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Percutaneous intervention (PCI)

Overview

Purpose

  • Improve symptoms (e.g., angina, dyspnoea)

  • In setting of STEMI, minimises myocardial damage or avoids death by restoring perfusion.

Procedure

  • Guide catheter positioned at ostium of LCA or RCA.

  • Guide wire inserted passed lesion

  • Balloon is inflated to widen blocked areas where blood flow to the myocardium has been reduced/blocked.

  • Stent deployed to improve long term outcome.

  • Post deployment balloon inflations may be performed to ensure stent is appopriately deployed

Equipment

Guide catheters

Has all the capabilities of a diagnostic catheter with addional options of placing interventional equipment down (wires, stents, balloons, etc).

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Examples

  • LCA Catheters: EBU, JL/FL, ++++

  • RCA Catheters: JR/FR, ++++

Guide wires

Inserted into vessel with lesion (past lesion) to help secure artery for PCI

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Examples

  • Sion blue

  • BMW wire

  • ++++

Semi compliant/non compliant balloons

Balloons are used to pre dilate or post dilate a coronary artery.

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Balloons can be semi compliant or non compliant.

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Semi compliant balloons

  • Growth is more significant as pressure increases.

  • Balloons grow at areas of low resistance.

  • Higher incidence of edge dissection.

  • Typically used for POBA, pre-dilatation, ultratight lesions or bifurcations

  • Features: softer material, better trackability, sizing flexibility (volume growth)

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Non compliant balloons

  • Low and focal growth as pressure increases

  • Little changes in volume with increased pressure (more force on lesions)

  • Typically used for highly calcified lesions, post dilatation – securing stent struts

  • Features: stiffer, more durable, ideal for focused dilatation (volume control)

 

Examples

  • Trek

  • Emerge

  • ++++

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Stents

Wire mesh used to keep vesell open.

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Is deployed with it's own balloon.

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Stens can be bare-metal or drug eluting.

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Bare metal stents

  • Uncoated stent (1st type of stents). Lower cost

  • 1 month dual antiplatelets (high risk of bleeding)

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Drug eluting stents

  • Slowly releases a drug to help prevent proliferation (growth) of cells that can block the artery

  • Lower chance of in stent restenosis.

  • 6-12 months dual antiplatelets

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Examples

  • Xience

  • Promus

  • Integrity

  • ++++

Rotablator

Overview

  • Rotablator involves a rapidly rotating olive-shaped steel burr whose leading hemisphere is coated with microscopic diamond chips that is used to remove calcified plaque blocking in coronary arteries.

  • Contact of the burr with fibrocalcific plaque grinds calcified atheroma into particles small enough to pass through the distal myocardial capillary bed.

  • Used predominantly for the following lesions;

1. balloon undilatable or uncrossable lesions (especially calcification)
2. ostial lesions, particularly aorto-ostial stenosis,
3. bifurcation lesions
4. long lesions less than 25 mm, especially with calcification.

Equipment

  • Guide Catheter

  • Guide wire

  • Rotablator wire (floppy wire)

  • Burr (1.25/1.50/1.75/2.00/2.25/2.50 mm)

Procedure

  • When burr is passed into coronary artery pressure damps

  • Rotablator turned on when at lesion –multiple attempts may be performed. RPM of burr cycle and duration of each attempt is documented.

  • May see pressure ↓ or arrhythmias in response to rotablating

Chronic total occlusion (CTO)

Overview

  • A completely blocked (100%) coronary artery

  • Has been blocked for at least 3 months

  • Typically the blocked vessel is collateralised from another vessel (still may not provide sufficient blood flow however).

  • Typically quite difficult to cross lesion – success rates low

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Equipment/set up

  • Possibility of 2 transducers if colaterals are connected to a separate CA

  • Diagnostic catheter

  • Guide catheter(s)

  • Guide wires (often several)

  • Stent(s)

  • Compliant/Non compliant balloons

  • OTW balloons

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