1. MCV Campus
Ginger Edwards

2. George W. Vetrovec, MD DISCLOSURES Consulting Fees Honoraria
Gilead Sciences, Merck & Co., Inc., Abbott Vascular
Honoraria
Cordis, a Johnson & Johnson company, Eli Lilly and Company, Daiichi Sankyo, Inc., Gilead Sciences
Grants/Contracted Research
Corindus, Inc., Cordis, a Johnson & Johnson company, Merck & Co., Inc.

3. Percutaneous Coronary Intervention: Basic Techniques
George W. Vetrovec, MD.
VCU Pauley Heart Center
MCV Campus
Virginia Commonwealth University

4. PCI Basics Radiation Safety Angiography Contrast Volume
Anatomic risk assessment of procedure
Pharmacology
Equipment use
Stent Deployment
Follow-up Angiography
Compliance

5. Radiation Safety In PCI flouro accounts for more radiation than Cine
Never fluoro when not viewing
Multiple views
Shielding
One Step Rule

6. Coronary Angiography

7. Contrast Volume
Limit!

8. Coronary Intervention: Optimal Coronary Angiography
Goal is to adequately opacify coronary artery without streaming
Properly positioned catheter
Sufficiently large catheter lumen for necessary and available contrast injection (including the inside “equipment”)
Always insure “reflux” (defining ostium)

9. Optimal Coronary Injection Pattern
Dehmer & Popma: Cathsap III

10. Coronary Angiography for PCI
Get a Clear View of vessel and lesion anatomy including side branches.
Better yet, get two high quality orthogonal views.
If the wire is not going properly in your “best view” look in a second view.

11. Proximal Ramus Stenosis

12. Coronary Angiography
Lesion Classification: Coronary Angiographic Outcomes Predictors Based on AHA/ACC Grading System
Type A
Discrete
Concentric
Readily accessible
Smooth Contour
Little or no calcification
Non ostial
No major side branch involved
Absence of thrombus

13. Coronary Angiography
Lesion Classification: Coronary Angiographic Outcomes Predictors Based on AHA/ACC Grading System
Type B
Tubular
Eccentric
Moderate tortuosity
Moderately angulated (45 – 900)
Irregular contour
Moderate – heavy calcification
Total occlusion (< 3 months)
Ostial
Bifurcation lesion
Thrombus present
Note: B1 = characteristic only; B2 = 2 or more characteristics

14. Coronary Angiography
Lesion Classification: Coronary Angiographic Outcomes Predictors Based on AHA/ACC Grading System
Type C
Diffuse
Excessive Tortuosity
Extremely angulated
Total occlusion (> 3 months)
Inability to protect major side branch
Degenerated vein graft

15. Current Applicability of Lesion Classification
Mayo Clinic 2004 review of 5000 cases
In hospital MACE by lesion grade:
Type A 1.2%
Type B1 1.1%
Type B2 2.2%
Type C 4.9%
Singh: J Am Coll Cardiol 2004;44:357-61

16. Distal Blood Flow/Collateral Classification Based on TIMI Trial
Coronary Angiography
Distal Blood Flow/Collateral Classification Based on TIMI Trial
TIMI Grade Contrast Flow
0 (No perfusion) Antegrade flow to lesion; no flow beyond occlusion
1 (Penetration with Contrast passes beyond minimal perfusion) lesion but does not opacify distal vessel during cine run
2 (Partial perfusion) Contrast passes obstruction and fills distal vessel.However, rate of filling and/or washout slower than vessel segments outside lesion
3 (Complete perfusion) Contrast passes freely into distal at same visual rate as unaffected adjacent vessels

17. Adjunctive Pharmacology

18. “Necessary” Pharmacology
Aspirin
Clopidogrel/Prasugrel
Anti-ischemic Therapy
CHF Management if needed
STATINS

19. General Patient Management
Pharmacology helps stabilize patient
Procedure electively only after patient clinically and hemodynamically stable!

20. Basic Equipment Use

21. Role of Guide Catheters
Inject Contrast.
Deliver Coronary Devices.
Support Delivery of Devices/wires.
Measure Arterial Pressure

22. Guide Catheters Shapes – Never the same as diagnostics
Sizes – 6fr. To 9fr. The larger the shaft the greater the support. (Manufacturers have been unable to make Guides with internal diameters larger than the outer diameter!)
Types – Judkins, Amplatz, Multi-purpose, Xb
Side holes – Useful for RCA, Caution on Left Coronary (Limit coronary flow and injection)

23. Guide Catheters Shapes – Never the same as diagnostics
Sizes – 6fr. To 9fr. The larger the shaft the greater the support. (Manufacturers have been unable to make Guides with internal diameters larger than the outer diameter!)
Types – Judkins, Amplatz, Multi-purpose, Xb
Side holes – Useful for RCA, Caution on Left Coronary (Limit coronary flow and injection)

24. Selection of Guide Catheters
Inside diameter determines the ability to inject contrast once equipment in place.
Solutions: Upsize or completely remove balloon from catheter for final pictures. Use monorail balloon catheters.
7fr. or 8fr. Improves visibility and flexibility using simultaneous or kissing balloons or stents in branch disease. (Monorails reduce size Guide Catheter size required)

25. Left Judkins Sizes
Dehmer & Popma: Cathsap III

26. Left Judkins Manipulation
Dehmer & Popma: Cathsap III

27. Left Judkins Manipulation
Dehmer & Popma: Cathsap III

28. Right Judkins Sizing
Dehmer & Popma: Cathsap III

29. Right Judkins Manipulation
Dehmer & Popma: Cathsap III

30. Right Judkins Manipulation
Dehmer & Popma: Cathsap III

31. Left Amplatz Curve Sizes
Dehmer & Popma: Cathsap III

32. Amplatz Manipulation
Dehmer & Popma: Cathsap III

33. Catheter Pressure Measurement
Dehmer & Popma: Cathsap III

34. Characteristics of Guide Catheters vs. Diagnostics
Relatively larger lumen.
“Stiffer”
Consequence as can “kink” readily. Forward and backward motion as well as rotation often necessary to deliver torque without “kinking” catheter.
Tip Non Tapered.
Tip May be Soft or Radiopaque.

35. Guiding Catheters Judkins Amplatz Voda XB Multipurpose Williams Kimny
El Gamal
Arani
Radial Shapes

36. Guide Catheters Support: Left Coronary:
Amplatz, XB, L Judkins – Smaller curve allows one to “Amplatzise” left.
Right Coronary:
Amplatz

37. Guide Catheters
Removing Amplatz Guide from Left Coronary (to avoid Deep-Throating)
Advance and turn counter clockwise to have fall out into ventricle.
Removing from Right Coronary
Turn counter clockwise and withraw.

38. Guideswire Tip characteristics:
Shapes – All shapeable, but some retain shape better. The stiffer the tip the greater push to cross a lesion but the greater the risk of perforation.
Stiffness - Floppy, Intermediate, etc.
Shaft Characteristics:
Support – regular, extra support, etc. The greater the support the easier deliverability except in tortuous vessels where stiffness may create friction in the vessel.

39. Guide Wires
Shaping:
Usual – 30 – 60 degree Hockey Stick configuration.
Circumflex Marginal – “S” bend.
LAD (High Takeoff) Left Judkins configuration.

40. Guide wires
Pearls:
Teflon coated wires increase risk of perforation while they may improve cross ability. Therefore always change out as soon as across lesion to avoid perforation.
High support guide wires may not traverse extreme tortuosity – so may need to cross with low support wire and then exchange.
Wires with graded shaft stiffness transition improves wire passage through tortuosity.
Rotating wire as advanced with balloon/stent backup will improve guide wire steerability and advancement.

41. Stent Deployment

42. Stent Deployment Correct size. Correct Position. Complete apposition
Before Placing DES be sure no impending surgery

43. Drug Eluting Stent: Significance of Apposition

47. DES: Restenosis

48. Post Procedure Angiography

49. Coronary Dissection

50. Coronary Dissection

52. Think first: Use force Last

53. Compliance
Stent Selection
Follow up

54. Percutaneous Interventional Techniques: The Basics
Conclusions:
Careful planning and appropriate use of angiography, pharmacology, basic equipment and procedures techniques can significantly reduce time, radiation and contrast volume while optimizing outcome and maximizing patient safety.