Peripheral Angioplasty / Endovascular Management of PVD - Principles
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This presentation covers the principles of peripheral angioplasty with and explanation of the TASC stratification and selection of appropriate management according to current guidelines. Endovascular management of peripheral vascular disease.
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The document discusses the history, anatomy, angiographic views, variations, and clinical relevance of coronary arteries. It provides a detailed overview of the typical anatomy and branches of the left main, left anterior descending, left circumflex, and right coronary arteries. It also describes common anatomical variations and anomalies seen in coronary arteries and their clinical implications. Angiographic classification methods for different coronary artery segments are presented.
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Intravascular Ultrasound (IVUS)
Intravascular ultrasound (IVUS) uses sound waves to visualize the inside of arteries. There are two types of IVUS systems - mechanical systems using a rotating internal cable and solid-state systems using externally mounted transducers. Both produce 360-degree images with a resolution of 100-150 μm. IVUS is used to assess plaque, vessel dimensions, stent deployment, and more. It produces cross-sectional images showing the lumen, layers of the artery wall, and plaque composition and size. Measurements include diameters, areas, plaque burden, and indices of eccentricity. IVUS helps identify vulnerable plaque and has diagnostic and interventional applications.
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The document discusses techniques for peripheral angiograms and potential complications. It covers operating room preparation including equipment such as needles, guide wires, sheaths, and catheters. Access site selection is discussed including the common femoral, popliteal, tibial, brachial, subclavian, and radial arteries. The angiogram procedure is outlined including artery puncture, sheath placement, guidewire insertion, catheter selection, contrast injection, and closure techniques such as manual compression or closure devices. Complications from the procedure are also mentioned.
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Ivus
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Left ventricular angiography is used to assess global and regional left ventricular function and anatomy. It involves inserting a catheter into the left ventricle and injecting contrast dye to visualize the ventricle on x-ray imaging. The procedure provides key information on mitral valve function, ventricular shape and wall motion abnormalities, and congenital defects like VSD. LV volumes and ejection fraction are calculated from the images to quantify function. Regional wall motion is graded and correlated to coronary artery territories. Characteristic appearances are seen in conditions like cardiomyopathy, mitral regurgitation, and septal defects. Potential complications include arrhythmias and endocardial injury.
Step by Step Rotational Athrectomy
Rotational atherectomy is described in detail including vascular access, wiring, burr selection, technique, complications and their management. Key steps include using the smallest burr possible, short ablation runs under 20 seconds, and avoiding sudden drops in rotational speed to minimize complications. Complications can include slow-flow/no-reflow, dissection, perforation and burr entrapment. Prevention focuses on optimal technique and treatment involves reversing anticoagulation, vasodilators, balloons, stents or surgery depending on the complication.
Coronary anatomy and angiographic views
The document discusses the history, anatomy, angiographic views, variations, and clinical relevance of coronary arteries. It provides a detailed overview of the typical anatomy and branches of the left main, left anterior descending, left circumflex, and right coronary arteries. It also describes common anatomical variations and anomalies seen in coronary arteries and their clinical implications. Angiographic classification methods for different coronary artery segments are presented.
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Basics of coronary angiography
Coronary angiography remains the gold standard for detecting coronary artery disease. The technique was first performed in 1958 and is used to visualize the coronary arteries and assess for stenosis. It can determine treatment options and prognosis. Complications are rare but include vascular injury and contrast reactions. Proper angiographic views are important for evaluating different coronary artery segments.
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Raja Lahiri provides an overview of coronary angiography. Key points include:
- Coronary angiography is the current gold standard for visualizing the coronary arteries through X-ray imaging with contrast injection.
- The history of coronary angiography began in the 1920s-1940s with early experiments in cerebral and cardiac catheterization.
- Modern techniques involve accessing arteries typically through the femoral or radial arteries to insert a catheter for contrast injection into the coronary arteries under X-ray imaging.
- Multiple angiographic views are needed to visualize different segments of the left and right coronary arteries. Coronary angiography is used to evaluate coronary artery disease, graft patency, and left ventricular function.
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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.
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This document provides information about percutaneous transvenous mitral commissurotomy (PTMC), a procedure used to treat mitral stenosis. It discusses the stages and severity of mitral stenosis, indications and contraindications for PTMC, assessment of valve morphology, the PTMC procedure technique, instruments used, balloon size selection, post-procedure evaluation, complications, follow-up care, and long-term prognosis. PTMC is performed to improve the opening of a stenosed mitral valve by splitting the fused commissures using a balloon catheter, and is an important therapeutic option for treating symptomatic mitral stenosis.
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The document discusses techniques for removing foreign bodies from the heart and blood vessels during cardiac catheterization procedures. It outlines the necessary equipment, including biplane fluoroscopy, long sheaths, wires, and various retrieval devices like snares, baskets, and forceps. While the latest tools and techniques allow expert interventional cardiologists to extract most objects, some large implanted devices may be too big to remove percutaneously and may require open heart surgery instead for safety. Consultation with a surgeon should be considered in difficult cases to prioritize patient well-being.
Distal protection device
Distal balloon occlusion devices and distal filter devices are the main types of embolic protection devices (EPDs) used during percutaneous coronary intervention (PCI). Distal balloon occlusion devices use a balloon to occlude blood flow distal to the lesion during PCI, while distal filter devices use a nitinol mesh filter to capture debris without interrupting blood flow. Major trials have shown the benefits of EPDs for saphenous vein graft interventions and for STEMI patients undergoing PCI. EPD selection depends on lesion location and vessel characteristics. EPDs are recommended for saphenous vein graft PCI but their routine use is not supported for native coronary artery PCI.
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Raja Lahiri provides an overview of coronary angiography. Key points include:
- Coronary angiography is the current gold standard for visualizing the coronary arteries through X-ray imaging with contrast injection.
- The history of coronary angiography began in the 1920s-1940s with early experiments in cerebral and cardiac catheterization.
- Modern techniques involve accessing arteries typically through the femoral or radial arteries to insert a catheter for contrast injection into the coronary arteries under X-ray imaging.
- Multiple angiographic views are needed to visualize different segments of the left and right coronary arteries. Coronary angiography is used to evaluate coronary artery disease, graft patency, and left ventricular function.
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This document discusses various factors that contribute to lesion complexity in coronary arteries, which can impact outcomes of percutaneous coronary intervention (PCI). It describes several scoring systems that classify lesions based on characteristics like vessel patency, morphology, length, location, calcification, and thrombus presence. Specific lesion features discussed in detail include ostial and angulated lesions, bifurcations, degenerated saphenous vein grafts, calcification, thrombus, total occlusions, and the coronary collateral circulation. Assessing these complexity factors can help identify risks for procedural complications and recurrent events.
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FFR(fractional flow reserve)
This document discusses fractional flow reserve (FFR), a technique used during coronary catheterization to measure pressure differences across a coronary stenosis and determine if it is causing myocardial ischemia. An FFR value below 0.75 is considered functionally significant while a value above 0.80 rules out ischemia. FFR is useful for evaluating single-vessel disease, left main stenosis, tandem lesions, diffuse disease, grafts, and ostial lesions. Limitations include inability to assess plaque morphology.
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The document defines no-reflow as inadequate myocardial perfusion through a coronary circulation segment without mechanical vessel obstruction. No-reflow occurs in 30% of patients after reperfusion for myocardial infarction and is associated with worse outcomes. It results from microvascular obstruction from distal embolization, ischemic injury, and reperfusion injury. Diagnosis involves assessing TIMI flow, myocardial blush grade, and imaging techniques. Prevention focuses on reducing embolization using thrombectomy or filters while treatment involves vasodilators like adenosine, verapamil, and glycoprotein IIb/IIIa inhibitors.
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Fraction flow reserve
Fractional flow reserve (FFR) is a technique that evaluates the hemodynamic significance of coronary artery stenoses. It is defined as the ratio of maximal flow achievable in the stenotic coronary artery to the maximal flow achievable if the artery was normal. An FFR value ≤ 0.80 is considered hemodynamically significant. Several clinical trials including DEFER and FAME have found that FFR-guided revascularization reduces major adverse cardiac events compared to angiography-guided procedures alone by helping to identify which intermediate lesions are functionally significant. Guidelines recommend using FFR to guide revascularization decisions, especially for intermediate lesions, multivessel disease, and acute coronary syndromes.
Guide catheters in coronary intervention
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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Basics of pci
Coronary heart disease is a major cause of mortality worldwide. Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is a non-surgical procedure used to treat blockages within the coronary arteries of the heart. During PCI, a catheter is inserted into an artery and guided to the site of blockage where a balloon is inflated to open the artery. Often a stent is placed to keep the artery open. PCI has become a common revascularization treatment for acute coronary syndromes and stable angina. While generally safe, complications from PCI occur in less than 2% of patients and include adverse reactions, acute myocardial infarction, bleeding, and death in less than 0.08% of patients.
A New Management For Hypogastric Flow Exclusion In Evar Using An Extension Of...
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OUR EXPERIENCE:A NEW MANAGEMENT FOR HYPOGASTRIC FLOW EXCLUSION USING AN EXTENSION OF THE SAC THROMBIZATION PROCEDURE
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(Vascular Surgery -ULSS 15 Alta Padovana)Infrapopliteal pad
This document discusses endovascular interventions for infrapopliteal peripheral vascular disease. Infrapopliteal disease is rising due to an aging population and increased rates of diabetes and kidney disease. Surgical and early endovascular interventions historically had high failure rates in this region. Endovascular procedures now provide an alternative to bypass surgery for treating critical limb ischemia in the infrapopliteal arteries, with the goal of establishing straight line blood flow to the foot. Success depends on factors like number of vessels opened, inflow status, and addressing more proximal disease first when needed. Complications can include access issues, vessel spasm or perforation, embolism, and contrast nephropathy.
Coronary Ostial stenting techniques:Current status
Ostial lesions, located within 3 mm of a vessel origin, pose unique challenges for percutaneous coronary intervention (PCI). Precise stent placement is required to avoid geographic miss and ensure optimal coverage of the lesion. Several techniques have been developed to aid accurate stent placement for ostial lesions, including aorto-free floating wire, stent pull-back, and Szabo/anchor wire methods. The use of these targeted approaches can reduce the risk of additional stenting and reintervention compared to conventional PCI for ostial lesions.
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Peripheral Angioplasty / Endovascular Management of PVD - Principles
- 1. PRINCIPLES OF ANGIOPLASTY Dr.Saurabh Joshi, MD, FNVIR www.mirainterventions.com
- 2. Charles Dotter : Father of Interventional Radiology. Performed first angioplasty using a system of serial dialators in 1964
- 3. Andreas Gruentzig : German Cardiologist. Invented the Angioplasty Balloon in 1977
- 4. SYMPTOMS OF PVD Rutherford Classification Of PVD Category / Grade Symptom Category 0 Assymptomatic Risk factor modification, Exercise, Cardiovascular Rehabilitation Category 1 Mild Claudication Category 2 Moderate Claudication Medications Category 3 Severe Claudication Category 4 Rest Pain Intervention Necessary Category 5 Minor Tissue Loss Category 6 Major Tissue Loss
- 5. MECHANISM OF ANGIOPLASTY • Rupture of plaque and fibers in the intima and media • Compression of plaque / thrombus • Compression of medial layers • Distribution of plaque / thrombus at inner surface of artery • Overstretching of artery
- 6. STEPS OF ANGIOPLASTY Insure the patient is on Dual Antiplatelets !! 1.Pretreatment angiography with localization of the arterial obstruction 2.Crossing the lesion with a guidewire or catheter with a flexible tip 3.Advancement of the treating catheter or instrument over the guidewire and confirming patency of runoff arteries 4.Exchange of the diagnostic catheter for the balloon catheter or stent
- 7. 5.Dilation of the stenosis with the angioplasty balloon, followed by deflation 6.Completion angiography followed by treatment of runoff vessels with different balloon catheters or stents 7.Exchange of catheter materials and occlusion of the arterial puncture site by manual compression or a closure device 8.Placement of a compression bandage above the puncture site, followed by patient monitoring for a minimum of 2 hours
- 8. TASC II CLASSIFICATION • Trans-Atlantic Inter-Society Consensus • TASC classification gives recommendations for the management of PVD secondary to atherosclerosis affecting the lower limbs.
- 9. TASC FOR AORTOILIAC DISEASE
- 13. TASC D Lesion
- 14. TASC FOR FEMORO-POPLITEAL DISEASE
- 16. TASC A LESION
- 17. TASC B Lesion
- 18. TASC C LESION
- 19. TASC FOR INFRAPOPLITEAL DISEASE
- 22. Angiography showed tight stenosis of tibio peroneal trunk and origins of peroneal and Posterior tibial arteries.
- 23. Angioplasty performed using dedicated Tibial balloon.
- 24. Post angioplasty angiogram showing good forward flow with no residual stenosis
- 25. • Thank You !