← All decks
Cardiology
Intravascular Lithotripsy
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
12 sections · 108 slides
Overview
- Scope of this presentation
Calcification as a barrier to PCI
- Coronary artery calcification as a risk factor
- Comorbidities associated with severe calcification
- Consequences of stenting a calcified vessel
- Histology of coronary atherosclerosis
- Stent deployment in a coronary artery
- Rationale for plaque modification
Current modalities for calcium modification
- Limitations of atherectomy
- Rotational atherectomy: device and mechanism
- Operator and burr size effects on complications
- Orbital atherectomy: device and mechanism
- Rotational versus orbital atherectomy: evidence
- Head-to-head OCT trial of RA versus OA
- Laser atherectomy in calcified lesions
- Super-high-pressure balloons
- Cutting and scoring balloons
- Comparison of established calcium-modifying tools
Fundamentals of intravascular lithotripsy
- Origin of lithotripsy in medicine
- Electro-hydraulic lithotripsy in the coronary catheter
- Advantages of IVL over existing technologies
- Wire bias and depth of calcium modification
- Mechanism of intravascular lithotripsy
- OCT evidence for calcium fracture as the mechanism
- Intravascular ultrasound of a coronary artery
- Pooled OCT results across the Disrupt CAD trials
- Regulatory approval and adoption
Procedural technique
- Lesion assessment before lithotripsy
- Pulse delivery sequence
- Pulse limits and pressure escalation
- Deliverability of the lithotripsy balloon
- Sequential atherectomy before lithotripsy
- Treating long and diffuse calcified segments
- Determining the number of pulses required
The Disrupt CAD programme
- Design of the Disrupt CAD trials
- Measures reported across the trials
- Lesion Characteristics and Procedural Outcomes in the Disrupt Cad Trials
- Interpreting the acute angiographic results
- Rates of Mace with Ivl in the Disrupt Cad I–IV Trials
- Rates of Mace with Ivl in the Disrupt Cad I–IV Trials (continued)
- Composition of MACE in the Disrupt CAD trials
- Calcium fracture identified in Disrupt CAD II
- Serial OCT through lithotripsy and stenting
- Calcium fracture rates before and after stenting
- Microfractures below the resolution of OCT
- Effect of stenting on fracture dimensions
- Calcium Fracture Analysis Post- Ivl and Post-Stenting by Oct in the Disrupt Cad II–IV Trials
Anatomic considerations
- Role of intravascular imaging before treatment
- Concentric and eccentric calcification defined
- Clinical impact of eccentric calcification
- Calcified nodules: definition and subtypes
- OCT morphology of calcified nodule lesions
- Outcomes of lithotripsy in calcified nodules
- Left main coronary artery disease
- Selecting bypass surgery over PCI in left main disease
- Haemodynamic considerations in left main lithotripsy
- Evidence status of lithotripsy in left main disease
In-stent restenosis and acute coronary syndromes
- Lithotripsy for stent under-expansion
- Polymer integrity and metal layers
- CathPCI registry experience in in-stent restenosis
- Adjunctive strategies used with lithotripsy in ISR
- In-hospital outcomes of lithotripsy for ISR
- Acute coronary syndromes: trial exclusion
- Registry cohort of lithotripsy in acute coronary syndromes
- Outcomes of lithotripsy in acute coronary syndromes
- Interpretation of the acute coronary syndrome data
Indications and equipment
- Circumstances favouring lithotripsy
- Calcium Volume Index Score
- Deep calcium as the target for lithotripsy
- Components of the coronary lithotripsy system
- Lithotripsy catheter, generator and connector cable
- Specifications of the C2+ lithotripsy catheter
- Catheter working length and emitter spacing
- Emitter configuration and wave dispersion
Limitations
- Evidence limitations of the Disrupt CAD programme
- Untested combination and bailout strategies
- Technical limitations of the device
Structural and valvular applications
- Lithotripsy beyond the coronary circulation
- Facilitating transfemoral access for TAVR
- Valvular calcification and procedural risk
- The L6 peripheral lithotripsy balloon
- Mitral annular calcification and valvuloplasty
- Lithotripsy before balloon mitral valvuloplasty
- Transcatheter mitral valve replacement and future devices
Conclusion
- Calcification and revascularisation outcomes
- Complementary role of atheroablation and lithotripsy
- Sequential calcium modification in severe disease
- Future directions for lithotripsy
- Summary of key points
- References
- References
- References
- References
- References
- References
- References
- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
- Join our WhatsApp groups