Archive for the ‘Tips and tricks in cath lab’ Category

Just roll over the virtual marker along the coronary lesion to get the underlying flow ratio. Blue is an absolute normal segment. Green is ok, orange and red slow-moving coronary traffic jam zones. it’s just like drawing a google map showing life traffic. No wire, no adenosine FFR comes inbuilt in every angio shot. Looks great Isn’t it? This is called QFR. Quantitative flow ratio derived from routine coronary angiograms. It can also guide us to find the optimal sites of both proximal and distal stent landing zone in the best physiological manner.

Which company makes this ?

Any studies done with QFR ?

FAVOR 2 study was reported in TCT. This modality is expected to evolve.

Final message

Whenever possible every anatomical lesion in the coronary should be substantiated by physiological parameter and possibly coronary Imaging to know plaque morphology and vulnerability. Though it is wishful thinking, still for all logistic reasons, most of the real world stenting will be based only on the blind anatomical luminogram.

At this point, please let me utter a non-academic hyperbole. Even a casual query to your beloved patients about their true symptoms and exercise capacity shall make these ultra-modern coronary physiology studies redundant in many. A well-performed and well-interpreted stress test is a good, objective, non-invasive indicator of coronary flow across lesions. It is wise to keep this as a basic clinical foundation in the evaluation of CAD, even as we continue to learn and forget half evolved modalities with rapid expiry dates like FFR, IFR, CT-FFR. QFR shows some promise though. Please watch for next in line coronary physiology – OFR, Optical flow ratio from OCT run through.


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I asked some of my experienced colleagues, how much time they inflate the balloon to deliver a stent? Most answers were spontaneous and unanimous “It’s hardly 10 seconds,  few said maybe up to 15s.

Can prolonged balloon inflation time reduce the need for post dilatation and prevent mal-apposition?

We know high-pressure Inflation( up to 20 atmospheres ) was a big revelation in the science of PTCA more than two decades ago. (Antonio Colombo JACC 1995  ) He proposed and proved high-pressure inflation eliminated the need for routine anticoagulation following stenting as approximation was better. He also pioneered the concept of dual antiplatelet therapy (DAPT) in the PCI arena.

Similarly, prolonged balloon Inflation  (30 to 60sec) could be another trendsetting tip to prevent malposition. It delivers more sustained pressure. Its believed the imparted centrifugal force and the inbuilt radial forces add up to the stent vessel wall Interface and prevent mal-apposition.

Is there a downside to high-pressure Inflation?

There must be few.  Potential new Ischemic events and arrhythmia. In calcium laden plaques( spur) risk of perforation may be enhanced.

Final message 

I don’t know why this concept never took off. Many of us still fear to inflate the stent balloon no longer than 10 to 20 seconds? Adhoc post dilatation with short NC balloon appears mandatory in areas of mal-apposition. Meanwhile, we also understand sustained (30-60s) high-pressure initial inflation could deliver the stent in a more synchronized and smooth fashion with a perfect metal/vessel wall interface. Further , prolonged balloon inflation times could make a routine (By the way who does routine ?)  IVUS/OCT redundant.

What do the experts say?  What does science say?  There is one meta-analysis that clearly says the advantage of long inflation time. This issue becomes much more relevant as it could avoid post dilatation which all of us know can be tricky. In fact, every balloon dilatation should be technically counted as another PTCA procedure and adds up to net total risk.


1.M. Saad, M. Bavineni, B. F. Uretsky, and S. Vallurupalli, “Improved stent expansion with prolonged compared with short balloon inflation: a meta-analysis,” Catheterization and Cardiovascular Interventions, vol. 92, pp. 873–880, 2018. View at Google Scholar 


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If human coronary artery is comparable to live wire , attempting  bifurcation (BFL) stenting is akin to tame a live snake .True BFL  (with Medina 1, 1, 1)  being the most complex of all .The fact is ,we have atleast a dozen strategies for BFL with varying loads of metal abutting the ostia ,side branch and carina.This  would essentially Imply we are still struggling with these lesions .

While current science tends to vouch PCI* for most  BFLs . . . wisdom  might whisper CABG !

Who should do complex PCI ?

Obviously,  not every interventional cardiologist can. Confidence is one thing , but , falling short of minimum standard of care is rampant in India. Newer Imaging tools, techniques are promising , unfortunately  still the gap between, knowledge , science and  reality continue to widen.

* Its true ,some expert Interventionists do a good job !

What is the simplest approach for Bifurcation lesions ?

Final message 

We have come a  long way in BFL. Still , some of the lesions can sting  like a snake ! I am sure, everyone of us would have lost sleep after a complex BFL PCI !( Praying the humble  heparin and DAPT to do the rescue act ! )

bifurcation lesions medina stenting srategies 002

How to escape this double headed threat ?

A meticulous assessment of  patient  &  lesion , mindfulness in choosing the hardware & Imaging , diligent usage of anticoagulants & DAPT and  . . . finally  willingness to listen to your own conscience ,  will ensure a gratifying result that includes abandoning the procedure !


For everything in Bifurcation Intervention

The ultimate source : Visit the in this link  European Bifurcation  Club

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It has become fashionable for many current generation cardiologists to stent the LAD   with proximal end  liberally extending into left main shaft  in Medina 0, 1, 0 or (1,1,1 )lesions involving distal left main often  jailing the LCX . This concept came into vogue as it helped bail  out few  hemo-dynamically  unstable patients with true left main bifurcation lesions during primary PCI .Of course , it’s potentially useful strategy in  emergency , if  extended into routine situations (like all stable proximal LAD/Bifurcation ) we are bound to create few problems.


Rapidly protecting the left main with a long single stent down into LAD is an easy way out for tackling distal left main /LAD combined lesions.  Conceptually it asks you to forget the LCX outright.(Coronary outrage for some to call LCX as  a side branch of left main ! ).Of course, one can reconstruct the LCX  ostium by other means or a second stent if required.

Final message

Conquering  left main disease  with a long stent right from its origin or mid shaft to  LAD (Some times  from Aortic ostium ! ) may be an  interventional pride for the cardiologist. But , in no way it  imply we have crossed the  final frontier in LM disease.In fact,  putting a left main coil is the  easiest task among all  PCI since there is little expertise required to cross the lesion .Maintaining its patency   medium  long run and thus beating the CABG  is  true achievement  ! Achieving  an acute patency  of left main and wheeling out the patient live from cath lab can not  be reason for permanent rejoice ! One should realise his life is at the mercy of DAPT and its pharmakinetics which we know can be unpredictable !

“Protecting the patient is more important than a protecting left main” 

Just because a technique is easy to accomplish it doesn’t confer the right to misuse it .The argument “my patient” is doing fine with this type of stenting  is not an appropriate way of justification.

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Radial coronary interventions has become a global norm .Even complex procedures are being accomplished with ease adding on to the patient comfort and low risk for access site complications.However !occasionally we need to have multiple access sites to know the detailed real time  contra lateral coronary  anatomy is desirable .This becomes  vital in the retrograde approach for CTO.

Want to  have a quick glimpse of  RCA flow while one is attempting LAD PCI without additional puncture ?

How about doing a contra-lateral  angiogram with the same guiding catheter and wire in-situ within the ipsilateral ostia ? Here is an Innovation.

Of course ,the same concept can be used in femoral angiogram as well.It could reduce procedural time, adds more  efficiency of the hardware system handling.  One can’t ignore the idea as well as the comment of the  author, who says the trick is only for an advanced Interventional cardiologist.


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