.2% vs. 4.8%, p = 0.04) and numerically less major adverse cardiac events at 1 year (9.1% vs. 13.5%, p = 0.07) and 2 years (12.9% vs. 16.7%, p = 0.18). Rates of MI were significantly lower in the IVUS group at 30 days (1.5% vs. 4.0%, p < 0.01), 1 year (1.8% vs. 4.8%, p < 0.01), and 2 years (2.1% vs. 5.7%, p < 0.01).
Identify the trial
Randomized a total of 1448 all-comer patients u going PCI to IVUS-guided PCI or angiography-guided PCI. At 12-month follow-up, this study showed that IVUS-guided DES implantation was associated with reduction in target vessel failure
Intravascular Ultrasound Guided Drug Eluting Stents Implantation in “All-comers” Coronary Lesions (ULTIMATE) trial
The primary outcome, target vessel failure at 12 months (cardiac death, MI, or target vessel revascularization), occurred in 2.9% of the IVUS-guided PCI group compared with 5.4% of the angiography-guided PCI group (p = 0.019). Among those who met the criteria for optimal IVUS-guided PCI, there appeared to be enhanced benefit from the use of IVUS compared with angiography-guided PCI.
Identify the trial
The trial compared 1905 patients with left main disease to PCI with cobaltchromium everolimus-eluting stents versus CABG has shown an extensive use of intravascular imaging, pre- and post-stent implantation
EXCEL trial
The EXCEL trial showed that PCI with second-generation DES (Xience) is noninferior to CABG for clinical outcomes at 3 years following revascularization of unprotected left main lesions.
The results of this important trial indicate that PCI with second-generation DES (Xience) is noninferior to CABG for clinical and functional outcomes at 3 years following revascularization of unprotected left main lesions. As noted earlier, repeat revascularization rates were higher with PCI. Thrombosis (stent vs. graft) rates were lower with PCI than with CABG. As expected, adverse clinical events were not uniformly distributed from a temporal standpoint between the two arms. The hazard was highest with CABG in the first 30 days and clinical outcomes were actually better with PCI up to 30 days. However, this reversed between 30 days and 3 years, such that outcomes were inferior with PCI compared with CABG beyond this time frame. This was also noted out to 5 years. Further longer-term follow-up is awaited.
Identify the trial
700 patients presenting with ACS underwent three-vessel coronary angiography and IVUS after PCI. The study showed that nonculprit lesion–related MACE (composite of all-cause death, cardiac arrest, MI, or rehospitalization due to unstable or progressive angina) was associated with plaque burden of 70% or more, minimum lumen area of 4 mm 2 or less, and thin-cap fibroatheroma less than 65 μ.
At 3 years, MACE was equally related to culprit and nonculprit vessel lesions.
Use of intracoronary imaging may facilitate early detection and treatment of vulnerable plaque in nonculprit lesions and decrease long-term MACE.
Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study
The results of this pilot trial indicate that PCI of proximal non–flow-limiting stenosis with angiographic stenosis <70%, FFR/iFR negative, and plaque burden on IVUS ≥65% with Absorb BVS resulted in a larger MLA on IVUS follow-up, with no difference in clinical endpoints at 24 months. MACE rates were numerically lower with Absorb BVS PCI, while TV-MI rates were slightly higher.
The _____ Trial was a randomized clinical study on 57 patients under- going coronary angiography and NIRS-IVUS imaging.
Patients were randomized to angioplasty with or without a distal embolic protection device.
The results showed that lipid-rich plaques identified by NIRS are associated with higher rates of periprocedural MI. However,the use of a distal protection filter did not prevent myonecrosis after PCI at lipid-rich plaques.
Coronary Assessment by Near-infrared of Atherosclerotic Rupture-prone Yellow (CANARY)
OCT is based on a fiberoptic wire with a rotating lens that emits near-infrared light (approximately 1300 nm) and records the light reflected from the analyzed tissue. One of the most valuable properties of OCT is its high resolution, up to 10 μ for axial resolution and 20 μ for lateral resolution (i.e., superior to IVUS). Although resolution is high, tissue penetration ranges from _____ mm (i.e., inferior to IVUS).
1.0 to 3.5 mm
True or False
OCT can identify intimal thickening: an early stage of atherosclerosis that appears as a signal-rich, homogeneous, thin rim of tissue
True
True or False
OCT is able to characterize vessel remodeling due to its extended tissue penetration
False
Limited tissue penetration
OCT is not able to characterize vessel remodeling.
In IVUS, general criteria for significant obstructive d ease include minimum lumen area _______________ in the LMCA or _______________ in the proximal LAD and other major vessels.
A. less than 6 mm2
B. less than 4 mm2
Coronary dissection may be diagnosed on IVUS with documentation of ___________________, _________________, ________________
A. Tissue flap, true and false lumens, and intramural hematoma
Give high risk features in plaque morphology (3) detected in OCT
High-risk features of plaques, including a large lipid core, thin fibrous cap, and increased macrophage infiltration, can be detected by OCT.
OCT provides the possibility to distinguish between fibrotic, lipid-rich, and calcified lesions
Lipids are _____________ with diffuse borders
Fibrous tissue appears as a _________________________
Fibrocalcific or calcific tissue appear as __________, _________ regions with sharp borders
A. Signal-poor regions
B. Signal-rich homogenous region (!!!!!)
C. Well-delineated, signal poor
OCT is the only imaging technique that in vivo allows an accurate evaluation of the fibrous cap and macrophage content
____ fibrous cap, lower collagen density, thinner collagen fibers, or low number of _______________ are highly related to plaque rupture
A. Thin
B. SMCs
True or False
OCT may allow visualization of plaque’s macrophages that appear as a signal-rich punctate dots, distinct or confluent, which exceed the intensity of background speckle noise
OCT may differentiate red and white thrombus in ACS
True
In patients with stable CAD, OCT imaging is used for _____. For the identification of hemodynamically severe coronary stenosis, OCT was shown to have only moderate diagnostic efficiency, when using the gold standard FFR as a reference, and similar accuracy compared with IVUS.
Quantitative assessment of the lesion by measuring the minimal lumen area (MLA)
High-risk features of plaques, including a _____, can be detected by OCT
Large lipid core
Thin fibrous cap
Increased macrophage infiltration
First, OCT provides the possibility to distinguish between fibrotic, lipid-rich, and calcified lesions.
_____ are signal-poor regions with diffuse borders, while _____ appears as a signal-rich homogenous region, and _____ appear as well-delineated, signal- poor regions with sharp borders.
Lipids
Fibrous tissue
Fibrocalcific or calcific tissue
OCT is the only imaging technique that in vivo allows an accurate evaluation of the fibrous cap and macrophage content. Smooth muscle cells organized in a collagenous-proteoglycan matrix, with varying degrees of infiltration by macrophages and lymphocytes, compose the fibrous cap of the plaque.
_____ are highly related to plaque rupture.
Thin fibrous cap
Lower collagen density
Thinner collagen fibers
Low number of smooth muscle cells (SMCs)
In patients with ACS, OCT has not only high sensitivity to detect intraluminal thrombus but also the capability of discriminating between ______ thrombus.
Furthermore, OCT has higher sensitivity in detecting fibrous cap rupture and fibrous cap erosion compared with IVUS.
Red and white
In procedural planning for PCI, OCT is a valuable tool for assessing the _____ and especially for measuring _____.
Landing zone
Calcium thickness
Stent underexpansion, associated with _____ measured by OCT, was shown to be an independent predictor of device-oriented clinical endpoints, including cardiac death, target vessel–related MI, target lesion revascularization, and stent thrombosis.
Small minimal stent area
The presence of _____ detected by OCT was proposed as an independent predictor of late stent thrombosis in drug-eluting stents. In particular, for bioresorbable scaffolds, the rate of stent thrombosis seems to increase significantly in malapposition. Therefore, use of OCT is strongly recommended after deployment of such a stent
Uncovered stent struts
Stent edge dissection (SED) is another post-PCI complication that is detectable by OCT that has been shown to be associated with adverse clinical outcomes. However, the vast majority of SEDs diagnosed by OCT heal without further treatment, and additional stenting should be reserved for the presence of _____, as recently suggested.
Deployment of stent edges within the normal vessel wall and appropriate selection of stent diameter may help to avoid SED.
Intramural hematoma
Compared with SED, ______ is a less investigated post-PCI complication. Irregular tissue protrusion was shown to be associated with device-related clinical endpoints, which were primarily driven by target lesion revascularization. However, the further management of tissue protrusion detected by OCT is not yet clear.
Tissue protrusion
The prospective single-arm_____ study, including patients admitted for elective PCI, assessed the relevance of co-registration for a correct stent implantation.Without access to co-registered data, the segment of the target lesion indicated by OCT was left uncovered by the stent in approximately 70% of the stented population
DOCTOR (Does Optical Coherence Tomography Optimize Revascularization)
