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Posts Tagged ‘tips and tricks in cath lab’

Dear Cardiologist, why don’t you spare that extra minute in cath lab?

clock

Suddenly  . . .  a primitive ,  common sense based question is asked!  How many seconds are required to optimally dilate and deploy the coronary stent ?

This simple and elegant study from the prestigious CCI journal tries to answer.

cci journal ptca pci balooln inflation time

Highlights

  • 105 patients, 150 lesions , Three different stents were used
  • Cypher Select (55%)  , Xience V (30.%), Taxus Liberté (15.%)
  • Three  balloon inflation timing
  • 5, 15, 25 seconds
  • Complex lesion (B2) formed 26 %

balloon inflation time pci ptca

 

This paper concludes, duration of stent balloon inflation has a significant impact on stent expansion. Stent deployment for >25 sec is recommended.

It again keeps the vital answer to our guess! Can we inflate it for 60 seconds  ?

Final message

This seemingly simple paper conveys a strong message.

Time is every thing , . . . we have to be fast . . . where we need to  (Time is muscle)  and we have to be slow where we  need to*  

Reference

http://onlinelibrary.wiley.com/doi/10.1002/ccd.23343/abstract

Further questions ?

  1. Can post dilatation be as  efficacious   as that of  stent- balloon  dilatation ?
  2. In difficult lesions  , the sum of  “Pre  / Per / Post”  balloon dilatation  gives  us net inflation  time(NIT)  Does it  add any sense to our understanding of optimal stent deployment  ?

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The other day a patient developed acute left main occlusion within 20 minutes of a  what looked like a successful PCI. When the angiogram was analysed  there was a distinct possibility of left main dissection.

The common causes  for left main injury during PCI include

  1. The guide catheter can it self  injure the tender left main ostium  by  size mis-match
  2. The frequent adjustment of  guiding catheter to get a co -axial alignment caries a definite risk
  3. The guide catheter slipping and subsequent repositioning  with the guide wire precariously snaring the left main ostia is the single important cause for left main injury.

How to prevent left main injury ?

  • Optimal guide catheter size and shape is vital.
  • Smaller the size it is better .(6 F is ideal for most )
  • As for as possible minimal handling of guide catheter is adviced . (Hands always  on guiding catheter  approach  is to be discouraged )
  • Deeper  engagement of guide catheter  as far as  possible  without hemo-dynamic compromise.This will ensure  not only better support for guide wire and balloon ,  low chances for guide wire to injure the left main ostia
  • Tapering guiding catheters with  soft ends are ideal. ( Which are available I think !)
  • Finally  and most importantly keep  the PCI procedure as short as possible ,  come out quickly  . After all ,  we  play  the   dangerous    coronary  game  right  in the mouth of the mysterious   coronary  cave  ( of Alibaba ! ) called Left main !

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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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