The document discusses definitions and etiology of in-stent restenosis as well as treatments for it. It defines angiographic, IVUS/OCT, and pathological definitions of restenosis. It also discusses the causes of in-stent restenosis including mechanical factors like underexpansion and biological factors like neointimal hyperplasia. The document then summarizes various treatment strategies for in-stent restenosis such as plain balloon angioplasty, atherectomy, brachytherapy, repeat stenting, and drug-coated balloons. It provides details on studies comparing the effectiveness of these different treatment methods.
Problem associated with drug eluting stentPRAVEEN GUPTA
This ppt will tell us about the problem which a cardiologist has to face after implantation of Drug eluting stent in a patient of coronary artery diseases. Although there are lots of problem but i am going to describe only three major problem.
Evolution and development, indications, advantages and challenges of drug coated balloons. Comparison of drug eluting stents with drug coated balloons. Types of Drug coated balloons. Revolutions in cardiology. Newer techniques in coronary angioplasty.
Problem associated with drug eluting stentPRAVEEN GUPTA
This ppt will tell us about the problem which a cardiologist has to face after implantation of Drug eluting stent in a patient of coronary artery diseases. Although there are lots of problem but i am going to describe only three major problem.
Evolution and development, indications, advantages and challenges of drug coated balloons. Comparison of drug eluting stents with drug coated balloons. Types of Drug coated balloons. Revolutions in cardiology. Newer techniques in coronary angioplasty.
InStent Resetenosis: An Algorithmic Approach to Diagnosis and TreatmentNAJEEB ULLAH SOFI
BMS were developed to mitigate elastic recoil and negative remodeling, but they remain prone to NIH. DES were developed to prevent NIH, and these devices (especially first-generation DES) can be accompanied by delayed reendothelialization, which has been associated with stent thrombosis.
Even in the contemporary era of percutaneous coronary intervention using drug-eluting stents, ISR remains a common problem, occurring in 5% to 20% of cases, depending on several patient and lesion characteristics.
The cumulative rates of DES failure have created a major clinical problem so that > 10% of all PCIs done in the United States are to treat ISR, and the number of ISR interventions appears to be increasing year over year
Coronary artery calcification (CAC) results in reduced vascular compliance, abnormal vasomotor responses, and impaired myocardial perfusion.
The presence of CAC is associated with worse outcomes in the general population and in patients undergoing revascularization
Two recognized types of CAC are
Atherosclerotic (Intimal)
Medial artery calcification
In this presentation, I talked about different ways to treat the blocked coronary artery and after that we discussed about the treatments of Infarcted site of heart.
S.Mohammad Zargar
Biomedical Engineering Student at University of Isfahan
Use of adjunct devices like cutting balloon, rotaablation, excimer laser,mechanical thrombectomy and EPD in complex PCI improve procedural success and reduce restenosis rate.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
InStent Resetenosis: An Algorithmic Approach to Diagnosis and TreatmentNAJEEB ULLAH SOFI
BMS were developed to mitigate elastic recoil and negative remodeling, but they remain prone to NIH. DES were developed to prevent NIH, and these devices (especially first-generation DES) can be accompanied by delayed reendothelialization, which has been associated with stent thrombosis.
Even in the contemporary era of percutaneous coronary intervention using drug-eluting stents, ISR remains a common problem, occurring in 5% to 20% of cases, depending on several patient and lesion characteristics.
The cumulative rates of DES failure have created a major clinical problem so that > 10% of all PCIs done in the United States are to treat ISR, and the number of ISR interventions appears to be increasing year over year
Coronary artery calcification (CAC) results in reduced vascular compliance, abnormal vasomotor responses, and impaired myocardial perfusion.
The presence of CAC is associated with worse outcomes in the general population and in patients undergoing revascularization
Two recognized types of CAC are
Atherosclerotic (Intimal)
Medial artery calcification
In this presentation, I talked about different ways to treat the blocked coronary artery and after that we discussed about the treatments of Infarcted site of heart.
S.Mohammad Zargar
Biomedical Engineering Student at University of Isfahan
Use of adjunct devices like cutting balloon, rotaablation, excimer laser,mechanical thrombectomy and EPD in complex PCI improve procedural success and reduce restenosis rate.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
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
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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3. Binary Angiographic Restenosis:
Re-narrowing of more than 50 % of the vessel diameter as determined by coronary
angiography.
IVUS/OCT Definition of Restenosis:
Re-narrowing of more than 75% of reference vessel area on cross section.
PATHOLOGICAL Definition of Restenosis:
Pathological vessel re-narrowing of more than 75% of vessel area in cross section.
CLINICAL Restenosis:
clinical restenosis is sometimes used to refer to restenosis of the treated lesion accompanied by
requirement for re-treatment, for example, due to symptoms or signs of ischemia.
4. DES caused a reduction of 35 – 70 % in stent restenosis observed with
BMS.
With DES rate of stent restenosis reported to be between 3 to 20 percent,
depending on:
› DES Type
› Duration of follow-up
› Complexity of the lesions
For first-generation DES (sirolimus or paclitaxel DES), the rate of
restenosis is between 13 and 16 percent at five years.
In a pooled analysis of multiple studies comparing everolimus-eluting with
zotarolimus-eluting stents, the rates of TVR at up to five years of follow-up
were 6.3 and 5.0 percent, respectively.
9. Features of DES Vs BMS Restenosis
Characteristic DES BMS
Imaging Features
Angiographic appearance Focal more common Diffuse more common
Time course of late luminal loss Out to 5 years Maximum by 6 – 8 months
OCT tissue characteristic Layered/Heterogenous
Homogenous high signal band
typical
Histopathological Features
Smooth Muscle Hypocellular Rich
Proteoglycal High Moderate
Peri-sturt fibrin/Inflamation Frequent Occasional
Time to edothelize Upto 48 mo. 3 – 6 mo.
Thrombus occasional occasional
Neoatherosclerosis Frequent, Accelerated Late , slow
10.
11. Focal: 10mm or less
Diffuse: >10mm
Importantly the pattern of restenosis at
presentation is a predictor of subsequent
outcome after re-intervention. In the
original study target lesion
revascularization rates were 19%, 35%,
50%, and 83% in groups I-IV, respectively
(p < 0.001).
12.
13.
14. Majority of ISR present with progressive
worsening angina.
Majority of BMS-ISR present within 3 – 6
months of stent implantation.
Majority of DES-ISR present around 6 – 12
months.
3 – 20 % of ISR present as acute MI.
15. Routine angiographic assessment for restenosis is not
recommended due to
› Increase morbidity and mortality.
› Asymptomatic pts. With non-functional angiographic
restenosis have a benign course.
› So called occulo-stenotic reflex leads to increase
revascularization rates with no clear benefit.
Non-invasive assessment of restenosis (Symptoms/Non
invasive testing) seems an appropriate approach.
16.
17.
18.
19. Earliest approach.
Addresse two causes of stent restenosis
Neointimal hyperplasia (Reduses tissue volume)
Stent underexpansion(Dilates stent)
Baloon to vessel ratio is 1.1 : 1.0.
Balloon length is targeted to treat restenotic segment only.
Inflated at restenosis site @ Nominal pressure.
Under expansion is manifested as dog boning.
If dog boning, switch to non compliant baloon that facilitates high pressures
upto 25 atm.
Dilation resistant lesions: High prsessure balloons with inflation pressure upto
40 atm. High perforation risk.
20. Watermalon seeding
› Proximal or distal displacement of ballon from targeted segment.
Geographic Miss
› Inadvertant trauma to non targeted segment due to baloon slip.
Solution:
› Stepwise ballon inflation
› Sequential angioplasty starting with smaller balloon size.
› Use od buddy wire.
› Anti-slip cutting or scoring balloons.
Stand alone angioplasty is not TOC because
› Residual stenosis after procedure is high.
› Significant early lumen loss after 30-60 mins.
› Superior other techniques.
21. Atherectomy devices treat ISR by removing
rather than compressing tissue.
Two categories
› Remove and retrieve (Directional atherectomy)
› Disrupt and displace (Rotational/Laser atherectomy)
22. Plaque debulking using a metal burr studded with diamonds.
Rotated at a speed of 150000 to 200000 rpm.
Plaque pulverization produces micro particles of size 20 to 50 um that
can pass microcirculation.
Roster Trial: (Rotational atherectomy vs. balloon angioplasty)
› No evidence of increased acute luminal gain.
› Improved rates of repeated revascularization.
ARTIST Trial: (Rotational Atherectomy + Balloon angioplasty vs.
Balloon angioplasty)
› Higher rates of repeat revascularization.
23. XeCl based excimer laser ablation using ultra violet
spectrum wavelengths.
A randomized multicenter trial showed increased acute
luminal gain and improved revascularization rates.
Longterm results are similar to rotational atherectomy in a
registry analysis using IVUS for comparison.
This technique is also fallen out of use due to superior
techniques.
24. Plaque is removed from vessel by a cutting device mounted on a directional
balloon catheter.
Upon inflation plaque is incised into the windowed balloon housing and
removed with catheter.
Tissue is avaiable for histological analysis.
Small-scale registries showed encouraging results and a comparison against
rotational atherectomy suggested more potent and a lower incidence of
subsequent target lesion revascularization with directional atherectomy.
However, as with other debulking techniques, compelling randomized trial data
against standard therapy were not realized and the deviceis no longer in
widespread use, at least in the coronary arena.
25. Cutting balloons are comprised of standard balloon catheters
mounted with lateral metallic blades known as athertomes.
Scoring balloons have a broadly similar mechanistic basis to cutting
balloons. The main difference is that low profile nitinol wires (on the
order of 125 μm) in spiral formation are mounted on the surface of
the balloon catheter instead of blades.
As a result the deliverability and flexibility of the catheters are
increased, at the expense of a lesser degree of plaque incision.
26. There are two main advantages to their use:
› The incision of the blades into the stenotic plaque may favor
subsequent extrusion.
› The interaction of the blades with the plaque anchors the balloon in
the plaque and prevents “watermelon-seeding”; this in turn might
reduce problems related to geographic miss.
ISAR-DESIRE 4:
› In patients presenting with DES restenosis neointimal modification with
scoring balloon significantly improves the angiographic antirestenotic
efficacy of paclitaxel-coated balloon angioplasty.
27. An initial large registry of patients treated with ISR from Lenox Hill, New
York, compared outcomes of matched patients according to treatment with
cutting balloon, rotational atherectomy, stenting, or plain angioplasty.
Results suggested a clear edge for cutting balloon angioplasty in terms of
angiographic and clinical outcomes at follow-up.
RESCUT randomized trial:
› Although cutting balloons showed less procedural balloon slippage, no advantage in terms
of the primary endpoint of binary angiographic restenosis at 7-month angiographic follow-up
was seen.
28. Intra-coronary radiation therapy.
The therapy is applied at the time of mechenical treatment
of stenosed stent.
Radioactive material usually in the form of seeds is applied
to the stenosed segment in a specialized catheter and is
left to dwell there for 3-5 min and 30-45 minutes.
Beta or Gamma radiation both are effective.
29. Two main drawbacks
Specialized laboratory equipments with difficult
treatment protocols.
Impaired vascular healing after treatment.
Two important multicenter trials SIRS & TAXUS
V ISR showed superiority of DES treatment
over brachytherapy.
30. Used to treat ISR in past.
Disadvantage.
› Additional stent layer resulting Onion skin layering/ Luminal
crowding.
› Chronic inflammation due to stent results in luminal hyperplasia
offsetting acute initial gain in case of stent restenosis.
RIBS Trial (Balloon Angioplasty Vs. BMS)
› Acute initial gain was offset by late lumen loss.
31. ISAR DESIRE TRIAL: (SES/PES vs Baloon angioplasty)
› Both DES outperformed balloon angioplasty in primary
angiographic end point.
› Similar results were observed for repeat TLR.
RIBS II: (SES Vs. Balloon Angioplasty)
› SES outperformed balloon angioplasty in both angiographic and
clinical end point at 9 months.
SISR & TAXUS V ISR showed DES superiority over brachytherapy.
32. DES Angioplasty already has a 35 – 70 % reduction in ISR
compared with BMS implantation.
There are two major factors recognized in DES restenosis.
› Drug Hyporesponsivness.
› In-stent neoatherosclerosis.
Stent fracture/Underexpansion results in impaired drug delivery to
underlying endothelium resulting in ISR.
DES ISR can be treated with same DES or Switch DES.
33. Study from Milan: No differences in patients treated
with same DES versus switch strategy.
RIBS-III registry: showed better angiographic
outcomes and lower rates of clinical events in patients
with switch DES versus no-switch strategy.
Only randomized trial to examine this issue was ISAR-
DESIRE 2: no difference(DES vs. switch DES) in late
lumen loss at 6-8 months.
34. DCB catheters are comprised of standard angioplasty
balloons and a matrix coating that is applied to the surface
of balloon.
The Balloon coating is typically comprised of two
elements:
› A lipophilic active drug (paclitaxel).
› Spacer or excipient (increases the solubility of the drug and
facilitates transfer from the balloon to the vessel wall).
35. The lesion must first be dilated with a standard or
noncompliant balloon in order to extrude and compress
neointima and correct stent under expansion if present.
Only after achieving satisfactory initial results should DCB
angioplasty be done.
single 30- to 60-second balloon inflation.
Transfer of paclitaxel to the vessel wall results in effective
suppression of neointimal hyperplasia.
36. PACCOCATH-ISR: Reduced late loss at 6 months
compared to balloon angioplasty alone. 5 Yrs. Results
confirmed durability of efficacy.
PEPCAD-II: Late loss at 6 month was less with deb versus
DES angioplasty.
RIBS-IV: Acute luminal gain was more with DES but
clinical events and restenosis at 1 year was not different
from DEB strategy.
37. PEPCAD DES: DEB is superior to plain angioplasty.
ISAR DESIRE III:
› DCB was comparable to repeat stenting with PES at 6-8
months.
› DCB & PES were superior to plain balloon angioplasty.
It seems reasonable to conclude that by obviating the
need for repeat stent implantation, DCB angioplasty
may be the preferred treatment option for this
indication.