Essential Angioplasty E-Book

E. von Schmilowski

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 576

Veröffentlichungsjahr: 2011

Beschreibung

A vast choice of techniques and technology confronts today’s interventional cardiologists, and those who are new to angioplasty need clear and practical guidance in order to develop good habits, avoid common pitfalls and become efficient and confident practitioners. Written to provide readers with a solid grounding in the basics of percutaneous techniques by providing selective, practical knowledge and a full range of useful tools and tips, Essential Angioplasty is:

• Ideal for those seeking a solid foundation in percutaneous interventions
• Designed for ease of use and retention of information; copiously illustrated with clear "take home messages" concluding each chapter
• Packed with over 300 tips and tricks which readers can apply in their training and practice
• Based on the authors' hands-on experience in the world's leading interventional cardiology training centers and years of proven teaching experience

Throughout, the authors follow the motto "keep it simple" and focus only on the information that will help the reader learn and master the relevant technique. This makes Essential Angioplasty the perfect companion for trainees and others seeking a reliable guide to achieving success in the cardiac catheterization laboratory.

Leseprobe

Table of Contents

Cover

Companion website

Title page

Copyright page

Foreword

Preface

Acknowledgments

List of Abbreviations

CHAPTER 1 Fundamentals

Standards of Excellence in Interventional Cardiology

Introduction to Interventional Procedures

Vascular Access

Coronary Anatomy and Projections

Anomalies

Left Ventriculography and Aortography

Radiation Safety

CHAPTER 2 Devices in Practice

Guiding Catheters

Guide Wires

Balloons

Stents

Closure Devices

CHAPTER 3 The Interventional Patient

Elective PCI for Stable Coronary Artery Disease

PCI in Acute Coronary Syndromes

The Diabetic Patient

CHAPTER 4 Interventional Pharmacotherapy

Antiplatelet Agents in PCI

Antithrombotic Agents in PCI

CHAPTER 5 Techniques in Specific Lesions

Left Main Coronary Artery

Bifurcation Lesions

Ostial Lesions

Chronic Total Occlusion

Grafts and Conduits

CHAPTER 6 Complications

Contrast Reactions

Femoral Access Site Problems

Radial Access Site Problems

Air Injection

No-Reflow/Slow-Reflow Phenomenon

Coronary Spasm

Pseudostenoses

Coronary Perforation

Coronary Dissection

Stent Thrombosis

Restenosis

Stent Loss

Hypotension

Hypoglycemia

Contrast-Induced Nephropathy

New ST Elevation or Marked ST Depression

Cardiac Arrest

Emergency CABG

Death

CHAPTER 7 Intracoronary Imaging

Intravascular Ultrasonography

Virtual Histology

Fractional Flow Reserve (FFR)

Optical Coherence Tomography

List of Trials and Studies

References

Index

Companion website

This book is accompanied by a website:

www.wiley.com/go/essentialangioplasty.com

The website contains additional resources including:

PowerPoint presentationsDetails of key meetingsFurther useful publications listAdditional images and captions

Further resources and updates to follow publication.

This edition first published 2012 © 2012 by John Wiley & Sons, Ltd.

Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing.

Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK

The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

111 River Street, Hoboken, NJ 07030-5774, USA

For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell

The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Library of Congress Cataloging-in-Publication Data

von Schmilowski, Eva.

Essential angioplasty / Eva von Schmilowski, Howard Swanton.

p. ; cm.

Includes bibliographical references and index.

ISBN-13: 978-0-470-65726-3 (hard cover : alk. paper)

ISBN-10: 0-470-65726-X (hard cover : alk. paper)

ISBN-13: 978-1-119-95051-6 (epdf)

ISBN-13: 978-1-119-95052-3 (epub)

ISBN-13: 978-1-119-95053-0 (mobi)

 1. Angioplasty. I. Swanton, Howard. II. Title.

[DNLM: 1. Angioplasty–instrumentation. 2. Angioplasty–methods. 3. Intraoperative Complications–prevention & control. 4. Postoperative Complications–prevention & control. WG 166.5.A3]

RD598.35.A53S65 2012

617.4'13–dc23

2011015324

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Foreword

Coronary angioplasty has become one of the great interventions in modern medicine. Over the last three decades since Gruentzig first introduced this procedure in 1977 the technique has developed to an astonishing degree and its application has spread worldwide. It has avoided the need for coronary bypass surgery in hundreds of thousands of patients with angina, and is increasingly managed as a day case procedure.

The plain old balloon designed by Gruentzig is still used in a design very similar to his original one. To it has been added firstly the bare metal stent, then the drug-eluting stent and now the fully absorbable stent which is entering trials. Remarkable improvements in intracoronary imaging have paralleled these advances.

The result is that almost all cases of coronary disease can be managed wholly or in part by coronary angioplasty. The question becomes not “Can I do this procedure?”, but “Should I do it?”

This guide book for the trainee starting coronary angioplasty goes through the procedure in a step by step fashion, and deals with all the modern technology available. It also answers the question fundamental to good practice: “Should I take this case on, or should I refer the patient for surgery?” The answer so often lies in trial data which are included in every section dealing with techniques. We have all struggled with a procedure and got into difficulties because we tried to do too much. The book’s motto “keep it simple” will stand the trainee in good stead. Although the technology is increasingly sophisticated this phrase must be in the operator’s mind with every case. This very helpful guide book will keep it there!

John Ormiston

MBChB, MD, FRACP, FRACR, FCSANZ, ONZM

Medical Director

Mercy Angiography

Auckland, New Zealand

Preface

It is hoped this book will be of help to the cardiologist starting out in coronary intervention. Standing at the catheter table for the first time as an assistant operator at a coronary angioplasty case can be a daunting experience however many coronary angiograms you have performed previously. A vast choice of techniques and technology confronts the beginner. This book is designed to guide you through the procedure, avoiding potential pitfalls and complications. It has been written to provide a solid basic background and allow you to develop your own personal approach in interventional cardiology. Our principle was to follow the motto “keep it simple,” to provide selected, practical knowledge with a full range of useful tools and tips and to avoid increasing amounts of useless information. The book also deals in detail with more complex intervention, which we hope will help the more experienced interventionist.

It is 35 years since Andreas Grntzig performed the first balloon coronary angioplasty in man in 1977. Since that time there have been huge advances in pharmacology, technology, and imaging – both X-ray and intracoronary imaging.

This book will help you apply all these advances with each stage of the coronary intervention. A section on angiographic projections will help in the selection of the best view of a lesion in any coronary segment. Radiation doses to patient, operator, and laboratory staff are higher in coronary angioplasty than in diagnostic coronary angiography and the radiation section will help remind the operator how to minimize the radiation dose. There are sections on choice of vascular access and closure devices. Pharmacology is covered in detail. The bewildering choice of guiding catheters, wires, balloons, and stents are dealt with in individual sections. All chapters are illustrated by diagrams, charts, and tables as well as angiographic pictures.

Even with the correct selection of equipment, the story has just started. Every common coronary lesion is dealt with in a step-by-step fashion with caveats listed. Included are sections on primary coronary angioplasty in acute myocardial infarction, the thrombotic lesion, bifurcation lesions, ostial lesions, graft lesions, and left main stem stenosis. There is a section on intracoronary imaging. Complications are covered and include contrast-induced nephropathy.

Cardiology is right at the forefront of medical specialties in its evidence base. We have literally hundreds of trials to guide our practice. The best relevant trials in coronary intervention are included at the end of each chapter with a full list at the back of the book. We would welcome and be very grateful for any suggestions and feedback on gaps in the subject or topics which you feel have been dealt with inadequately.

An integral and very important part of the book is a website, www.wiley.com/go/essentialangioplasty.com. This will provide you with regular updates on topics or content covered in the book, updates on relevant clinical trials, news of new equipment, techniques, and technologies, and reports from key interventional meetings. Additionally, you will benefit from many downloadable color images and illustrations which will cover the most important areas of interventional cardiology. Also included are PowerPoint presentations and clinical cases with video clips which will, we hope, be both entertaining and instructive.

Finally, we encourage you to use this book in the catheter lab on a regular basis. We believe it will help you develop excellent standards in your daily interventional practice.

Good luck!

E. von Schmilowski

R. H. Swanton

Acknowledgments

We would like to thank all our mentors, teachers, friends and colleagues in the numerous catheter laboratories in which we have worked. We are very grateful for all their help, wise advice and shared knowledge. Thank you to the radiographic staff at the Heart Hospital for their great goodwill in helping access angioplasty cases.

A special thanks to John Ormiston for his continuing support and supervision over the years. His angioplasty experience and ideas have been invaluable.

We owe a massive debt to Osamu Yamamoto for his amazing illustrations in the book. A big thank you for all the long hours working together on initial drafts and sketches and bringing these/them to reality. His patience with endless corrections has been extraordinary.

A huge thank you to Diana Simich for her support, patience and understanding. Our enriching conversations were always inspiring and gave much needed motivation. Without her the book would never be the same. To Kerry Spackman for sharing his great thoughts and ideas and for his strong belief in this project. To Lucie and Dominic Sleeman for their encouragement and support on the final stages of the writing. Thank you for your wonderful friendship.

Thank you to a great team of editors who have been so patient and understanding. A special thank you to Tom Hartman who showed immediate interest in the project and shared our enthusiasm for the book and the companion website. We are most grateful for his loyalty and priceless editorial suggestions. We are equally grateful to Kate Newell, Ruth Swan, Cathryn Gates and Kevin Fung for their encouragement and uncomplaining assistance with the final preparations of the manuscript.

Finally and most especially we would like to thank our families for their unconditional love, patience and endless faith in us.

E. von Schmilowski

R. H. Swanton

List of Abbreviations

AA,

arachidonic acid

ACS,

acute coronary syndrome

ACT,

activated clotting time

AP,

anteroposterior

APTT,

activated partial thromboplastin time

ARC,

Academic Research Consortium

ARU,

aspirin reaction unit

BMS,

bare metal stents

CAD,

coronary artery disease

CART,

controlled antegrade and retrograde subintimal tracking

CIN,

contrast-induced nephropathy

CMR,

cardiac magnetic resonance

CPR,

cardiopulmonary resuscitation

CSA,

cross-sectional area

CTFC,

corrected TIMI frame count

CTO,

chronic total occlusion

DAPT,

dual antiplatelet therapy

DEB,

drug-eluting balloons

DES,

drug-eluting stent

DS,

digital subtraction (angiography)

EEM,

external elastic membrane

FFR,

fractional flow reserve

GPI,

glycoprotein inhibitor

GTN,

glyceryl trinitrate

HPPR,

high post-clopidogrel platelet reactivity

IABP,

intra-aortic balloon pump

IC,

intracoronary

IM,

intramuscular(ly)

IMA,

internal mammary artery

IMC,

internal mammary artery catheter

IRA,

infarct-related artery

IV,

intravenous(ly)

IVUS,

intravascular ultrasound

JVP,

jugular venous pulse/pressure

LA,

left atrium

LBBB,

left bundle branch block

LCB,

left coronary bypass

LIMA,

left internal mammary artery

LM,

left main

LV,

left ventricle, left ventricular

LVEDP,

left ventricular end-diastolic pressure

MACE,

major adverse cardiac events

MBS,

myocardial blush score

MLA,

minimum luminal cross-sectional area

MLD,

minimum luminal diameter

MVD,

multivessel disease

NAC,

N-Acetylcysteine

NSTEMI,

non-ST-elevation myocardial infarction

NURD,

nonuniform rotational distortion

OMB,

obtuse marginal branches

OTW,

over the wire

PA,

posteroanterior; pulmonary artery

PCI,

percutaneous coronary intervention

PEA,

pulseless electrical activity

PGA,

polyglycolic acid

PLLA,

poly-L-lactic acid

PO,

per orem

POBA,

plain old balloon angioplasty

PTT,

partial thromboplastin time

QCA,

quantitative coronary angiography

RCB,

right coronary bypass

RPFA,

rapid platelet function assay

RSV,

right sinus of Valsalva

RWMA,

regional wall motion abnormalities

SBP,

systolic blood pressure

STAR,

subintimal tracking and re-entry (technique)

STEMI,

ST-elevation myocardial infarction

SVR,

systemic vascular resistance

TAVI,

transcatheter aortic valve implantation

TIMI,

thrombolysis in myocardial infarction

TLD,

thermoluminescent dosimeter

TLF,

target lesion failure

TLR,

target lesion revascularization

TOE,

transesophageal echocardiography

TT,

thrombin time

TVF,

target vessel failure

TVR,

target vessel revascularization

UFH,

unfractionated heparin

VASP,

vasodilator-stimulated phosphoprotein

VASP-P,

VASP phosphorylation

VSD,

ventricular septal defect

CHAPTER 1

Fundamentals

Standards of Excellence in Interventional Cardiology

Introduction to Interventional Procedures

Vascular Access

Coronary Anatomy and Projections

Anomalies

Left Ventriculography and Aortography

Radiation Safety

Standards of Excellence in Interventional Cardiology

As you are reading this, interventional cardiology has become an important part of your life. After a demanding training and long hours in hospital cardiology practice you have become a member of the interventional community. You undoubtedly have great potential, strong motivation, and a determination to learn and master your profession.

Interventional cardiology is not only about how educated, intelligent, or skilled you are. Good qualifications are indeed important, but being an excellent operator does not necessarily make you an excellent interventional cardiologist. There is much more to it than educational achievements and manual skills.

A skilled angioplasty operator should select patients appropriately and use the best and most up-to-date techniques, equipment, and pharmacotherapy. An interventional cardiologist, on the other hand, should in addition to these skills have a wide knowledge base, common sense, and the ability to cooperate and communicate effectively with both colleagues and patients.

Much of what follows is about being a first-class doctor rather than being a skilled technician. It may be taken for granted by the patient and medical colleagues that the conduct described below is to be expected as part of a first-class service. However, we have all seen how pressure of time and work and the stress of a difficult procedure can erode these standards. It is important that good standards of practice should develop from the very beginning of training. You will make a positive impact on both patients and the people you work with, and in a few years time your younger colleagues will learn from you.

We hope these few practical thoughts will help you see interventional cardiology from a more human perspective and will make your profession more worthwhile, rewarding, and enjoyable.

Take Care of the Patient

You are a physician and cardiologist, not just an interventionist. Treat the whole patient, not just the lesion in the coronary artery. Try to imagine what it must be like facing up to a coronary angioplasty.Meet the patient and the patient’s family before and after the procedure. Explain what will be done and what has been done.Be available, kind, and keen to talk. Be honest, quietly confident, and do not hide anything. In getting consent, be realistic about the risks involved. These should be the risks in your hands in your hospital, not national risks.During the procedure, mind your language and be careful with comments you make. Don’t forget that most patients are awake during a percutaneous coronary intervention (PCI), and sedation does not necessarily stop them hearing or remembering remarks.

Treat the patient, not the lesion.

Quality and Respect Are Essential

Be humble and respect the people you work with. You are not the master of the universe. Don’t act in a superior way.Be professional. Build your reputation as a professional physician and a decent human being, not a pop star.Dress properly. Have clean hands and fingernails.Be available and well organized. Keep your desk clean, keep your files in order, manage your time effectively by planning ahead.Be reliable, honest, and truthful. We all want to work with people whom we can trust and rely on.Be effective, but not arrogant.Be decisive. Don’t dwell on problems, solve them. A good decision made quickly is ideal, but when you are stuck, any decision is better than no decision.Be strong and determined. Do not give up because things are getting difficult.Be adaptable as well as decisive. Be prepared to change strategy if your initial plan is not working out.Be a good speaker. Express your opinions in sentences rather than in paragraphs.Don’t argue with anyone. Accept constructive criticism.Be calm and peaceful. Control your emotions when things go wrong. Do not raise your voice.Be well balanced. Keep your mind and body in healthy shape. Your mind is like a parachute. It only works when open.

Any decision is better than no decision.