PCI Flashcards
One yr Stent thrombosis rate with new generation DES
<1%
One yr restenosis rate with new generation DES
<5%
Rates of very late Stent thrombosis beyond 1 yr
0.1-0.2% per year
Rates of very late stent restenosis beyond one year
1-2% per year
Theoretical advantage of BRS (bio reabsorbable scaffold ) is
Restoring vessel physiology
Length of catheters, normal GW, PTCA wire, Balloon, microcatheter
100;145;190; 145; 150
3 types of newer stents
- Bioreabsorbable polymer DES
- Polymer free DES
- Bioreabsorbable DES or scaffolds
Stent thrombosis types
- Late-1 month to 12 months
- Early-Less than 1 month
- Very late- More than 12 months
ie 2nd month is Late
2nd Year is Very Late
SB occlusion is higher if the angle with main branch is less than
45 degrees
SB of —-size should be preserved
More than 2mm
Most frequently used bifurcation strategy
Provisional T stenting
Strategy for side branch <2.5 mm is
Balloon Angio if required to KIO- Keep it open
When to consider elective stenting of SB
Size 2.5 mm or more
Lesion more than 3 mm from ostia
Consider in these cases
The inner diameter of 6F,7F& 8F guides are
.07 inch, .08 inch and .09 inch respectively
ie one plus
2 stent technique can be done with —–guide
7F
One stent and a balloon can be accomadated in a 6 F.( monorail)
In bifurcation which branch to wire first
SB as it is usually the difficult one
The main technical concern in 2 stent bifurcation tech is
Preventing wire wrapping
Maneuver for removing Amplatz catheter
Push and Turn maneuver
NEVER pull back like a Judkins. Will dissect infr wall of Vessel
What is angle Theta in coronary intervention
Angle between the JL and opposite wall of Aorta .The inferior angle.
If angle Theta is 90 degree the Cos Theta is 0 So force of dislodgement is less. So greater the angle better the support.
That’s why in TRI JL3.5 gives better support than JL 4 . As angle Theta will be more
Tricks and Tips
Persistent thrombus in PCI. What to do
If wire is in lumen,
A. For large thrombus- Thromectomy using Angiojet device
B. For smaller and distal thrombus-Aspiration
If still thrombus…
C. Can give intracoronary rTPA 5mg ever 5 mts to a max dose of 50 mg ? some say 25 mg max
Then if coronary is clean Heparin infusion for 24 hrs and maintain ACT above 200
If coronary is not clean (thrombus or distal flow suboptimal)Intracoronary bolus of 2b3a followed by infusion for IV 12 hours
Preferred bifurcation tech when LMCA is short or in Emergency
V stenting
Coulette technique is indicated inLM when
LM/LCx angle is less than 60
Treatment of kink site stenosis of LIMA in CABG
Usually resolves spontaneously.
To treat only if ischemic sequelae
Order and site of putting grafts in CABG
RCA grafts -attached to Rt side of Aorta. So use LAO view
Left sided grafts- LAD, Diagonal, LCx in that order. LAD closest to Aortic valve. From ANTERIOR aspect of Aorta. So use RAO view
Diameter of normal adult LIMA
1.9-2.6 cm
While SVG is 3.1-8.5 cm
Gold standard for calcification lesions
Rotational atherectomy
Stent grafts may shorten upto____% on inflation
25%
Burr to artery ratio when rotablation done prior to stenting
0.6-0.7/1
Intermediary coronary stenosis means
B/w 40-80%
How to untwist a twisted guide
- If possible push it into a larger area like Aorta from a smaller branch
- Gently push an .035 wire through the twisted area
How to change a guide with wire across a lesion
- Extend the wire
- While injecting CONTRAST from a syringe; pull Guide out retaining PTCA wire.
Then insert the new guide through 0.035 wire keeping PTCA wire in position.
Then finally reinsert the Guide though a balloon catheter
D2B time in PPCI
Less than 90 mts
Further reduction may not result in better outcomes
Now D2B is not preferred. FMC -first medical contact (ie time at which someone makes the ECG diagnosis) is used 2017
The skin crease in thigh is distal to CFA bifurcation in ……..%
70%. .CFA bifurcation was on an average 6mm above skin crease.
Esp obese
Skin nick site for FA puncture flouroscopically
Inferior border of femoral head
Puncture at center of femoral head
Heparin dose in TRA Angio
50 units/kg
NTG and Diltiazem inTRA
N-100-200 mcg
D- 2-5 mg
Radial artery occlusion rate in TRA
5%
Higher rates with routine Doppler
Complications with ulnar access
Nerve injury more likely
Don’t do after failed ipsilateral radial attempt
Site of brachial access
2-3 cm above elbow crease
Medial aspect of cubital fossa
Femoral vein insertion site
2cm below Ing ligament, not the crease
Preferred arm Position in Subclavian access
Abducted
When RCA or LCA originates from the opposite Sinus the 4 routes taken are
- Septal - Most common
- Retroaortic
- Anterior
- Interarterial- Least common and most serious one
How to identify septal pathway of an anomalous course of coronary
RAO view
Fish hook picture
Because LM goes down to septum and then comes up in the epicardium
LCx then would curve backwards and form the eye with LCx as upper border
View for differentiating different anomalous coronary courses
RAO 30
Most dangerous course of anomalous LMCA is seen in CAG as
RAO 30
Dot in front of Aorta
Interarterial course
Dot behind Aorta is Retroaortic course- Benign
Other 2 are Septal and Anterior courses
Most common coronary anomaly
Is the variation in origin from Aorta
2nd common is LCx arising from RCA
In RAO view RCA looks like ……And in LAO view it looks like ……,
RAO- L shaped
LAO- C shaped
How to canulate a slightly anteriorly misplaced RCA
LAO view and JR as usual direct to Right side
Timing of sheath removal
Diagnostic- immediately
Interventions- 4-6 hours when ACT less than 170
Compression time required after sheath removal
3-4 mts compression/ 1 French
ie for 5 Fr: 3x 5 = 15 mts
Dr Suresh presentation
Which IJV is preferred
Right side
Thoracic duct on left
Left may be tortuous
Depth of IJV from surface
Only 1-1.5 cm
How to puncture Subclavian
Arm abducted
10-15 Trendelenburg
Shoulders mild retraction
Orators hands occurs in ……..artery puncture
Brachial Artery
Median nerve injury
Which is medial SFA or Deep FA
SFA is Medial.
SFAm
In leg which artery is medial most
Posterior tibial
Lateral most- Anterior tibial
Peroneal artery seen between these 2 vessels
First coronary angioplasty was in
1977 by Gruntzig
Arteria lusoria means
Rt Subclavian arises as 4th branch from desc Aorta after LSA.
Then it passes 80% posterior to esophagus 15% in b/w esophagus and trachea &5% antr to trachea And reaches Rt side.
Otherwise known as ARSA.Aberrant RSA
Lusoria is from Lusus naturae which means Sports of Nature ( ie congenital anomaly)
Rupturing balloon inside the lesion is called
Granedoplasty
WIfI classification is for
Lower extremity PAD-ESC2017
Wound
Ischemia
foot INFECTION
LAO view spine is towards
Left of screen
Right of screen- RAO
Centre- AP view
View for LMCA
Bifurcation- LAO Caudal
Mid- AP caudal
Ostium-AP caudal
RJM 2017
When catheter is kept in LMCA look for
Reflux and Ventriculaization
First branch of LCx
LA Circumflex
Upto —% of ACS is MINOCA
14%
ESC 2017
Coronary Ectasia definition
Dilatation of atleast 1.5 Times adjacent segment
Many times used interchangeably with Coronary Aneurysm
Markis classification: Type 1- Diffuse in 2 or more vessels
Type2- Diffuse in 1 and localized in 1
Type 3-Diffuse in 1
Type 4- Localized in 1
Causes of coronary ectasia
Atherosclerosis, Kawasaki, PAN, Scleroderma,Ehler Danlos ,
PEAKS
50% thought to be atherosclerosis related
30%congenital
Rest- inflammatory or connective tissue disease.
ANCA related vasculitis, Syphilitic aortitis
Use of nitrates in coronary ectasia
May exacerbate Coronary ischemia
If MPI shows defect more than……consider PCI
10%
Internet
First per cutaneous Coronary intervention was done by ……..in ……
Andreas Gruntzig 1977
The clock for STEMI PCI starts at
ECG diagnosis of STEMI-
defined as FMC - first Med contact
Door to Balloon is no longer useful-ESC 2017
Time delay to reperfusion has reduced from …..mts in 2012 to …..mts in 2017
ESC 2017
30 mts to 10 mts
Deferred stenting is
Opening the Artery and waiting for 48 hours to implant stent
Duration of DAPT in PCI in stable CAD
1-6 months depending on bleeding risk
ESC 2017
In ACS- 12 months. 6 If bleeding risk high
DAPT after CABG in stable CAD
Insufficient data to recommend
ESC 2017
Obesity paradox is
Elevated BMI-is a risk factor for CAD But Obese and Overweight pts have better outcomes after PCI compared to Normal wt pts
In 2013 of the 10 million patients who underwent Cath———% were underweight; ———% were obese
0.4%
20%(8% morbidly Obese)
Studies supporting complete revasc in STEMI
PRAMI, CvLPRIT.
ESC 2017
CABG vs PCI
No difference in Cardiovascular Mortality or MI
Revasc more with PCI
2017 SNTAX II Trial compared
450 pts with TVD with PCI with SYNTAX I pts who underwent PCI with first gen stents
Scoring system to predict risk of out of Hospital bleeding with DAPT after PCI
PRECISE -DAPT
Difference between SYNTAX score I &II
Unlike the Anatomical Syntax Score SYNTAX SCORE II uses both anatomical and clinical characteristics
Study which showed no significant difference between DES and BMS in SVG graft
2017 DIVA trial
Previous 4 studies: 3 showed DES superior-ISAR-DES; BASKET-SAVAGE; SOS
1 study: RRISC- higher events with DES
None of these were blinded, used 1st gen DES,And low use of emboli protection unlike the DIVA
The 2017 studies which showed that iFR( instantaneous wave free ratio) is a better alternative to FFR
2017 DEFINE- FLAIR
and
2017 SWEEDHEART trial
With I FR PTCA and ACE were loss
