1. Catheter Based Percutaneous Coronary Angiography “The Byrne Identity”
William O. Suddath, MD
Director, Interventional Cardiology Fellowship Program
Washington Hospital Center
Institute of Cardiac and Vascular Disease

2. Section 4: Plaque dynamics and stenosis
Atherosclerosis timeline
Content Points:
The degeneration of healthy endothelium via the pathogenesis of atherosclerosis occurs slowly over decades.27 It appears to begin with a subtle form of endothelial injury that alters function. Foam cells are the earliest sign of endothelial dysfunction. They are macrophages that contain Ox LDL-C and are most frequent in infants and children.
Foam cells may then infiltrate the vessel, progressing to a fatty streak. As the lesion progresses to an intermediate lesion, small pools of extracellular lipid form within the smooth muscle layers, disrupting the intimal lining of the vessel.
Progression to an advanced lesion occurs when the accumulated lipid, cells and other components of the plaque disrupt the artery wall. This lesion is termed an atheroma.
Once the plaque becomes fibrous, it is primed to rupture. This type of advanced lesion can be found from the fourth decade of life onward.
The endothelium itself appears to participate in some of this remodeling through secretion of specific compounds.5

3. Evolution of Percutaneous Coronary Intervention
FDA Approval-Cordis DES
CMS Approval DES
FDA Approval
Cook Stent-bail out
JJIS stent-elective
HFICA Approval
Stent
Brachytherapy
NHLBI-PTCA Reg #2
n=1802
1st PTCA
FDA Approval
-USCI
-ACS
HFICA Approval
NHLBI-PTCA Reg
n=3079
FDA Approval
ACS Multilink
Clinical Trials
-Dir Atherectomy
-Stent
-Rotablator
-Excimer Laser
BSC Approval
TAXUS

4. The Future Paradigm: Integrated Cardiovascular Care
Hybrid Cardiac Endovascular Operating Room CV
Surgery
Percutaneous
Intervention
Vanderbilt Hybrid Lab
Hybrid
Care
Medical
Therapy
Traditional paradigm
Future paradigm

5. The Hybrid OR: The embodiment of the hybrid way of thinking: we are all “interventional cardiologists”, with different tools
Vanderbilt Hybrid Lab
Intra-operative imaging
Combines the tools of the OR and cath lab to meet the needs of an increasingly complex patient population
John Byrne, M. D.

7. Guidewires: Guidewires are described by:
a) their length in centimeters
b) their diameter in inches
c) their tip confirmation
e.g. a commonly used guidewire is the 175 cm, to inch, J-tipped wire, available exchange length, 220 cm.

8. 150 cm 0.035” Straight “GLIDEWIRE” with 3 cm flexible tip.

9. Catheters:
Catheters vary from 50 to 125 cm in length. The 100 cm catheter is commonly used for LHC’s from the femoral artery approach.
The outer diameter of the catheter is specified using French units, where one French unit {F} = 0.33 mm, 6F is 1.98mm in diameter.
The inner diameter of the catheter is smaller than the outside diameter owing to the thickness of the catheter material.

10. Guides
Diameters 6F 7F 8F 9F
10F
Lengths
130cm
90cm
Sideholes
Soft tips
Variety of
Shapes, variable
Stiffness for backup
support

11. Judkins Left

12. Judkins Right

13. Pigtail Catheter

14. Available Catheters: IMA, IM “T”, IM “C”
Right and Left Coronary Bypass Catheters
Right IMA, 5.2F catheter
RCA, 3DRC
LCA, sizes and configurations, JL 4+/-.
Guides: Similar in configuration, but are
Stiffer, bulkier, range in size from 6-10F,
lengths are essentially of two types, Tip configuration is important to the CA ostium.

15. Contrast Agents
The necessary evil to angiography and PCI

16. CARE – Comparison with other prospective randomized trials
Low osmolal
(osmolality)
Iso-osmolal
Condition
Statistical result
Iohexol (844)
Iodixanol (290)
Coronary, CKD (SCr* 3.1), 35% DM
No difference1
Coronary, CKD (SCr 1.5), 100% DM
Iodixanol superior to iohexol2
Ioversol (792)
Coronary, CKD (SCr 2.0), 52% DM
No difference3
Iopamidol (796)
MDCT, CKD (SCr 1.6)
No difference4
Coronary, CKD (SCr 1.45), 41% DM
No difference5
Ioxaglate (600)
Coronary, CKD (SCr 1.34, 48% DM
Iodixanol superior to ioxaglate6
*SCr: serum creatinine (mg/dl)
1Chalmer and Jackson, BJR Barrett et al (IMPACT), Invest Rad 2006
2Aspelin et al (NEPHRIC), NEJM Solomon et al (CARE), TCT 2006
3Rudnick et al, (VALOR), ASN Jo et al (RECOVER), JACC 2006

17. Syringe and Manifold
Off Position
Contrast
Pressure
Flush

19. Insertion and Flushing of the Coronary Catheter
Advance the catheter over the guidewire stopping at level of the left mainstem bronchus to remove the guidewire.
Aspirate to minimize any catheter contamination with blood clots then attach the catheter to the manifold system and clear the system of blood.
Advance the catheter cautiously over the arch .
RISK: Avoid snagging the catheter tip on plaque that “may” be on the aorta or at the arch.

23. Views: Cranial views, RAO, AP, LAO for the LAD system.

24. Views: LCX is best visualized from the Caudal views, RAO, AP, LAO.

25. Views: RCA best visualized in the LAO straight, then cranial in the LAO, RAO.