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Cardiology
Atherectomy, Thrombectomy, and Emboli Protection Devices
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
7 sections · 136 slides
Overview
- Scope of this topic
- Three device families
Atherectomy devices
- Coronary artery calcification and PCI outcomes
- Atherectomy devices in current use
- Rotational atherectomy: history and utilisation
- Randomised evidence for rotational atherectomy
- Guideline recommendation for rotational atherectomy
- Angiographic definition of coronary calcification
- Intravascular imaging of coronary calcium
- Imaging predictors of stent underexpansion
- Severely calcified mid right coronary artery lesion
- Intravascular ultrasound of the calcified mid-RCA lesion
- Indications for rotational atherectomy
- Rotational atherectomy in chronic total occlusion
- Perforation and dissection risk with rotational atherectomy
- Rotational atherectomy burr and drive system
- Advancer, driveshaft and console
- Planned versus provisional rotational atherectomy
- Burr sizing and burr-to-artery ratio
- Guide catheter size for different burr sizes
- Periprocedural pharmacology and pacing
- The RotaWire: construction and variants
- Choosing between floppy and extra support RotaWire
- Wire handling during rotational atherectomy
- The flush cocktail
- Burr speed and ablation technique
- Slow flow and microvascular embolisation
- Dissection and perforation rates
- Morphological predictors of perforation
- Burr entrapment: mechanisms
- Retrieval of an entrapped burr
Orbital atherectomy
- Orbital atherectomy device description
- Mechanism of orbital atherectomy
- Indications for orbital atherectomy
- ORBIT I trial
- ORBIT II trial
- Real-world registry and the ECLIPSE trial
- Guideline recommendation for orbital atherectomy
- Technique of orbital atherectomy
- Complications of orbital atherectomy
- Precautions during orbital atherectomy
- Run duration and device rest periods
- Conduction disturbance and ostial lesions
Excimer laser coronary atherectomy
- Excimer laser coronary atherectomy: the device
- Three mechanisms of excimer laser action
- Advantages of excimer laser atherectomy
- Indications for excimer laser atherectomy
- Excimer laser in uncrossable lesions and in-stent restenosis
- Guideline recommendation for excimer laser
- Laser settings and catheter selection
- Operational tips for safe laser use
- Complications and success rates of excimer laser
Intravascular lithotripsy and plaque-modifying balloons
- Coronary intravascular lithotripsy
- Disrupt CAD pooled analysis outcomes
- Guideline recommendation for intravascular lithotripsy
- Intravascular lithotripsy balloon in the mid right coronary artery
- Non-compliant balloon expansion after lithotripsy
- Final angiographic result after lithotripsy and stenting
- Plaque-modifying balloons available
- Cutting balloon design and advantages
- Scoring balloons and guideline recommendation
Thrombectomy devices
- Pathophysiology of ST-elevation myocardial infarction
- TIMI 3 flow as a marker of reperfusion
- TIMI flow grading
- Myocardial blush grade
- Myocardial blush grade
- Angiographic definition of successful reperfusion
- Consequences of a large thrombus burden
- Coronary thrombus grading
- Classification of thrombectomy devices
- Commonly used manual aspiration catheters with sheath sizes
- Commonly used manual aspiration catheters with sheath sizes (continued)
- AngioJet rheolytic thrombectomy
- CAT RX continuous aspiration catheter
- CHEETAH study of the CAT RX system
- The CHEETAH-ACS trial
- Technique of CAT RX thrombectomy
- In-stent thrombus in the right coronary artery
- Residual thrombus burden after balloon angioplasty
- Angiographic result after CAT RX thrombectomy
- Final result after stenting the right coronary artery
- REMEDIA trial
- TAPAS trial
- EXPIRA trial
- Meta-analysis supporting manual thrombectomy
- Studies supporting thrombus aspiration in acute myocardial infarction
- AiMI trial
- JETSTENT trial
- TASTE trial
- TOTAL trial
- Patient-level meta-analysis of aspiration trials
- Studies not favouring routine thrombus aspiration in acute myocardial infarction
- INFUSE-AMI trial
- Summary of the thrombectomy evidence
- Current guideline on aspiration thrombectomy
Embolic protection devices
- Rationale for embolic protection
- Evidence for embolic protection in vein graft intervention
- Types of embolic protection device
- Distal embolic protection devices available
- Filter wire versus distal occlusion balloon
- Limitations of filter wire protection
- Landing zone and side branch limitations
- Filter entrapment and retrieval difficulty
- No-reflow with a loaded filter
- Applicability of embolic protection in vein grafts
- Calcified vein graft stenosis unsuitable for distal protection
- Long diffusely degenerated vein graft to the diagonal
- Final result in the vein graft without embolic protection
- Proximal protection devices
- Advantages and limitations of proximal occlusion
- SAFER trial of distal protection in vein grafts
- Components of the SAFER benefit
- Meta-analysis of embolic protection in vein graft PCI
- Guideline recommendations for embolic protection
- Guideline classes across the devices
- Key principles for device selection
- Points worth remembering
- References
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- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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