Coronary shock wave lithotripsy balloon (IVL)
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This document discusses intravascular lithotripsy (IVL), a new technique for treating calcified coronary lesions. It provides an overview of IVL, including how it works using shockwaves to fracture calcium, the components of the system, and how to perform the procedure. The document outlines when IVL may be used compared to rotational atherectomy, such as for heavily calcified lesions, stent failure, or bifurcations. It presents examples of calcium fractures achieved with IVL and a practical algorithm for deciding between IVL and rotational atherectomy based on lesion characteristics.
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06 aimradial2016 thu2 MG Cohen Guiding catheters
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This document discusses guide catheter selection for transradial coronary procedures. It provides guidance on the most commonly used guide catheters for accessing the left and right coronary arteries from the radial approach. Specific catheter shapes like the Judkins left and extra backup are recommended for the left coronary while the Judkins right is suitable for the right coronary. Newer catheter technologies including hydrophilic sheathless catheters are also reviewed. The conclusion emphasizes that knowledge of guide catheter selection and engagement technique enables successful transradial PCI.Approach to cto
This document provides an overview of approaches to chronic total occlusion percutaneous coronary intervention (CTO PCI). It defines CTOs and discusses their prevalence. Key points include:
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This document discusses chronic total occlusion (CTO) of coronary arteries. It defines CTO and differentiates it from functional occlusions and pseudo-occlusions. The prevalence of CTO is estimated to be around 15% based on registry data. CTOs present technical challenges for percutaneous coronary intervention (PCI) due to factors like lesion length, calcification, and tortuosity. Proper preparation is important for CTO PCI, including adequate guide support and anticoagulation. Scoring systems can help predict the difficulty of crossing a CTO. Special guidewires and techniques may be needed depending on the lesion characteristics and collateral pathways.
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- Imaging like angiography, CT angiography, and IVUS help plan procedures by assessing lesion characteristics and collateral circulation.
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IVUS may not be clinically warranted in all interventions, and should be seen as an adjunct to angiography. IVUS provides information about vessel morphology, plaque topography, and therapeutic outcomes that is often either equivocal or unavailable in angiographic images.
There are 3 situations in which IVUS has the most clinical utility:
Small vessel stenting: Studies have shown that post-stent restenosis rates are higher in small vessels. This is particularly true for vessels with diameters of 3.0mm or less, wherein small increases in stent diameter have been shown to significantly decrease the rate of restenosis. A study by Moussa et al showed that, as measured by IVUS, the incidence of restenosis has an inverse relationship to the post-procedure in-stent lumen CSA1.
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Components and classification of coronary guide wire dr md toufiqur rahman ca...
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This document discusses rotablation, a technique for treating heavily calcified coronary lesions. It involves using a high-speed rotating burr to cut through calcium deposits. The burr ablates calcium into small particles that are carried away, allowing stent placement. Key points covered include:
- Rotablation differentially cuts calcium while sparing softer tissues
- Orthogonal friction from high-speed rotation allows passing the burr through tortuous segments
- It requires specialized equipment, guidewires, and catheters to position the burr and control its rotation
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IVUS may not be clinically warranted in all interventions, and should be seen as an adjunct to angiography. IVUS provides information about vessel morphology, plaque topography, and therapeutic outcomes that is often either equivocal or unavailable in angiographic images.
There are 3 situations in which IVUS has the most clinical utility:
Small vessel stenting: Studies have shown that post-stent restenosis rates are higher in small vessels. This is particularly true for vessels with diameters of 3.0mm or less, wherein small increases in stent diameter have been shown to significantly decrease the rate of restenosis. A study by Moussa et al showed that, as measured by IVUS, the incidence of restenosis has an inverse relationship to the post-procedure in-stent lumen CSA1.
In-Stent restenosis: In these cases, IVUS helps to determine whether the restenosis is due to inadequate stent deployment (underexpansion or incomplete apposition) due to intimal hyperplasia. IVUS will also help you select the proper device size for treatment of the stented area.
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The parallel wire technique is used to overcome difficulties in chronic total occlusion percutaneous coronary intervention. It involves leaving a wire in the subintimal space after initial entry to act as a marker while a second stiffer wire is used in an attempt to re-enter the true lumen distally. This technique has been shown to increase procedural success in CTO PCI by reducing fluoroscopy time and contrast use. Important considerations include ensuring the distal lumen is visible and using wires with different characteristics for the first and second wires.
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This document discusses techniques for recanalizing chronic total occlusions (CTOs). It defines a CTO and explains their etiology. Successful recanalization is associated with improved angina and reduced ischemia. Key steps include careful pre-procedure planning, selecting appropriate guidewires and microcatheters, and using techniques like parallel wiring or penetration when standard wiring fails. Expertise is important for high success rates. Proper wire shaping and handling can help avoid subintimal tracking.
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This document discusses rotablation, a technique for treating heavily calcified coronary lesions. It involves using a high-speed rotating burr to cut through calcium deposits. The burr ablates calcium into small particles that are carried away, allowing stent placement. Key points covered include:
- Rotablation differentially cuts calcium while sparing softer tissues
- Orthogonal friction from high-speed rotation allows passing the burr through tortuous segments
- It requires specialized equipment, guidewires, and catheters to position the burr and control its rotation
- Complications can include slow flow, perforation, or getting the burr lodged in the vessel
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This document discusses optical coherence tomography (OCT) in coronary artery disease. It provides an overview of OCT, including its history and clinical evidence. It then outlines how to perform an OCT study and presents an algorithmic approach to interpreting OCT images, including assessing plaque morphology, stent sizing and apposition. The document discusses several clinical applications of OCT, such as evaluating acute coronary syndrome, plaque vulnerability, and stent failure. It also reviews limitations and future directions of OCT, including hybrid OCT/IVUS catheters and the use of artificial intelligence.
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Guide catheters are essential for coronary interventions as they deliver hardware into the arteries. The document discusses the properties and types of guide catheters, highlighting how their structure provides support and torque control. It describes commonly used guide catheters like the Judkins, Amplatz and EBU catheters, noting what vessels each is best suited for. Specialty guide catheters for difficult anatomies are also reviewed. Proper guide selection and positioning are emphasized for coaxial engagement and optimal device delivery during interventions.
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How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
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This document discusses restenosis (renarrowing of arteries) after percutaneous coronary intervention (PCI) procedures like balloon angioplasty and stent placement. It notes that drug-eluting stents have significantly reduced restenosis rates compared to bare metal stents. However, in-stent restenosis remains a problem, occurring in approximately 5-7% of patients within 1-2 years after PCI. The document examines factors that can influence restenosis risk like patient characteristics, lesion characteristics, technical aspects of the procedure, and properties of the stents. It also discusses challenges in treating in-stent restenosis when it does occur.Rotablation - An overview
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ACC: Slides from ORBIT II
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Similar to Coronary shock wave lithotripsy balloon (IVL)
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Intravascular lithotripsy (ivl) for peripheral arterial disease
There are a number of observations that suggest IVL produces
compliance changes in the vessel wall:Effacement of calcified stenoses with lithotripsy at low pressure with no change in angioplasty balloon pressure •Changes in echotexture on Duplex Ultrasound•Changes in appearances on Optical Coherence Tomography
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This document describes techniques for enhancing bail-out re-entry during chronic total occlusion percutaneous coronary intervention (CTO PCI), including the straw technique and use of the Stingray re-entry system. The straw technique uses continuous aspiration through an over-the-wire balloon to remove blood from a subintimal hematoma and restore distal visualization. The Stingray system involves inflating a balloon subintimally to provide leverage for a guidewire to re-enter the true lumen. Several clinical cases demonstrate successful use of these techniques to complete CTO PCI procedures. Further technical advances are needed to improve re-entry success and reduce risks of complications.
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Andrzej Ochała - RCA CTO with rotablation
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T evar
in endo era. aortic is one of the industrial driven medical proedure & one of the most expensive. Its morbidity are quoet acceptable, but......... surgeon if the best deal behind this awsome techno
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1. The document discusses the basics of percutaneous coronary intervention (PCI) through the transradial approach. It covers the history, access routes, procedural steps, guide catheter selection, complications and tips for successful PCI.
2. Key points include that the radial approach has a narrow pathway but fewer complications compared to the femoral approach. Guide catheter size selection depends on the vessel diameter and intended devices. Wiring, balloon angioplasty, stenting and post-dilatation are the standard steps of PCI.
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This document discusses complications that can occur during percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). It provides information on recognizing, preventing, and managing various complications including perforations, dissections, radiation exposure, contrast-induced nephropathy, and trapped equipment. Specific techniques are outlined for dealing with complications involving the septal channels, donor arteries, and aortic root. The importance of being prepared with the proper equipment and reversing anticoagulation at the right time is emphasized.
A Tale of Two Lesions, CVI 2018
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The document provides an overview of canaloplasty, a non-penetrating glaucoma surgery technique. Canaloplasty aims to restore normal aqueous outflow by accessing and dilating Schlemm's canal using a microcatheter. This allows placement of a tensioning suture to maintain canal patency. Clinical studies show canaloplasty reduces intraocular pressure by 35-41% at 3 years with a low complication rate, providing an alternative to traditional glaucoma surgeries.
Vascular plugs
Vascular plugs are self-expanding devices made of nitinol wire mesh that can be used to close abnormal blood vessel connections or leaks without surgery. The main types discussed are the Amplatzer Vascular Plug (AVP) models, which come in various sizes and designs to occlude vessels of different sizes and flows. The document outlines the characteristics of the different AVP models and how they are delivered via a catheter to the target site under imaging guidance. Potential issues include residual flow, recanalization or device migration, but overall vascular plugs are effective and less invasive than traditional surgery or coil embolization for many vascular abnormalities.
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2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
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Coronary shock wave lithotripsy balloon (IVL)
- 1. The new kid on the block Intravascular Lithotripsy Ahmed Elborae, M.D, Ph.D, MRCP (UK), EAPCI certified Lecturer of Cardiology, Cairo University
- 2. Agenda • IVL concept • How to perform? • When? • Rota or IVL? • Practical algorithm
- 3. Rota unmet need… • Technically demanding • Extra procedural steps • Learning curve (20-30 cases)….. • Deep calcium ?
- 4. IVL concept • Same idea of renal stone ESWL therapy • EU approval 2017, FDA approval 2021 for coronary use • Make use of balloon system (Ultrasonic emitters) • Receive electric discharge from the generator > vaporizes the fluid inside > micro bubbles> High-speed sonic shock waves (equivalent to 50 atm) > Density proportional effect >intimal and medial Ca fractures Hennessey B, et al. Open Heart 2023;10:e002182.
- 5. IVL components (3) • Generator • Connecter cable (Therapy button) • IVL Rx catheter
- 6. IVL components (3) • Generator • Connecter cable (Therapy button) • IVL Rx catheter
- 7. IVL components (3) • Generator • Connecter cable (Therapy button) • IVL Rx catheter Covered by Sterile sleeve
- 8. IVL Rx catheter • Compatible with 6F guide • All 12 mm length • Available diameters (2.5-3.0-3.5-4.0 mm) • Use 1:1 sizing ratio
- 9. Agenda • IVL concept • How to perform? • When? • Rota or IVL? • Practical algorithm
- 10. Simple as this! If you can do balloon angioplasty You can do it !
- 12. No air!
- 13. (8 cycles, each cycle= 10 pulses, total = 80) Generator is programmed to stop for 10 seconds after each cycle Recommended cycles: At least 2 cycles/segment *New C2+ system provides 120 pulses
- 15. Agenda • IVL concept • How to perform? • When? • Rota or IVL? • Practical algorithm
- 16. When to use? Percutaneous interventional cardiovascular medicine – The PCR-EAPCI Textbook OCT score >3 IVUS score ≥ 2 Native heavily calcified lesion ? = Predictors of stent under-expansion
- 17. When to use? • Stent failure (Under-expanded stent in calcified vessel) > SMILE , CRUNCH registries (Procedural success 92%) • Avoid use in freshly implanted stents (Potential damage to the polymer) Percutaneous interventional cardiovascular medicine – The PCR-EAPCI Textbook
- 18. A 67-year-old female patient, CC III 360° ARC 40 mm Length
- 19. 3.5 x 12 mm shockwave C2 IVL balloon After 10 pulses After 20 pulses
- 21. Rota or IVL?
- 22. Rota Superficial Ca Diff. abrasions IVL +Deep Ca fractures
- 23. Calcified lesions are not the same… doi.org/10.3389/fcvm.2023.1133510
- 24. Eccentric calcification need more pulses ! Eccentric Vs. concentric calcification ? Less
- 25. IVL favored • Large vessels • Thick calcium >0.5 mm • Bifurcations (Keep wire) • Tortuosity & angulation Rota-ablation favored • Small vessel < 2.5 mm • Diffuse long lesions >50 mm • Nodular calcification • Balloon uncrossable & CTO
- 27. Shocktopics ! Disrupt CAD III : IVL-induced capture was noted in 41.1% (Mechanical energy) Did not result in sustained ventricular arrhythmias Especially in patients with low heart rate < 60 Bpm
- 28. Evidence behind
- 29. Rota-shock trial.Catheter Cardiovasc Interv. 2023;102:823–833. ROTA-shock trial IVL is non‐inferior to RA regarding MSA; with no significant differences in periprocedural myocardial damage
- 30. Rotatripsy concept ! • Balloon un-dilatable lesion after Rota > Lithotripsy • Balloon un-crossable extremely calcified (Superficial +deep) > Tunneling with Rota + cracking with lithotripsy J INVASIVE CARDIOL 2023;35(2):E70-E74. Epub 2023 January 6.
- 31. Agenda • IVL concept • How to perform? • When? • Rota or IVL? • Practical algorithm
- 32. Hennessey B, et al. Open Heart 2023;10:e002182. Practical algorithm If intracoronary imaging available
- 33. EAPCI consensus 2023.academic.oup.com/eurheartj/article/44/41/4340/7174174 Practical algorithm If no intracoronary imaging available
- 34. Thank you !