This document discusses complications that can occur during percutaneous coronary intervention (PCI), specifically contrast-induced nephropathy and coronary perforation. It defines contrast-induced nephropathy as acute kidney injury occurring after administration of radiocontrast media. Coronary perforation is defined as extravasation of contrast or blood from the coronary artery during or after PCI. The document discusses risk factors, prevention, diagnosis and management of these complications.
rotablation is procedure used in complex pci with heavily calcified lesion for adequate expansion of stent.if used in indicated case and well aware of contraindication is necessary for achieving good results.
Based on the principle that the distal coronary pressure measured during vasodilation is directly proportional to maximum vasodilated perfusion.
FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow in the same artery if there were no stenosis.
FFR is simply calculated as a ratio of mean pressure distal to a stenosis (Pd) to the mean pressure proximal stenosis, that is the mean pressure in the aorta (Pa), during maximal hyperaemia.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Significant, defined as a greater than 50 percent narrowing, left main coronary artery disease is found in 4 to 6 percent of all patients who undergo coronary arteriography. When present, it is associated with multivessel coronary artery disease about 70 percent of the time
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
rotablation is procedure used in complex pci with heavily calcified lesion for adequate expansion of stent.if used in indicated case and well aware of contraindication is necessary for achieving good results.
Based on the principle that the distal coronary pressure measured during vasodilation is directly proportional to maximum vasodilated perfusion.
FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow in the same artery if there were no stenosis.
FFR is simply calculated as a ratio of mean pressure distal to a stenosis (Pd) to the mean pressure proximal stenosis, that is the mean pressure in the aorta (Pa), during maximal hyperaemia.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Significant, defined as a greater than 50 percent narrowing, left main coronary artery disease is found in 4 to 6 percent of all patients who undergo coronary arteriography. When present, it is associated with multivessel coronary artery disease about 70 percent of the time
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
Spontaneous coronary artery dissection (SCAD) is an infrequent and often missed diagnosis among patients presenting with acute coronary syndrome (ACS). Unfortunately, SCAD can result in significant morbidities such as myocardial ischemia and infarction, ventricular arrhythmias and sudden cardiac death. Lack of angiographic recognition from clinicians is a major factor of under-diagnosis. With the advent of new imaging modalities, particularly with intracoronary imaging, there has been improved diagnosis of SCAD. The aim of this paper is to review the epidemiology, etiology, presentation, diagnosis and management of SCAD.
SCAD is a rare, sometimes fatal, traumatic condition with approximately eighty percent of cases affecting women. The coronary artery can suddenly develop a tear, causing blood to flow between the layers which forces them apart, potentially causing a blockage of blood flow through the artery and a resulting heart attack. The condition may be related to female hormone levels, as it is often seen in post-partum women, or in women during or very near menstruation, but not always. It is not uncommon for SCAD to occur in people in good physical shape and with no known prior history of heart related illness. It is also not uncommon for SCAD to occur in people in their 20's, 30's, and 40's, as well as older.
This is a recreation of a presentation that I created in the early 2000s for a nursing inservice about femoral vascular access site complications. Post cardiac catheterization and post interventional radiology patients were a new patient population for these nurses.
What is a SCAD (spontaneous coronary artery dissection)?Laura Haywood-Cory
PPT presentation I created to educate people about how SCAD survivors use social media to support each other and organize. Katherine Leon had input on this as well, and the two of us presented a slightly different version of this in the WomenHeart "Champions Educating Champions" webinar series back in November of 2011.
Percutaneus coronary intervention in Non ST elevation myocardial infarctionRamachandra Barik
Unstable angina (UA), acute non-ST elevation myocardial infarction (NSTEMI), and acute ST elevation myocardial infarction (STEMI) are the three presentations of acute coronary syndromes (ACS). The first step in the management of patients with ACS is prompt recognition, since the beneficial effects of therapy are greatest when performed soon after hospital presentation. For patients presenting to the emergency department with chest pain suspicious for an ACS, the diagnosis of myocardial infarction can be confirmed by the electrocardiogram (ECG) and serum cardiac biomarker elevation; the history is relied upon heavily to make the diagnosis of unstable angina
Primary PCI with stenting immediately after coronary reperfusion salvage procedures jeopardizes myocardium, improves prognosis, and is the current standard of care for acute STEMI .
No-reflow is defined as an acute reduction in myocardial blood flow despite a patent epicardial coronary artery .
The pathophysiology of no-reflow involves microvascular obstruction secondary to distal embolization of clot, microvascular spasm, and thrombosis .
No-reflow occurs in ~10% of cases of primary PCI and is associated with patient characteristics such as advanced age and delayed presentation and coronary characteristics such as a completely occluded culprit artery and heavy thrombus burden .
When to dialyse a patient and with what modality of dialysis will be topic of discussion.The recent advances and debates surrounding the topic will be discussed in detail
Disseminated intravascular coagulation (DIC) is a condition in which blood clots form throughout the body, blocking small blood vessels. Symptoms may include chest pain, shortness of breath, leg pain, problems speaking, or problems moving parts of the body.
Physician should have a high suspicion to diagnose patient with pulmonary Embolism, this slides will give you precise Diagnosis, Investigation and guideline directed Treatment.
A condition affecting the blood's ability to clot and stop bleeding.
In disseminated intravascular coagulation, abnormal clumps of thickened blood (clots) form inside blood vessels. These abnormal clots use up the blood's clotting factors, which can lead to massive bleeding in other places. Causes include inflammation, infection and cancer.
Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. I'm barely responsible for compilation of various resources per my interest. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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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
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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
2. There has been dramatic expansion in the use of
PCI to treat coronary artery disease in last three
decades
6 lac PCI procedures performed yearly in USA and
20 lac world wide
PCI expected to grow @ 5% yearly
Major contributors are advances in equipment
design and deliverability and development of
adjunctive pharmacological strategies
3. PCI is relatively a safe procedure in a well equipped
catheterization lab with a very low complication rate
Complication if occur are usually very serious
Knowledge of recognition and management of
complications vital for favorable outcome
7. Contrast induced nephropathy(CIN) Is a generally
reversible form of acute kidney injury(AKI) that
occurs soon after the administration of radio
contrast media.
After intravascular CM injection, immediate renal
toxicity may occur,and in most cases it remains
fortunately free of significant clinical consequences.
Sandler CM. Contrast-agent-induced acute renal dysfunction –is
iodixanolthe answer? N EnglJ Med. 2003;348(6):551–3.
13. A decreased incidence of contrast nephropathy
appears to be associated with nonionic agents,
which, are either low osmolal (500to850mosmol/kg)
or iso-osmolal (approximately290mosmol/kg).
Iodixanol, the only currently available iso-osmolal
nonionic contrast agent
(approximately290mosmol/kg), may be associated
with a lower risk of nephropathy than some low-
osmolal agents, particularly iohexol
14. To assess the cumulative risk of several variables on renal
function,a simple CIN risk score that could be readily applied
was developed.(MEHRAN RISK SCORE)
15. PREVENTION OF CIN
General consideration
Consider alternate Imaging studies not requiring
iodinated contrast medium.
The use of lower doses of low-or iso-osmolal non
ionic contrast agents and avoidance of repetitive
studies that are closely spaced
(within48to72hours).
Avoidance of volume depletion.
16. Concomitant nephrotoxic drugs such as NSAID and
nephrotoxic antibiotics, ACEI and diuretics should
be discontinued 48 hours prior to contrast
administration.
Metformin should be discontinued on the day of the
proposed CM administration and for the
subsequent 48hours.
17.
18. HYDRATION
Isotonic saline is superior to one-half isotonic saline
since isotonic saline is a more effective volume
expander.
In a study by Mueller et al, intravenous
administration of isotonic saline was found to be
superior, compared with half-isotonic saline, in
reducing the rates of CIN after percutaneous
coronary intervention (0.7%versus2%,respectively).
19. Hydration with Saline
IVF= 1 mL/kg/hr (MAX 100 ml/hr) 3 hours pre & 12
hours post contrast
CHF or left ventricular ejection fraction (LVEF) <
40% 0.5 ml/kg/hr(max 50 ml/hr) 3 hrs pre& post
contrast
Emergent procedure? (suggested regimen):
Fluid bolus of 3ml/Kg prior to procedure. Hydration
during procedure and/or 12 hrs after if possible
(dependent on clinical status)
20. Bicarbonate Dosing
IVF= 150 meqof sodium bicarbonate in 850 ml of
D5W 3 ml/kg bolus (MAX 300 ml) 1 hour prior to
procedure and 1 mL/kg/hour (MAX 100 ml/hr)
during and for 6 hours post-procedure.
Glycemic control issues (including patients with
diabetes) Consider mixing sodium bicarbonate in 1
liter of sterile water instead of D5W
22. Can be precipitated by
Local anesthetic
Contrast agent
Protamine sulfate
Local anesthetic:
In patients with previous reaction-
Use preservative free agents e.g., bupivicane,
mepivicaine
23. Contrast Allergy
Upto 1% of patients
Risk is highest in patients with prior history of reaction
Risk is also in patients with asthma, atopy, history of sea
food allergy (contain iodine)
Prevention
Risk reduced by premedication with steroids, H1 blocker
and H2 blocker
Use of non-ionic dye
Treatment
If anaphylactic reaction then use epinephrine 1:10,000
(1ml = 0.1mg) admistered I/V every minute until pulse
restored
I/V Fluids infused rapidly as overall fluid status warrents
Consider vasopressors if hypotension do not responds
I/V Hydrocortisone
If bradycardia consider Atropine
24. Protamine:
Occasionally in diabetic patients using NPH insulin
Rapid injection can also provoke back pain of unknown
etiology
Rarely used now a days
28. Coronary Perforation
Coronary artery perforation is defined as
evidence of extravasation of contrast medium
or blood from the coronary artery, during or
following percutaneous intervention.
29. Anatomically, perforation is categorized as –
• Proximal or mid vessel
Usually more profound with greater likelihood
of significant sequelae
• Distal vessel
There the aetiology is often the guide wire
(WIRE EXIT) and the clinical course is
frequently benign
30.
31.
32. Other classifications
Fukutomi
Type I: Epicardial staining without a contrast
extravasation
Type II: Epicardial staining with a visible jet of contrast
extravasation
Kini2
Type I: Myocardial staining without contrast
extravasation
Type II: Contrast extravasation into pericardium,
coronary sinus, or cardiac chambers
33. First data…
• Ellis and colleagues reported first large scale series derived
from data obtained from 11 centres, from 1990 and 1991.
• Of 12,900 procedures performed, 62 were complicated by
coronary perforation (0.5%). •
• They observed that the use of ‘new devices’ increased risk of
perforation
34. • Only 14 out of 62 perforations (23%) occurred
following POBA, others from debulking techniques.
• Complication rate –
POBA - 0.1%
Excimer laser - 1.9%
Rotational atherectomy - 1.3%
• Predesposing patient characteristics –
Female gender
Increasing age
35. • Over sizing of the angioplasty balloon was one of the
key causes for perforation.
• The development of cardiac temponade was
associated with appreciable mortality (20%)
particularly if it occurred in catheter laboratory as a
result of brisk extravasation (Type III)
36. Incidence and outcomes
• The incidence of Coronary Artery Perforation
(CAP) has not changed significantly over two
decades.
• It is reported between 0.2% and 0.9%.
37.
38. Sequelae of CAP
• Caused by CAP
Blood loss
Distal ischemia
Pericardial Temponade
Cardiogenic shock
Death
• Caused by management strategies
Myocardial Ischemia
Acute vessel occlusion
Myocardial infarction
Operative morbidity and mortality
Death
39. Diagnosis
• Not all perforations are immediately visible on coronary
angiography.
• Remarkable proportion of patients may develop temponade
more than 2 to 6 hours after procedure. •
• The clinical manifestation may be non-specific, and the
patient may simply develop progressive hypotension.
• A high index of suspicion should be maintained in order to
secure the correct diagnosis in a timely fashion.
40. Outcomes
• In various studies, outcomes depend largely upon the severity of
perforation.
• The outcome is worse if the temponade develops abruptly within the
catheter laboratory, rather than in the delayed fashion in the recovery
room or ICU.
• Outcomes also depend upon associated co-morbidities.
Chronic renal dysfunction
Pre-procedural impairment of LV function
Older patient
• Cavitary spilling type III perforation – may cause coronary steel in long
term
43. • A study1 of 38559 patients with 72 perforations reported that
more than 40% of perforations were seen in vessels of less
than 2.5mm diameter.
• The authors describe that the device-lumen mismatch is more
important than the vessel reference diameter.
• Other study2 of 8932 patients with 35 perforations showed
that balloon induced perforation was more likely where the
balloon to artery ratio was 1.3±0.3 compared with a ratio of
1.0±0.3 where no problem ensued.
1.Javaid A, Buch AN, Satler LF, et al. Management and
outcomes of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol 2006;98:911-4. 2.Ajluni S,
Glazier S, Blankenship L, et al: Perforations after percutaneous coronary interventions: clinical, angiographic, and therapeutic
observations. Catheter Cardiovasc Diagn 32:206– 212, 1994.
44. Use of GP IIb-IIIa inhibitors
• Studies comparing outcomes of CAP in patients with or
without use of GPI reported a modest adverse influence
where GPI were used.
• In a study* of 16,298 patients with 95 perforations, GPI
were used in 33 cases.
• When these 33 cases were compared with the other 62
cases (where GPI were not used), they found no difference
in
• Mortality and
• Myocardial Infarction
But, GPI use was associated with
• Higher incidence of temponade and
• Greater requirement of emergency surgery
*Fasseas P, Orford JL, Panetta CJ, et al. Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures. Am Heart J
2004;147:140-5.
45. GPI and perforations
• Great caution should be exercised if any perforation is
identified, even if seemingly trivial, where GPI is used.
• Abciximab binds irreversibly to platelet receptors, rendering
platelet activity almost negligible for 24 – 36 hours.
• In case of perforation with Abciximab, unlike the small
molecules Tirofiban and Eptifibatide, simply discontinuing the
infusion of Abciximab will not reverse its effect.
• Platelet transfusion may be required to restore bleeding time.
• The strategy should be case based, balancing the stoppage of
life threatening haemorrhage with the importance of
maintaining crucial revascularization in a given case.
46.
47. BIVALIRUDIN
• This study compared the consequences of CAP in patients who
underwent anticoagulation with bivalirudin to those in patients
who underwent anticoagulation with heparin at time of CP.
• From 33,613 procedures, 69 patients (0.2%) had CAP, Bivalirudin was
used in 41 patients, while Heparin in 28.
• The primary end point for this analysis was the composite of in-
hospital death, cardiac tamponade, or emergency cardiac surgery.
• The primary composite end point was similar between groups.
• However, there was a lower rate of cardiac surgery requirement in
BIV- treated patients.
• The study suggests that choice of procedural anticoagulant agent
does not influence outcome when CP occurs.
49. BIVALIRUDIN
• A pooled analysis of patients treated with PCI in three randomized trials
including REPLACE-2, ACUITY, and HORIZONS-AMI.
• Among a total of 12,921 patients, CAP occurred in 35 patients (0.27%).
• Baseline creatinine clearance was the only independent predictor of CA
perforation.
• Patients assigned to BIVALIRUDIN versus UFH plus a GPI had
• non significantly lower rates of death,
• similar rates of MI,
• significantly lower rates of TVR, and
• similar rates of the composite end-point of death/MI/TVR.
• In three PCI trials, treatment of patients experiencing CA perforation with
bivalirudin monotherapy was not associated with worse outcomes
compared to treatment with UFH plus GP IIb/IIIa inhibitors.
51. Atherectomy
• Use of either atherectomy or laser ablative technology is associated
with a higher incidence of perforation than in convention balloon and
stent PCI.
• However, the increased complication rate using these devices is strongly
influenced by the complexity of the coronary disease being treated.
• Ellis1 and colleagues reported that the incidence of perforation with
balloon angioplasty was 14 out of 9080 cases (0.1%), whereas that of
debulking techniques collectively was 48 out of 3820 cases (1.3%).
• Later reports suggested CAP rate of 0.4% for rotablation.
1.Ellis SG, Ajluni S, Arnold AZ, et al. Increased coronary perforation in the new device era: incidence, classification, management, and outcome. Circulation
1994;90:2725-30. 2.Gruberg L, Pinnow E, Flood R, et al. Incidence, management, and outcome of coronary artery perforation during percutaneous coronary
intervention. Am J Cardiol 2000;86:680-2, A8. 3.Fejka M, Dixon SR, Safian RD, et al. Diagnosis, management, and clinical outcome of cardiac tamponade complicating
percutaneous coronary intervention. Am J Cardiol 2002;90:1183-6.
52. Guide Wires
• Several authors have clearly pin-pointed the
hydrophilic wire as a more risky equipment for
perforation.
• Javaid et al1 found that 13 out of 15 wire associated
perforations had hydrophilic coating.
• Ramana el2 at found that the majority of 25
perforations were caused by guide wires and these
were usually hydrophilic and stiff.
• Witzke3 and group found that 51% of perforations were
wire mediated
1.Javaid A, Buch AN, Satler LF, et al. Management and outcomes of coronary artery perforation during percutaneous coronary intervention. Am J
Cardiol 2006;98:911-4. 2.Ramana RK, Arab D, Joyal D, et al. Coronary artery perforation during percutaneous coronary intervention: incidence and
outcomes in the new interventional era. J Invasive Cardiol 2005;17:603-5. 3.Witzke CF, Martin-Herrero F, Clarke SC, Pomerantzev E, Palacios IF. The
changing pattern of coronary perforation during percutaneous coronary intervention in the new device era. J Invasive Cardiol 2004;16:257- 301.
53. Guide Wires
• Wires are much less likely to cause a breach in the
proximal or mid vessel, but more likely to do so distally,
in the terminal sub branches.
• They are also less likely to cause frank rupture of the
vessel than a high pressure balloon barotrauma.
• Hence, the appearance of angiography is more subtle
when the wire is the culprit.
• Fasseas classified 86% of guide wire mediated ruptures
as Ellis type I or II on angiography.
Fasseas P, Orford JL, Panetta CJ, et al. Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of
16,298 procedures. Am Heart J 2004;147:140-5.
54. Guide Wires
• A proportion of such patients may go on to
develop pericardial temponade.
• In some instances this only becomes manifest late
(between 2-24 hours post procedure)
• One way to minimize distal trauma is to create
loop at the end of the wire, rendering it less likely
to inadvertently puncture the vessel wall.
• The adjunctive use of GPI may potentiate
prolonged bleeding from a seemingly minor
blemish in the vessel.
55. Chronic Total Occlusions
• In CTO intervention, there is always a high risk of coronary
perforation, and more so with the heavy weight, stiff tipped wire.
• If there is no balloon inflation where the wire is incorrectly
positioned, there is minimal extravasation of contrast and blood.
• Use of GPI should be withheld until the occlusion is safely crossed
and the operator is confident that the distal tip of the wire is seated
intraluminally.
• Shimony* and colleagues studied 9568 procedures and compared 57
patients having CAP with 171 patients who had no CAP and found
that CTO intervention is the strongest independent predictor of
CAP, followed by calcified lesions and NSTEMI.
*Shimony A, Zahger D, Van Straten M, et al. Incidence, risk factors, management and outcomes of coronary artery perforation
during percutaneous coronary intervention. Am J Cardiol 2009;104:1674-7.
57. • Most important step is to recognize and
identify presence of a perforation.
High index of suspicion
• Subtle signs:
Unusual migration of wire tip
dye staining
unexplained hypotension
58. Strategy
Strategy depends upon –
• Site of the perforation
• Severity of the insult
• Hemodynamic stability of patient
• Persistent bleeding
59. Supportive measures
• Intravenous fluids
• Oxygen
• Analgesia
• Inotropic support
• Atropine
• Intra aortic balloon counterpulsation
60. Type I perforations
It usually respond to conservative measures.
• In any case, indispensable measures are:
Fastidious post-procedural care
Cautious monitoring of hemodynamic parameters
At least one, and if required, serial echocardiographic
assessment.
Javaid A, Buch AN, Satler LF, et al. Management and outcomes of coronary artery perforation during percutaneous
coronary intervention. Am J Cardiol 2006;98:911-4.
61. Type II or III perforations
• Initial management is similar.
• First objective is to stop bleeding.
• Immediate step is to inflate a balloon at the site of
bleeding if it is in the mid or proximal vessel, and
more distally for a remotely situated wire
perforation to buy the time for further strategy
making.
• This prevents the development of temponade,
and favourably alters the outlook of the situation.
62. • In significant proportion of cases, prolonged
balloon dilatation is all that is required.
• Balloon inflation for upto 30 min is required.
• If the patient can not tolerate ischemia, then
perfusion balloon, if available may be helpful.
• Fukotomi reported excellent results using
perfusion balloon for Ellis type III rupture
Fukutomi T, Suzuki T, Popma JJ, et al. Early and late clinical outcomes following coronary perforation in patients undergoing percutaneous
coronary intervention. Circ J 2002;66:349– 356.
63. • A number of authors advocated deployment
of standard intracoronary stents to secure
perforation site.
• This may involve the deployment of a number
of layers of stent over the point of rupture
before it can be sealed off.
64. Anticoagulant therapy and platelet
inhibitors
Important question –
Whether dealing with the perforation signals the
end of the procedure or the operator wants to
continue the procedure after control of bleeding
is achieved.
• If the case is to be discontinued, reversal of the
heparin with protamine has been shown to be
effective alongside other measures.
• But this should be deferred till balloons and wires
are still in the artery.
65. GPI
• Intravenous GPI should be discontinued in
majority of cases where perforation is identified.
• Even seemingly trivial blush of extravasation may
progress to severe problems if these agents are
ongoing.
• Abciximab counteraction with fresh platelets
transfusion, as earlier discussed, should be
executed with precaution on case by case base
66. ACT
• There is no clear recommendation regarding
which level of the heparin anticoagulant effect
should be maintained after CAP.
• Because intervention devices remain in the
patient, the heparin effect should not be
completely reversed, and it might be acceptable
to maintain the ACT at 150–250 s.
• The ACT should be measured immediately after
CAP.
• Further treatment is dependent on the bleeding
level and hemodynamic status.
67. Cardiac Temponade
• Immediate Echocardiography, urgent drainage by
pericardiocentesis is must.
• Drainage not only alleviates hemodynamic problem, but
also allows for an active evaluation of the rate of
ongoing bleeding from the perforation site.
• Sometimes, accumulation of very small amount of
pericardial blood may result in profound hemodynamic
suppression or cardiac arrest.
• Deploying a drain in such situation is very difficult.
• At least a clear rim of fluid should be visible on
echocardiography before putting a drain, otherwise
there is a risk of puncturing RV free wall.
69. Pericardiocentesis
• Once the space is completely dry, the volume
which is further accumulated should be
counted every minute to know the success of
local treatment at perforation site.
• If there is no resolution of bleeding at 30
minute, further action is required.
• This may include Surgery.
• Pericardial temponade in this situation carries
mortality of 20-50%.
70. Covered Stents
• Frank rupture of proximal or mid coronary
artery often constitute a tear in the vessel,
upto 5 mm in length.
• Deploying a covered stent isolates the point of
haemorrhage from the circulation.
• The most widely used device is PTFE covered
stent.
• Sandwich design
• Inflexible, difficult to deliver in certain areas
71. Covered Stents
• Briguori1 and colleagues reported 11 cases treated in this fashion
and compared them with other 17 cases treated with BMS.
• In both groups, balloon temponade and reversal of anticoagulation
failed.
• MACE rate was 18% in covered stent group compared to 88% in BMS
group.
• Stankovic2 reported reduction in MACE rate for TYPE III perforations
using PTFE covered stents but no benefit was gained in type II
perforations.
1.Briguori C, Nishida T, Anzuini A, Di Mario C, Grube E, Colombo A. Emergency polytetrafluoroethylene-covered stent implantation to treat coronary
ruptures. Circulation 2000;102:3028 –3031. 2. Stankovic G, Orlic D, Corvaja N, Airoldi F, Chieffo A, Spanos V, Montorfano M, Carlino M, Finci L,
Sangiorgi G, Colombo A. Incidence, predictors, in- hospital, and late outcomes of coronary artery perforations. Am J Cardiol 2004;93:213–216.
72. Covered Stents
• On the other side, Ly and colleagues achieved successful seal of the
perforation using PTFE in 71% of cases, but there was no statistically
significant reduction in the development of temponade, nor the
requirement of emergency surgery when it was compared to prolonged
balloon dilatation.
• Difficulty in delivery of this inflexible device is most troublesome in the
calcified, tortuous vessel which is usual substrate in the perforated vessel.
73. Covered Stents
• Additional late concern is of in-stent restenosis.
• Although poorly quantified, a small number of
patients undergoing angiographic follow-up showed
29% restenosis rate.
Briguori C, Nishida T, Anzuini A, Di Mario C, Grube E, Colombo A. Emergency polytetrafluoroethylene-covered stent implantation to
treat coronary ruptures. Circulation 2000;102:3028 –3031
74. Distal Perforation
• Covered stents are of no benefit.
• Most of them are caused by angioplasty guide
wire.
• Objective is to seal off the leaking branch.
• Little concern for ischemia to the small region
of myocardium supplied by it.
75. • If conventional measures fail, vessel may be
occluded by –
• Platinum microcoils (Trufill – Terumo)
• Injection of Thrombin
• Autologous clotted blood
• Subcutaneous adipose tissue
• Tris-Acryl gelatin microspheres
• Polyvinyl alcohol foam
76. Emergency Surgery
• Cases not responding to conventional
measures are sent for emergency surgery.
• These perforations are frank ruptures, and not
modest distal perforations.
• Ellis reports 63% of type III perforations had to
go for surgery, while very few of type I or type
II underwent surgery.
77. Surgical outcomes
• The results are disappointing.
• The mortality of emergency surgery in reports
of both Fejka and Witzke was 50%.
So
why is an operation such a poor option for these
cases
78. Because….
These are cases with
• Other treatment options failed
• Ongoing bleeding
• Hemodynamic compromise
• On inotropic support
• Coagulopathy
• Myocardial infarction
• Deterioration of renal function
79. Other views
No surgery…
• Some operators send remarkably few patients for an operation, and their
overall mortality figures are impressively low.
• Fukutomi1 and colleagues reported 69 cases of CAP, 29 progressing to
temponade.
• The mortality was zero.
• Only two of the 69 underwent surgery.
• Therefore, conservative or percutaneous treatment options may be
successful in vast majority of patients too.
1.Fukutomi T, Suzuki T, Popma JJ, et al. Early and late clinical outcomes following coronary perforation in patients
undergoing percutaneous coronary intervention. Circ J 2002;66:349– 356.
80. Surgery
when….
• it is always sensible to keep surgical team
ready to take patient on operative table at any
moment.
• If the bleeding from pericardial tube is
persisting at a rate above 10mL per minute
despite all other action being taken,
mechanical and pharmacological, it is prudent
to call a surgeon.
83. Special measures
A case report of LAD CTO intervention complicated by
Type III perforation with Conquest pro wire over
Finecross Microcatheter.
• Immediate removal of wire and applying negative
pressure of 2-3 mmHg for 3-5 minutes through
microcatheter while preparing the fat emboli
sealed the perforation successfully. TCTAP C-031,
Case from Indonesia
84.
85. Dual guiding catheter technique
• Retrieving the balloon and inserting a covered
stent may require some time and it is possible
that the stent will not reach or cross the lesion.
• Hence, the perforation may be without sealing
for an unpredictably long period of time.
• Use of a dual guiding catheter approach reduces
the duration of uncontrolled hemorrhage through
the perforation.
86. Dual guiding catheter technique
• After placing a second guiding catheter and guide wire,
the covered stent can be advanced and placed
immediately proximal to the sealing balloon.
• In a rapid maneuver, the sealing balloon can be
retracted and the covered stent advanced and
implanted.
• If initial delivery of the covered stent fails, re-insertion
of the blocking balloon can be performed quickly which
provides time to consider options for a second attempt
(smaller covered stent, additional guide wire, upsizing
the guiding catheter, etc.).
89. Persistent Complete Occlusion
• Balloon inflated to completely occlude the
artery
• Usually not more than 20 min, max 30 min
• Good results WITH 60-70% SUCCESS RATE
• Drawback-Heparin can not be reversed with
protamine at the perforation place
90. Persistent Partial Occlusion
• Controlled Hypotension
MAP 55-65, in Hypertensives <30% of baseline
• Partial Occlusion causes stenosis of the vessel
with drop in pressure and TIMI flow distal to
occlusion casuing decreased rate of bleed and
facilitating sealing of perforation
• Short length, highly compliant balloon
inflation at the location of CAP
91. Intermittent Complete Occlusion
• An intermittent, nonfatal complete ischemic model is found to
improve tissue tolerability to reperfusion injury after long-term
ischemia and to delay cell death.
• This is known to induce “ischemic preconditioning (IPC)”
• A 10 min ischemia/1 min reperfusion model is optimal. • If
necessary, this procedure can be repeated three or four times.
• Notably, IPC can attenuate ischemia reperfusion injury during cardiac
surgery, which is the ultimate method to treat CAP.
• However, this model may not be satisfactory for patients with
preexisting cardiac dysfunction.
• To avoid cardiac function deterioration, a shortened ischemic time or
prolonged reperfusion time (such as 5 min/5 min) model should be
an alternative in these patients.
93. Conclusion
• It is favourable that CAP remains a rare complication.
• High index of suspicion.
• Immediate diagnosis and localization of perforation
• Urgent and serial echocardiographic monitoring
• “Stop the bleeding” first
• Prolonged balloon dilatation always
• May need covered stent
• Quick Pericardiocentesis
• Worse outcomes if emergency surgery is warranted