Essentials of Restenosis: For the Interventional Cardiologist (Contemporary Cardiology)

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In an accompanying editorial, however, Baim et al. In another study to evaluate the clinical and serial angiographic outcomes of patients undergoing SES implantation for ULM, Price et al. There were two acute stent thromboses and five deaths at 1 year. Although alarming, this study confirms the need for meticulous surveillance of patients receiving DES for ULM even if they remain asymptomatic.

Future Trends Although PCI for ULM has yielded encouraging results thus far, particularly with DES, there remain a number of unanswered questions that confront this relatively new interventional discipline. Introduction Bifurcations are prone to lesion development by virtue of the greater shear stress and more frequent turbulent blood flow conditions.

Classification Several classification systems of varying complexity have been proposed to describe bifurcation lesions. The Duke classification is ordered A through F depending on the location of plaque both within the main vessel or side branch see Fig. Lefevre et al. The lesion classification proposed by Lefevre et al. Here, type 1 lesions are defined as true bifurcation lesions involving the main branch, proximal and distal, and the ostium of the side branch with type 2 lesions involving only the main branch at the bifurcation site and not the ostium of the side branch.

This may necessitate the operator to then dilate or stent the side branch. Angiography of the distal left main bifurcation demonstrating the plaque shift phenomenon snow plough effect. A Severe ostial stenosis of the left anterior descending artery LAD with a relatively disease free left circumflex artery LCx.

The mere fact a lesion is located at a bifurcation confers a worse prognosis following PCI compared with nonbifurcation lesions. DES have had a significant impact on angiographic and clinical outcomes compared to their BMS counterparts. The use of DES has led to reduced rates of restenosis with less need for repeat interventions, particularly to the main vessel.

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The problem of focal restenosis at the side branch ostium continues to be problematic and one that has not been fully elucidated to date. This phenomenon has made the treatment of the side branch in bifurcation lesions with DES a major focus point within the interventional community. In deciding on an appropriate strategy for PCI to a bifurcation lesion, the operator will choose between a simple DES implantation only at the main vessel with optional balloon angioplasty or stenting at the side branch or complex DES implantation at the main vessel and the side branch technique Table 2.

In one of only a few randomized trials looking at these bifurcation strategies, Colombo et al. In another study, Pan et al.


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Depending on the size of the side branch, the operator may choose to wire it as means of protection during dilatation of the balloon and stenting in the main vessel. If plaque shift occurs and the operator choses to treat the side branch then this may be accomplished by kissing balloon inflation, provisional T stenting, culotte, or by the provisional reverse crush technique Fig.

All such procedures, however, depend on being able to successfully recross the side branch through the stent struts in the main vessel. However, if after predilatation of the main vessel or side branch a severe stenosis or dissection develops, the order of stent insertion can be reversed with the side branch stent implanted first. Simple stenting: Treatment options if the side branch becomes compromised following treatment of the main vessel.


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A Stent only in main vessel with final kissing balloon dilatation. Note that kissing balloon inflation during placement of the second stent in the side branch is important to prevent distortion of the main vessel stent.

What Would Be the Ideal Drug-eluting Stent for Managing Patients with Long Lesions?

Paul, MN. At 7 months, the overall rate of major cardiac events was The overall rate of repeat TLR was Two patients 2. Although the use of DES for bifurcation lesions has resulted in improved outcomes compared with BMS, concern still remains because of late adverse events occurring at the ostium of the side branch. Stent thrombosis as high as 3. A second wire is left in position in the side branch and jailed by the main vessel stent.

Key points

The favorable modification of the angle of origin of the side branch and the angiographic reference offered by the jailed wire facilitates crossing of the side branch using the wire in the main vessel or a separate wire. After opening of the stent struts, a second stent is implanted right from the ostium with final kissing balloon dilatation. Still, incomplete coverage of the side branch ostium remains a major limitation in case of too distal deployment of the side branch stent.

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Conversely, too proximal deployment of the side branch stent results in protrusion of stent struts into the main vessel. Here, the side branch stent is advanced into position followed by the parent vessel stent without deployment. It is then carefully positioned at the ostium and deployed first with only the proximal stent marker protruding into the main branch. Following removal of stent and guidewire from the side branch, the main vessel stent is deployed covering across the ostium of the side branch.

Staff View: Essentials of restenosis

The side branch is then rewired with final kissing balloon dilatation performed. The crush technique, popularized by Colombo et al. Being that the second stent is already in position, there is no danger of impairing access to the main vessel. After withdrawal of the wire and stent delivery balloon from the side branch, the main vessel stent is subsequently deployed crushing the proximal part of the side branch stent thereby creating three layers of stent struts in the main vessel.

Finally, kissing balloon dilatation is undertaken having to traverse through three layers of stent struts at the bifurcation to give the final result.

Aim and Focus

Simultaneous kissing stents. A—B —both stents are positioned side by side and are deployed simultaneously which also helps to minimize plaque shift. Kissing inflation C is not mandatory if a satisfactory result has been achieved by the simultaneous stent deployment. Crush stenting A—B —the side branch stent is positioned and deployed first with the proximal stent marker placed 2—3 mm proximal to the bifurcation within the main vessel. Finally, kissing balloon dilatation is undertaken having to traverse through three layers of stent struts at the bifurcation—D to give the final result E—F.

Culotte stenting A—D —The first stent is usually positioned in the vessel with the sharpest angulation usually the side branch and deployed using 12—14 atm pressure. This traps the other wire placed within the main vessel behind the stent struts and a third wire is used to recross the struts of the first stent and enter distal main branch. After removal of the first main branch wire the struts of the stent are dilated with a balloon to enable passage of a second stent through the struts and into the main vessel.

The procedure ends with kissing balloon inflation E which requires another wire passage through the stent struts.

The technique results in considerable stent burden at the side branch ostium F. The culotte technique was developed by Chevalier et al. In its original description, it was recommended to insert the first stent in the vessel with the sharpest angulation usually the side branch and deployed using 12—14 atm pressure. Obviously, with modern flexible stents, a reversed order can be followed should an attempt to use a single stent be considered possible.

The procedure ends with kissing balloon postdilatation which requires another wire passage through the stent struts.

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The culotte technique for bifurcation lesions has been limited by high thrombosis and restenosis rates in the setting of BMS. Chevalier et al. Technical complexity and high rates of preprocedural events and restenosis in other registries led to the technique falling out of favor amongst interventional cardiologists. The simultaneous kissing stents SKS technique is best suited to easily accessible bifurcations with large proximal reference diameter containing plaque and when both branches are of similar diameter Fig. The procedure involves wiring the main and side branches which maintains access to both during the entire procedure.

By having both stents parallel, this extends the carina of the bifurcation proximally. This technique was developed to allow complete lesion coverage but is limited by its procedural complexity and the need to use three stents. Stents are deployed in each of the branch vessels with a third stent paced in the main vessel proximal to the bifurcation. A number of dedicated bifurcation stents have been developed and some are commercially available.

However, they have failed to achieve widespread application in the management of bifurcation lesions.