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Archive for the ‘cath lab tips and tricks’ Category

Cullotte technique for bifurcation stenting . . . a best technique . . . under utilised

Posted in cath lab tips and tricks, tagged , on June 28, 2013| Leave a Comment »

culotte technique for bifurcation senting
Original article
Chevalier B, Glatt B, Royer T, Guyon P. Placement of coronary stents in bifur-

cation lesions by the ‘culotte’ technique.Am J Cardiol 1998;82:943 – 949

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Basic instincts in cath lab : It is too tempting to poke the non IRA . . . What shall I do ?

Posted in Cardiology -Interventional -PCI, cath lab tips and tricks, tagged , , , on May 19, 2013| Leave a Comment »

Multivessel PCI during acute STEMI is forbidden except in cardiogenic  shock . (or in some very unstable patients without cardiogenic shock)

The reason

  • During acute MI   hemodynamics  are precariously balanced.We do not know yet how  emergency multivessel plasty alters this .
  • Our  initial aim should be   confined to myocardial salvage in the IRA . Total myocardial revascularization is niether  the  priority nor its desirable.
  • The more  time  you spend  within the inflamed coronary artery , more its  hazardous.
  • Multiple stenting  is prone for thrombus   and  migration  into side branch .
  • Stent opposition is sub optimal in many thrombus infested lesions.

Still  . . .  in real world it is extremely difficult to curtail the urge to stent  all eligible lesion during primary PCI !

multivessel angioplasy during stemi

How to avoid it ? 

If the patient is poor or the insurance limit is low , the issue  of multi vessel stenting does not arise at all  !

Always  ignore  complex  non IRA lesions  during primary  PCI. Be happy if a non IRA has a bifurcation lesion !

Still , some lovely looking lesions in non IRA  would be  tempting  and inviting .  Indulge at your own risk !

* Please remember if  the proximal  LAD  has a non IRA lesion , it may be sensible to attempt  simultaneous revascularisation even if the patient is stable !

Other unrealistic advice

  • Keep the professional fee and other benefits   fixed whether  we do a single or multiple   vessel stenting (Realise  . . .  surgeons do not charge more for a  4  vessel by-pass graft  than a single  ! )
  • Keep the current AHA/ACC/ESC guidelines pasted right next to the fluroscopy monitor .
  • Ask your subordinates to repeatedly caution   you  about the possible  excesses and ask them to wave a red flag !
  • You may  empower the   senior staff nurse   with a veto power  to shut off the cath lab once IRA plasty is  completed and the patient  is stable.
  • In extreme  situations , keep a cath  marshal ready to manually evacuate  the primary operator  from cath lab !

Reference

multivessel angioplasty during stemi

ACC GUIDELINES FOR STEMI 2013

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Why don’t we have pre-formed RCA catheter ?

Posted in cath lab tips and tricks, Hardware techniques tips, tagged , , on April 30, 2013| Leave a Comment »

Interventional   cardiology has  grown leaps and bound in the last few decades  .We are able to clip the wings of mitral valve  without surgery when it prolapses

We  can deliver a huge aortic valve and fix it with wires .

But  . . . we have no proper  preformed   guiding catheter  that can  sit into RCA ostium directly   and snugly  for a long time to enable complex RCA angioplasties !

An now try this one .

 

Here is  a  pending patent for  a preformed RCA catheter

preformed rca catheter

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Bifurcation angle is what ?

Posted in Cardiology -Interventional -PCI, cardiology -Therapeutics, cardiology- coronary care, cath lab tips and tricks, tagged , , , , on April 7, 2013| Leave a Comment »

bifurcation angle

  • At any branch point three angles are possible .True bifurcation angle is formed between LAD and LCX .
  • The angle between LM and LAD or LM and LCX can also be important in specific situations ,especially when we encounter short left mains and Medina 1,1,0 lesions .
  • Major bifurcation angle can  occur in mid  segments  as well ,  between LAD / major Diagonal  , LCX and OM.
  • Logic would tell us the  left main  bifurcation  angle is relatively fixed by the anatomical AV and IV grooves. Still early course of LAD and LCX can be out of grooves.
  • Further ,the bifurcation angle is imparted some amount of dynamism by cardiac cycle . It can vary between 80 -120 degrees (LAD/LCX).
  • Most importantly various  angiographic views can alter the true angle (by illusion ) in dramatic fashion . RAO caudal view appear ideal to measure it. (LAO caudal make every bifurcation angle obtuse !)
  • Acute angled bifurcations are prone for stent related mechanical issues both during deployment and in the long term outcome . (When two stent technique is used) This is because ,  acute  angled bifurcations has a tendency to drift the carina , and  encroach  the lumen  which can create new  turbulence . Of course final kissing balloon is expected to reduce this hemodynamic side effect at least on paper !

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How to predict success in CTO : The Japanese CTO score sheet !

Posted in Cardiology -Interventional -PCI, Cardiology-Coronary artery disese, cath lab tips and tricks, cto chronic total occlusion, PCI PTCA Hardware, tagged , , on February 28, 2013| Leave a Comment »

Japanese are the pioneers in CTO reopening .(I understand they do less   CABG surgeries  for  religious reasons ) CTO is the ultimate test for cardiologist patience .  it may  take  hours to open up a CTO (or even to abandon it .)  Here is a  success prediction tool from Japan .

cto score success in chronic total occlusion

j cto score sheet

Source courtesy  : JACC: Cardiovascular Interventions Volume 4, Issue 2, February 2011

Reference

http://www.sciencedirect.com/science/article/pii/S193687981000912X

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CTO : The most important factor that determines the successful PCI ?

Posted in cardiology- coronary care, Cardiology-Coronary artery disese, cath lab tips and tricks, cto chronic total occlusion, Hardware techniques tips, tagged , , , , , , on February 27, 2013| Leave a Comment »

chronic total occlusion cto tips and tricks

Answer :

While each one of the above factor appears very much important  morphology of the lesion is the  clear winner  ( Which includes , the content of the lesion , hardness , micro channels , thickness of the proximal and distal caps, the length and   tortuosity   of the CTO     ( which is invisible ) the collateral status will ultimately determine the success)

It is becoming increasingly clear  cardiologist expertise is getting less and  less important .

Finally ,  it must  be told to our  younger generation of cardiologists , crossing a  CTO and deploying a stent  is not synonymous with success .It should result in long term sustained distal flow and make a significant impact on the patients symptoms (If at all any !) and survival.

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Innovation in Interventional cardiology : Catheter retrival of infective vegetation and mobile clots from cardiac valves and chambers !

Posted in Cardiology -Interventional -PCI, carotid interventions, cath lab tips and tricks, tagged on September 30, 2012| 1 Comment »

Intra cardiac foreign bodies are frequent occurrences  in clinical cardiology practice. The common ones  are intra chamber clots , vegetations  and rarely tumors. Some of these masses are very mobile are  precariously attached to the cardiac strutures  . It becomes a cardiac emergency as a major embolic event  is imminent .

While surgery  remains the  mainstay approach in such situations ,   now it seems possible to trap these mobile  masses with help of catheter and retrieval devices   safely.

The only  issue is , while retrieving  these masses   it  should not be let into the circulation and result in  embolisation  . For this we can develop a   porous net (Fishing net like ) that can be  blown in the distal  chamber or Aorta .

Devices can be structured in way  that a single catheter can be used with different  ports  to capture and  filter  and retrieve  the mass . (  vacuum  enabled suction catheters can be additional option  ) .The whole procedure can  be  accomplished with fluroscoy and fluroscopic guidance . Intra cardiac echocardiography might also contribute .

This innovation will    be  a great  value addition  to the  interventional  cardiology   armamentarium   ,would be   be appreciated by clinical  cardiologists . We in our tertiary  teaching hospital   have  felt  the need for a such a device quiet often  .Currently many patients land up  in  surgical tables  for the sole purpose of removing these clots and vegetations  .Similarly left atrial clots becomes  a contraindication for percutaneous   mitral  commissurotomy(PTMC)   . Such capture devices can be very useful.

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Tips and Tricks in cath lab : Cortical sense and Guidewire crossing !

Posted in cath lab tips and tricks, Hardware techniques tips, tagged , , , , , , on June 9, 2012| Leave a Comment »

Years ago ,  I  remember asking my professor during  a balloon mitral valvotomy workshop .

How  is that ,  you  are able to  puncture the  IAS  effortlessly and efficiently sir ?

Every thing is in the feel  Venkat ,  he used to say !

What  feel ?  I  used to wonder !

Now , I  realise the guide wires  and catheters are just an  extension of our hand and fingers.

When we   tackle  CTO lesions we should   be  able to feel  and differentiate the  capsule and dimple .

More sensitive hands (Brains)  can tell whether the guide wire  is poking the vessel wall or the lesion .

Of-course ,  now  we have sophisticated OCT, IVUS, and camera  tipped ( Is it really there ?)   guide wires to guide us.

Still ,  a cardiologist  who  is able to feel the  lesion intimately  . . .  would be  a clear  winner !

How to feel a lesion ? (Plaque palpation ,  Hitting the calcium  , Feeling  the  thrombus  !   Cuddling the  foramen ovale  etc )

Key word : Guide wire tactile sensitivity .We are familiar with   guide wire torque .Now , a new technology  that can transmit the feel of the target lesion  ,  to the hands  of  the operator  would be very much desirable .

Two point discrimination  and temporal cortex  plays a critical role here. Irrespective of  the hard ware  used   , how  the  brain  perceives  touch is going to determine whether you are going to cross  a difficult  lesion .

Can you electronically amplify tactile feeling like sound amplification ?

It may be possible in near future. But it has  other issues  like   hypersensitiveness

Can a physician with defective cortical sensory  system  face difficulty in catheter based  interventions ? 

I have observed at least  two  cardiologists with diabetes  , acknowledging  major  difficulty  to  feel the palque and  cross  the  lesion   (Due to autonomic  neuropathy ?) With many  cardiologists  rapidly aging  , the quest  for intervention  goes unabated   (Still  unwilling to quit !   )  one may  experience  cortical dementia  as a hurdle for  guide wire manipulation . These issues need  to be tested  in  real  world .

Final message

It  is   fascinating  ,  how the feel  of  coronary plaque  reaches  our brain . It is picked  by the tip of  guide wire , travels about 150cm , handing over the weak signals across the  gloved fingers ,  reaching all the way through cervical spinal cord and spino-thalamic tracts ,  brainstem  and finally to the  cortex.

There are  multitude of factors that determine   the success of   complex  angioplasties . I realised  suddenly , Intact  cortical sense  could  be an  important one,  among  them . Let us train our brain  centres for this specific sensation of cath lab hardware . After all ,  the brain is  maneuvering force in any cardaic intervention !

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