Coronary angioplasty : simplified

A brief description on coronary angioplasty for beginners

1. Percutaneous Coronary Interventions: Simplified Dr. Jain T. Kallarakkal MD, FRCP, DM St Mary’s Hospital, Thodupuzha

2. History GRUENTZIG f irst performed Coronary angioplasty in 1977 1986 – First stainless steel stent inserted in human artery

3. Clinical Factors That can Influence The outcome of PCI Diabetes mellitus Chronic kidney disease Completeness of revascularization LV systolic dysfunction Previous CABG Ability to comply with and tolerate DAPT

4. Pre-Procedural Considerations Contrast induced AKI Anaphylactic reactions High dose statins Evaluation of bleeding risk Evaluation of GFR

5. Radiation Safety Patients radiation exposure is reduced as possible Operators radiation exposure is reduced as possible

6. Vascular Access Radial Femoral

7. Guide Catheters Functions Support for device advancement Conduit for device and wire transport Vehicle for contrast injection Measurement of Pressure

8. Parts of Guide Catheter

9. Selection of Guide Catheter Guide selection depends on the size of the ascending aorta, location and orientation of the ostia to be cannulated , degree of tortuosity and calcification of the coronary artery segment proximal to the target area Side hole catheters are useful where the pressure gets frequently damped as in RCA interventions, CTO interventions or left main interventions

10. Commonly Used Guides Judkins , Amplatz , and Extraback up guides Multipurpose for RCA bypass or a high left main (LM) takeoff LIMA catheter for right and left coronary bypass graft

11. Judkins Guide Catheters: Left and Right

12. Judkins Guide Catheter Engage the LM ostium without much manipulation Engages the artery unless thwarted by the operator For most of the patients, a 3.5 cm Judkins left guide usually fits well For superiorly directed LAD or narrow aortic root – smaller guide Horizontal or wide aortic root - JL with long secondary curve (size 5 or 6)

13. Amplatz Guide

14. Amplatz Guide Offers firm platform for advancement of device Tip points slightly downward - higher danger of ostial injury causing dissection Selection of the proper size is essential For RCA ostium which is very high – left Amplatz guide may be used to engage the right ostium

15. Long Tip Catheters Incude Voda , XB, EBU Gives coaxial intubation, better support and stability, precise control and manipulation Relatively better in advancement of devices, decreases the loss of supportive forces

16. Extra Back Up Guide

17. Extra Back Up Guide Long tip forms a fairly straight line with the LM axis or the proximal ostial RCA Tip in the coronary artery is not easily displaced Provide a very stable platform

18. Multipurpose Guide

19. Multipurpose Guide Straight with a single minor bend at the tip Ideal for RCA bypass graft or a high left main (LM) takeoff

20. Tips to Remember Aspirate the guide once it is inserted into the ascending aorta Look for back flow to avoid air embolism Flush frequently Watch the tip when withdrawal of the device especially with ostial or proximal plaques Watch the blood pressure curve for dampening During injection, keep the tip of the syringe pointed down

21. Shepherds Crook in RCA Arani and Voda right support from aorta Amplatz right and Hockey stick support from sinus

22. SVG and LIMA interventions Usually JR For abnormal positions and take offs MP or AL1 Internal mammary artery – IMA catheter , LCB IMA Catheter is designed for both Right and left Internal Mammary arteries

23. Choice in Radial Interventions Left coronary artery: down size JL by 0.5 Judkins left , Amplatz left , Multipurpose , EBU, IKARI left, El Gamal Right coronary artery: Judkins right, Amplatz right, Amplatz left, Multipurpose, IKARI right, El Gamal

24. Guide Wires Used to reach far end of the vessel Rail the devices into coronaries Give access to the lesion Helps to cross the lesion atraumatically Provides support for interventional devices

25. Features of Guide Wire Torque control Trackability Flexibility Visibility Support Crossing

26. Other Features Core material affects the flexibility, support, steering and trackability Keeps the diameter at .014 inch Visibility of the wire tip is provided by platinum coils Hydrophobic coatings are silicone based coatings

27. Classifications Based on Tip Flexibility • Floppy - Hi torque balance middle weight, Hi torque balance, Choice floppy • Intermediate - Hi torque intermediate, Choice intermediate • Standard – Shinobi , Boston Scientific

28. Classifications Based on coating • Hydrophilic - CholCE TM PT Floppy • Hydrophobic - Asahi soft Based on Device support • Light - Hi torque balance • Moderate - Hi torque balance middle Weight • Extra support - Hi torque whisper, Choice

29. Commonly Used Guide Wires ATW/ATW Marker BMW / BMW Universal Zinger Cougar XT Asahi Light / Medium / Asahi Standard / Asahi Prowater Flex / Asahi Sion Blue Choice Floppy LugeS Forte Floppy Runthrough NS Galeo

30. Guide Wire Selection Depends on vessel anatomy Lesion morphology Devices to be used Operator's choice

31. Balloon Catheters The ability of a balloon material to increase in size or stretch as the pressure is increased Nominal pressure - The amount of pressure required to inflate the balloon to its labeled diameter Rated burst pressure - The pressure level a balloon is designed to accept without rupture Deflation – changing from nominal configuration to wrapped

32. Types Semi compliant Balloons Better flexibility & trackability Better cross and recross performance Limited durability Increased diameter and longitudinal growth variance Limited dilatation force

33. Types Non compliant balloons Low growth as pressure increases Designed for dilatation of calcified or resistant lesions

34. Coronary Stents DES is an alternative to BMS to reduce restenosis Preferred in left main disease, small vessels, in stent restenosis , bifurcation lesions, long lesions, muliple lesions, SVG lesions and in diabetic patients BMS is preferred in patients who cannot tolerate DAPT, anticipated surgery and those with high risk of bleeding

35. UA/NSTEMI: Choice of Strategy Patients with refractory angina, electrical or hemodynamic instebility Elevated risk of clinical events Troponin positive patients

36. PCI in STEMI Primary PCI Heart failure Cardiogenic shock Failed fibrinolysis Elective procedure after successful fibrinolysis

37. Adjunctive Diagnostic Devices FFR IVUS OCT Cutting balloon angioplasty Aspiration thrombectomy Rotablator Distal embolic protection devices Hemodynamic support devices

38. Aspirin in PCI 81-325 mg before PCI if on aspirin therapy Non enteric coated aspirin 325 mg if not on aspirin 81 mg – 100 mg / day to be continued indefinitely

39. P2Y 12 Inhibitors and DAPT In patients after BMS implantation, P2Y 12 inhibitor therapy ( clopidogrel ) should be given for a minimum of 1 month In patients with DES implantation, P2Y 12 inhibitor therapy ( clopidogrel ) should be given for at least 6 months In patients with NSTEMI / STEMI treated with DAPT after BMS or DES implantation, P2Y 12 inhibitor therapy ( clopidogrel , prasugrel , or ticagrelor ) should be given for at least 12 months.

40. P2Y 12 Inhibitors and DAPT In patients with NSTEMI / STEMI treated with DAPT after coronary stent implantation, it is reasonable to use ticagrelor in preference to clopidogrel for maintenance therapy In patients with NSTEMI / STEMI treated with DAPT after coronary stent implantation who are not at high risk for bleeding complications and who do not have a history of stroke or TIA, it is reasonable to choose prasugrel over clopidogrel for maintenance therapy .

41. P2Y 12 Inhibitors and DAPT Prasugrel should not be administered to patients with a prior history of stroke or TIA In patients with NSTEMI / STEMI treated with DAPT after DES implantation who develop a high risk of bleeding, are at high risk of severe bleeding complication or develop significant overt bleeding, discontinuation of P2Y 12 inhibitor therapy after 6 months may be reasonable

42. GP IIb / IIIa Inhibitor Therapy Early potent anti platelet therapy Adjunctive use improves outcome May improve flow Safe

43. No Reflow Pharmacological Therapy Gp llb / llla inhibitors Adenosine Nitrates Verapamil Diltiazem Sodiun nitroprusside Nikorandil

44. Steps Involved in PCI Insertion of radial / femoral sheath Administration of heparin / bivalrudin Engagement of coronary ostium using guide catheter Crossing of lesion using guide wire and parking it as distal as possible Pre-dilatation of lesion Deployment of stent Post dilate the stent Removal of balloon, guide wire, guide catheter and sheath

45. Thank you