Introduction
Technique
Schematic diagram of the primary mechanisms of balloon angioplasty and stenting. A. A balloon angioplasty catheter is positioned into the stenosis over a guidewire under fluoroscopic guidance. B. The balloon is inflated, temporarily occluding the vessel. C. The lumen is enlarged primarily by stretching the vessel, often resulting in small dissections in the neointima. D. A stent mounted on a deflated balloon is placed into the lesion and pressed against the vessel wall with balloon inflation (not shown). The balloon is deflated and removed, leaving the stent permanently against the wall acting as a scaffold to hold the dissections against the wall and prevent vessel recoil.
Success and complications
A successful procedure (angiographic success), defined as a reduction of the stenosis to less than a 20% diameter narrowing, occurs in 95–99% of patients.
Complications
Stent thrombosis (1-3%)
- Clinical presentation
- Skin manifestations (34%)
- “Blue toe syndrome” – cyanotic toes with intact pulses
- Livedo reticularis – reticular, lacy skin discoloration/erythema that blanches on pressure.
- Gangrene and ulcers
- ICA: Hollenhorst plaques, bright, yellow, refractile plaques in the retinal artery
- Cerebral or intestinal ischemia, AKI
- Results in death in 10-20%, and MI in 30-70%
- Skin manifestations (34%)
- Acute (<24hr), subacute (1-30days)
- Can be ameliorated by DAPT (up to 1 year)
- Late (30days – 1year), very late (>1year)
Restenosis
- Recurrence of angina or symptoms <12 months
- 20-50% in balloon angioplasty alone
- 10-30% in BMS
- 5-15% in DES
# Bleeding complications
- Bleeding from the arterial access site (with retroperitoneal extension).
- Hematoma
- Arterial dissection
- Pseudoaneurysm
- Bleeding from the arterial access site (with retroperitoneal extension).
- Hematoma
- Arterial dissection
- Pseudoaneurysm
- Bleeding from the arterial access site (with retroperitoneal extension).
- Hematoma
- Arterial dissection
- Pseudoaneurysm (<1%)
- Uncomplicated
- Ultrasound-guided thrombin injection initiates the rapid formation of a fibrin clot, stopping blood flow to the hematoma. This procedure has become the gold standard for the treatment of uncomplicated postcatheterization pseudoaneurysms that measure ? 3 cm, and it has a success rate of > 90%
- Stent implantation, coil embolization (invasive)
- Complicated
- Hemodynamic instability, tissue compromise (e.g., limb ischemia, neuropathy, skin necrosis), rapid hematoma expansion, or infection
- Open surgical repair
- Uncomplicated
- AV fistula formation
- Ultrasound-guided compression
Retroperitoneal hematoma
- Clinical presentation
- Occurs within 12 hours of catheterization
- Sudden hemodynamic instability + ipsilateral flank or back pain.
- Diagnosis is confirmed with non-contrast CT scan of abdomen and pelvis or abdominal ultrasound.
- Treatment is usually supportive
- Intensive monitoring, bed rest, and IV fluids or blood transfusion
- Surgical repair is rarely required.
- Prevention
- Patients should be advised to avoid strenuous activity or lifting heavy objects for 1 week post catheterization
Indications
PCI vs. CABG
- CABG? medical group?? survival ? Except 2 vessel dx
- Cumulative surviving? ? ??? ???. Except High risk group
- Indication
- Left main disease
- Two vessel disease with P-LAD disease
- Three vessel disease
- Significant left ventricular impairment
Conduits for CABG : Int.mammary a. (=int. thoracic a.)? best
Myocardial protection : Retrograde perfused cardioplegia (???? ????)
- Significant left ventricular impairment
- Cx
• Arrhythmia? 26%, Neuroevent(CVA,TIA), bleeding? ?? 2.3%
• Motality? 2.5% ??. 70? ???? 1% ?? - Off pump CABG
• On pump? ??? ??.
• Avoiding CP Bypass Cx : CVA/TIA, RF, SIRS
• ??? ? ? valve ?? ???, ??? ?? ?? ??.
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