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Posts Tagged ‘coronary’

There are numerous complex grading for bifurcation lesions available.

The one proposed by Medina is simple and most useful.

In this grading three segments

  • Proximal main vessel
  • Distal main vessel
  • Branch vessel

Are given a code 0, and 1 if  lesion is present or absent .

This grading gives simple and fast method to label a bifurcatiuon lesion and to asssess the response to PCI. The only issue here is the individual  lesions are not graded , for example branch vessel ostium just involved about 20 % is not addressed . Further TIMI flow in these vessels may also be incorporated

How medina grading can be used to assess effectiveness of

angioplasty  ?

A patient with 1.1.1  after the treatment should revert back to 0.0.0.  if converted into 0.0.(.5) may indicate a residual side branch lesion  .5 shall indicate 50% residual lesion, .3 , 30% etc

 

What is the best management strategy for bifurcation lesions?

The topic has been discussed extensively for over a decade in various forums.

Though the lesions and intervention techniques  appear complex the basic concept is simple.

Following is the 8 point algorithm

1. Assess the bifurcation lesion accurately.

2. Apply the general rule and ask the first question whether PCI is neccessary at all ? if decided for PCI

3. Stent the main vessel.Protect the side branch.  

4. Dilate the side branch with a balloon.(KIss or through the struts) 

5. Very rarely,  if the side vessel is more significant and large  stent it and balloon the main vessel.

6. Use drug eluting stents with caution .

7. Resist the temptation of using two stents unless the situation demands and is absolutely required.

8. Never attempt to do bifurcation angioplasty during ACS as apart of primary angioplasty.( Unless you’re extremely competent, even then aim of primary PCI is to salvage myocarium quickly , not to provide TIMI 3 flow in non IRA vessel.)

Dr.S.Venkatesan.Madras medical college.Chennai.

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Thousands of dissections happen in cath labs  all over the world every day  very rarely it is painful . The answer is not clear. Both have rich vasa nervorum. Aortic dissection  involves media and smooth muscle . Coronary dissection may also be a  equally painful  , probably we are not recognising it ! or we attribute   all  chest pain in ACS  to ischemia .

Deep dissections into the smooth muscle should be painful.  Type c nerve fibers carry pain signals from heart

Answers welcome.

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How is LAD angina differnt from RCA angina ?

Can we localise the “Angina related artery ”  from the  the type of chest pain ?

Patients with stable  angia  many times have  multivessel CAD. There has been some correlation with radiation of anginal pain and the culprit artery.If the angina spreads to jaw or neck it is possibleit might indicate RCA(RIGHT coronary angina) but rarely it indicates LAD/LCX lesions. if the angina radiates to left shoulder it virtually ruels out a RCA disease

Source .Braunwald 1992 Edition

Dr.S.Venkatesan ., Madras medical college. Chennai.

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Coronary artery disease has a strong   predilection  to involve proximal segments.

But in a significant population it affects only the distal vascular bed ! What is the extent of this problem ?

This paper was presented in  the annual sessions of Cardiological society of India , Mumbai 2005

Down load presentation

distal-cad-csi-2005

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2b -3a antagonists have revolutinised ACS management .

But the irony is Reo pro is approved for use only  inside cath lab or on the way to cath lab ! when PCI is done . 

If PCI with stenting is planned,  then subsequently cancelled due to  minimal coronary lesion or spontaneous reperfusion  what will be the effect of Abxicimab on outcome ?

Message 1

Abxicimab (Reopro,Faximab)

Useful only if PCI and stenting is done.

Dont use it for regular managment of UA/NSTEMI

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