RESUMO
Dedicated coronary artery drug-eluting stents may be inadequate in coronary arteries >6 mm in diameter, due to the risk of stent undersizing if the stent is not fully expanded or to loss of radial strength or damage to the drug coating if the stent is expanded >6 mm. We present two patients with large coronary arteries who were successfully treated with biliary balloon expandable stents.
RESUMO
Invasive pressure measurements using hyperemic fractional flow reserve (FFR) and nonhyperemic pressure measurements (NHPR) are superior to angiography alone for assessment of 50-90% stenoses. FFR devices using piezoelectric and optical sensors achieve 94% concordance in FFR values; microcatheter designs have more lesion-crossing failures and less pressure drift compared with guidewire designs. Despite the similarity in statistical performance among FFR devices, interventional cardiologists may prefer to use NHPR to avoid the need for adenosine-related side effects, variations in vasodilator response, and limited application in patients with certain clinical and anatomic features.
Assuntos
Estenose Coronária , Reserva Fracionada de Fluxo Miocárdico , Angiografia Coronária , Reserva Fracionada de Fluxo Miocárdico/efeitos dos fármacos , Cabeça , Humanos , Índice de Gravidade de Doença , Tecnologia , Resultado do Tratamento , VasodilatadoresRESUMO
Fractional flow reserve derived by coronary computed tomography angiography (CTA; FFRCT) is an accurate noninvasive method for identifying coronary artery disease (CAD) and detecting hemodynamically significant stenosis. Although initially proposed as noninvasive tools to "rule out" significant CAD in low-risk patients, CTA and FFRCT are now utilized in higher-risk patients. Furthermore, new applications of CTA and FFRCT include a planning tool for percutaneous coronary intervention (PCI), which allows the cardiologist to assess lesion-specific ischemia, plan stent locations and sizes, and use virtual remodeling of the lumen (virtual stenting) to assess the functional impact of PCI. The purpose of this review is to discuss the principles of CTA and FFRCT acquisition, and their application for PCI planning, even before invasive angiography is performed.
Assuntos
Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Estenose Coronária/terapia , Vasos Coronários/diagnóstico por imagem , Reserva Fracionada de Fluxo Miocárdico , Hemodinâmica , Tomada de Decisão Clínica , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/terapia , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/fisiopatologia , Vasos Coronários/fisiopatologia , Humanos , Intervenção Coronária Percutânea , Valor Preditivo dos Testes , Índice de Gravidade de DoençaRESUMO
Optical coherence tomography (OCT) is rarely necessary to guide clinical decisions about the appropriateness of carotid revascularization. For carotid artery stenting (CAS), computed tomography angiography is the best imaging tool to assess arch, carotid, and lesion-specific anatomy, including vessel dimensions and calcification. OCT is a coherent strategy after CAS to assess ambiguous angiographic findings and to guide appropriate therapy for dissection, thrombosis, and plaque prolapse.
Assuntos
Artéria Carótida Primitiva , Tomografia de Coerência Óptica , Artérias Carótidas , Humanos , Placa Aterosclerótica , StentsRESUMO
The use of double layer (covered) stents during carotid artery stenting (CAS) appears to be safe; attenuation of plaque prolapse and distal embolization is reasonable but unproven. Double layer stents are commercially available in Europe but not in the United States; similar benefits might be obtained by implanting two self-expanding stents, to decrease the effective free cell area. Embolic protection devices (EPDs) are recommended in all CAS patients; the use of double layer stents does not eliminate the need for EPDs.
Assuntos
Angioplastia , Dispositivos de Proteção Embólica , Europa (Continente) , Humanos , Stents , Resultado do TratamentoRESUMO
Retroperitoneal hemorrhage (RPH) arises in < 0.5% of patients undergoing percutaneous intervention, but is associated with high risks of morbidity and mortality. More than 50% of medical malpractice claims against interventional cardiologists are related to death and hemorrhage from vascular injury; delays in diagnosis and treatment are common. The current approach to RPH is characterized by "too little" to diagnose and "too late" to manage patients in extremis. Immediate CTA allows rapid diagnosis and triage to appropriate endovascular therapy, without delay.
Assuntos
Angioplastia Coronária com Balão , Hemodinâmica , Hemorragia , Humanos , Espaço Retroperitoneal , Estudos RetrospectivosRESUMO
Within 1 year of coronary artery bypass surgery , 64% of percutaneous coronary interventions were performed for graft failure and 36% for native vessel disease. Predictors of graft failure were small diameter of the graft and native vessel, poor distal run-off, and disease distal to the graft. In the near future, cardiac computed tomography angiography (CCTA) and fractional flow reserve by CT (FFRct) will incorporate accurate determination of coronary anatomy and the presence and extent of myocardial ischemia.
Assuntos
Doença da Artéria Coronariana , Reserva Fracionada de Fluxo Miocárdico , Intervenção Coronária Percutânea , Angiografia Coronária , Ponte de Artéria Coronária , HumanosRESUMO
Contemporary approaches to minimize the risk of acute kidney injury from radiographic contrast (AKI-RC) rely on preferential use of low- or non-ionic contrast; pre-hydration; and limiting contrast volume. This study utilized a meta-analysis of 677 patients to compare the risk of AKI-RC after CO2 peripheral angiography versus iodinated contrast (4.3% vs. 11.1%, odds ratio [OR] 0.465, P = 0.048). There was no difference in AKI-RC in patients with CKD. This study has many limitations. CO2 angiography is an important technique; proper understanding of its strengths and limitations is essential.
Assuntos
Injúria Renal Aguda , Dióxido de Carbono , Angiografia , Meios de Contraste , Humanos , Fatores de RiscoRESUMO
OBJECTIVES: We describe the characteristics of atherosclerotic plaque in patients with peripheral arterial disease (PAD) using near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) BACKGROUND: Imaging and autopsy studies have described atherosclerotic plaque in different vascular beds, including varying degrees of lipid, fibrosis, and calcification. Recently, NIRS has been validated as an accurate method for detecting lipid-core plaque (LCP) in the coronary circulation. Invasive evaluation of plaque composition using NIRS-IVUS has not been reported in different peripheral arterial circulations. METHODS: We performed invasive angiography and NIRS-IVUS in consecutive PAD patients prior to percutaneous revascularization. Imaging evaluation included parameters from angiography, IVUS, and NIRS. NIRS-IVUS findings were compared among different vascular beds with regard to the presence and extent of calcification and LCP. RESULTS: One hundred and forty-nine lesions in 126 PAD patients were enrolled, including the internal carotid (n = 10), subclavian/axillary (n = 9), renal (n = 14), iliac (n = 35), femoropopliteal (n = 69), and infrapopliteal (n = 12) arteries. Plaque morphology was calcified in 132 lesions (89%) and fibrous in 17 lesions (11%). Calcification varied from 100% of renal artery stenoses to 55% of subclavian/axillary artery stenoses. LCP was present in 48 lesions (32%) and prevalence varied from 60% in carotid artery stenoses to 0% in renal artery stenoses (P < 0.005). LCP was only observed in fibrocalcific plaque, and was longitudinally and circumferentially surrounded by a more extensive degree of calcium. CONCLUSIONS: NIRS-IVUS in stable PAD patients demonstrates a high frequency of calcific plaque and statistically significant differences in the frequency of LCP in different arterial beds. LCP, when present in the peripheral circulation, is always associated with calcified plaque. The strong co-localization of calcified plaque and LCP in severe PAD lesions may provide plaque-stabilizing effects; further studies are needed. © 2017 Wiley Periodicals, Inc.
Assuntos
Doença Arterial Periférica/diagnóstico por imagem , Placa Aterosclerótica , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Ultrassonografia de Intervenção/métodos , Calcificação Vascular/diagnóstico por imagem , Idoso , Angiografia Digital , Feminino , Fibrose , Humanos , Lipídeos/análise , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/metabolismo , Doença Arterial Periférica/patologia , Valor Preditivo dos Testes , Índice de Gravidade de Doença , Calcificação Vascular/metabolismo , Calcificação Vascular/patologiaRESUMO
In the United States, women account for 4% of interventional cardiologists and perform 3% of interventional procedures. Male and female cardiology fellows share concerns that dissuade them from careers in interventional cardiology; unique issues for women include professional isolation and childbearing. Interventional fellowships should enhance female mentorship and develop friendly policies regarding maternity leave; other issues require comprehensive solutions to medical school debt, duration of training, and balancing professional goals with lifestyle.
Assuntos
Cardiologia/educação , Resultado do Tratamento , Bolsas de Estudo , Feminino , Humanos , MentoresRESUMO
During carotid artery stenting (CAS), atheroemboli may arise from the aorta, arch, and ipsilateral carotid artery. Embolic protection devices (EPD) are designed to decrease the risk of stroke resulting from atheroembolization from the ipsilateral carotid artery during CAS; double (proximal and distal) EPDs may decrease the risk of stroke in high-risk patients and lesions. Further studies are needed to determine if double EPDs are superior to single EPDs or other devices.
Assuntos
Estenose das Carótidas , Resultado do Tratamento , Angioplastia/instrumentação , Dispositivos de Proteção Embólica , Humanos , Embolia Intracraniana/prevenção & controle , Stents , Acidente Vascular Cerebral/prevenção & controleRESUMO
Professional societies recommend embolic protection devices (EPDs) during percutaneous intervention of saphenous vein bypass grafts (SVGs; class I, level of evidence B). Practice patterns indicate that 21% of SVG interventions are performed with EPDs. Despite a single randomized trial that demonstrated efficacy for EPDs, other studies suggest that the benefits of EPDs are controversial. Consideration should be given toward performing a contemporary EPD trial to incorporate new technologies and pharmacotherapies; in the meantime, guideline recommendations for use of EPDs should be downgraded.
Assuntos
Oclusão de Enxerto Vascular , Veia Safena/transplante , Angioplastia Coronária com Balão/instrumentação , Ponte de Artéria Coronária , Dispositivos de Proteção Embólica , Embolia/prevenção & controle , Humanos , Intervenção Coronária Percutânea , Resultado do TratamentoRESUMO
Bleeding and vascular complications are major causes of morbidity and mortality after transfemoral TAVR. Compared with standard approaches to hemostasis, the catheter balloon occlusion technique CBOT) resulted in significant reduction in major bleeding and vascular complications (18.6% vs. 5.5%, P = 0.042). Femoral crossover could not be achieved in 3.6%, and CBOT led to vessel dissection in 7.2%, major or life-threatening bleeding in 5.5%, need for transfusion > 2 units in 10.9%, and minor bleeding or hematoma in 21.8% of patients.
Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Cateterismo Cardíaco , Artéria Femoral/cirurgia , Próteses Valvulares Cardíacas , Humanos , Substituição da Valva Aórtica Transcateter , Resultado do TratamentoRESUMO
Carotid artery stenting (CAS) has become an integral part of the therapeutic armamentarium offered by cardiovascular medicine programs for the prevention of stroke. The purpose of this expert consensus statement is to provide physician training and credentialing guidance to facilitate the safe and effective incorporation of CAS into clinical practice within these programs. Since publication of the 2005 Clinical Competence Statement on Carotid Stenting, there has been substantial device innovation, publication of numerous clinical trials and observational studies, accumulation of extensive real-world clinical experience and widespread participation in robust national quality improvement initiatives [5]. Collectively, these advances have led to substantial evolution in the selection of appropriate patients, as well as in the cognitive, technical and clinical skills required to perform safe and effective CAS. Herein, we summarize published guidelines, describe training pathways, outline elements of competency, offer strategies for tracking outcomes, specify facility, equipment and personnel requirements, and propose criteria for maintenance of CAS competency.
Assuntos
Angioplastia/educação , Angioplastia/instrumentação , Doenças das Artérias Carótidas/terapia , Credenciamento , Stents , Doenças das Artérias Carótidas/diagnóstico por imagem , Angiografia Cerebral , Competência Clínica/normas , Consenso , Credenciamento/normas , Currículo , Educação de Pós-Graduação em Medicina/normas , Humanos , Valor Preditivo dos Testes , Sociedades Médicas/normas , Resultado do TratamentoRESUMO
The purpose of this study is to characterize the plaque morphology of severe stenoses in the superficial femoral artery (SFA) employing combined near-infrared spectroscopy and intravascular ultrasound (NIRS-IVUS). Atherosclerosis is the most common cause of symptomatic peripheral arterial disease. Plaque composition of SFA stenoses has been characterized as primarily fibrous or fibrocalcific by non-invasive and autopsy studies. NIRS has been validated to detect lipid-core plaque (LCP) in the coronary circulation. We imaged severe SFA stenoses with NIRS-IVUS prior to revascularization in 31 patients (46 stenoses) with Rutherford claudication ⩾ class 3. Angiographic parameters included lesion location and stenosis severity. IVUS parameters included plaque burden and presence of calcium. NIRS images were analyzed for LCP and maximum lipid-core burden index in a 4-mm length of artery (maxLCBI4mm). By angiography, 38 (82.6%) lesions were calcified and 9 (19.6%) were chronic total occlusions. Baseline stenosis severity and lesion length were 86.0 ± 11.0% and 36.5 ± 46.5 mm, respectively. NIRS-IVUS identified calcium in 45 (97.8%) lesions and LCP in 17 (37.0%) lesions. MaxLCBI4mm was 433 ± 244. All lesions with LCP also contained calcium; there were no non-calcified lesions with LCP. In conclusion, this is the first study of combined NIRS-IVUS in patients with PAD. NIRS-IVUS demonstrates that nearly all patients with symptomatic severe SFA disease have fibrocalcific plaque, and one-third of such lesions contain LCP. These findings contrast with those in patients with acute coronary syndromes, and may have implications regarding the pathophysiology of atherosclerosis in different vascular beds.
Assuntos
Artéria Femoral/diagnóstico por imagem , Doença Arterial Periférica/diagnóstico por imagem , Placa Aterosclerótica , Espectroscopia de Luz Próxima ao Infravermelho , Ultrassonografia de Intervenção , Idoso , Angiografia Digital , Constrição Patológica , Feminino , Artéria Femoral/química , Artéria Femoral/patologia , Fibrose , Humanos , Lipídeos/análise , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/metabolismo , Doença Arterial Periférica/patologia , Valor Preditivo dos Testes , Prognóstico , Índice de Gravidade de Doença , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/patologiaRESUMO
Complex arch anatomy (type 2, type 3) and bovine configuration were identified in 34.4% and 20.5% of carotid stent patients, respectively. Catheter manipulation time (CMT), rather than arch complexity per se, was the only independent predictor of adverse events after carotid stenting. Careful attention to patient selection, preprocedural planning, and stent technique are important to ensure success.
Assuntos
Aorta Torácica/anatomia & histologia , Estenose das Carótidas/terapia , Stents , Feminino , Humanos , MasculinoRESUMO
Compared with successful PCI, failed PCI of CTOs is associated with higher rates of in-hospital death, MI, CABG, perforation, and cardiac tamponade, but the absolute risk difference is small. Since 1991, the overall rates of in-hospital complications are declining, due to significant improvements in CTO technology and operator expertise. Outcomes after CTO-PCI may be enhanced by proper patient selection (resistant angina; large areas of ischemia; and anatomic suitability for antegrade, retrograde, and/or subintimal recanalization) and by reliance on expert operators using a flexible incremental approach to recanalization.
Assuntos
Oclusão Coronária/cirurgia , Estudos Observacionais como Assunto , Intervenção Coronária Percutânea , Complicações Pós-Operatórias , HumanosRESUMO
In patients with aortic stenosis (AS) and eccentric transaortic flow, greater pressure loss occurs as the jet collides with the aortic wall together with delayed and diminished pressure recovery. This leads to the elevated transaortic valve pressure gradients noted on both Doppler and cardiac catheterization. Such situations may present a diagnostic dilemma where traditional measures of stenosis severity indicate severe AS, while imaging modalities of the aortic valve geometric aortic valve area (GOA) suggest less than severe stenosis. In this study, we present a series of cases exemplifying this clinical dilemma and demonstrate how color M-mode, 2D and 3D transthoracic (TTE) and transesophageal (TEE) echocardiography, cardiac computed tomography angiography (CTA), and magnetic resonance imaging (MRI), may be used to resolve such discrepancies.
Assuntos
Estenose da Valva Aórtica/fisiopatologia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Pressão Sanguínea/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Velocidade do Fluxo Sanguíneo , Ecocardiografia Doppler , Feminino , Humanos , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Adulto JovemRESUMO
Hyperemic and nonhyperemic pressure ratios are frequently used to assess the hemodynamic significance of coronary artery disease and to guide the need for myocardial revascularization. However, there are limited data on the diagnostic performance of the diastolic hyperemia-free ratio (DFR). We evaluated the diagnostic performance of the DFR compared with invasive fractional flow reserve (FFR). We performed a prospective, single-center study of 308 patients (343 lesions) who underwent DFR and FFR for evaluation of visually estimated 40% to 90% stenoses. Diagnostic performance of the DFR compared with FFR was evaluated using linear regression, Bland-Altman analysis, and receiver operating characteristic curves. The overall diagnostic accuracy of the DFR was 83%; the accuracy rates were 86%, 40%, and 95% when the DFR was <0.86, 0.88 to 0.90, and >0.93, respectively. The sensitivity, specificity, positive predicative value, and negative predictive value were 60%, 91%, 71%, and 87%, respectively. The Pearson correlation coefficient was 0.75 (p <0.05). The Bland-Altman analysis showed a mean difference of 0.09, and the area under the receiver operating characteristic curve was 0.88 (95% confidence interval 0.84 to 0.92, p <0.05). In conclusion, the DFR has a good diagnostic performance compared with FFR but 17% of the measurements were discordant. The diagnostic accuracy of the DFR was only 40% when the DFR was 0.88 to 0.90, suggesting that FFR may be useful in these arteries.