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Cardiology
Percutaneous Coronary Intervention (PCI) Navigating Acute Procedural Complications and Optim
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
12 sections · 154 slides
Overview
- Scope of this presentation
Introduction
- PCI as the dominant revascularization strategy
- Historical drivers of PCI innovation
- Radial access and bleeding reduction
- Rising procedural complexity
- Terminal complications of PCI
- Acute percutaneous coronary intervention complications
- Acute percutaneous coronary intervention complications (continued)
Fundamentals of prevention
- Prevention as the governing principle
- Case selection and multidisciplinary input
- Updated PCI metrics from the CathPCI Registry
- Updated PCI metrics from the CathPCI Registry (continued)
- Domains of pre-procedural risk stratification
- Patient risk factors for PCI complications
- Cardiovascular risk factors for PCI complications
- Anatomically complex coronary disease
- Lesion and clinical classification systems: ACC/AHA, SCAI and Mayo Clinic
- Lesion and clinical classification systems: ACC/AHA, SCAI and Mayo Clinic (continued)
- SCAI lesion classification
- SYNTAX score and revascularization choice
- Mayo Clinic risk score and SYNTAX II
- SYNTAX score II variables
- Operator experience and PCI volume
- Pre-procedure planning to prevent complications
- Intraprocedural technique that prevents complications
- Office-based labs and rescue capability
- Role of the catheterization laboratory team
- Quality improvement after a complication
- Operator composure during a complication
Advances that improved PCI safety
- Enhanced intravascular imaging techniques
- Guidewire in a false lumen on intravascular ultrasound
- Transradial approach
- Improved stent deliverability
- Adjunctive equipment
- Mechanical circulatory support for high-risk PCI
- Calcium modification and covered stents
Acute vessel closure
- Definition and presentation of acute vessel closure
- Historical incidence of acute vessel closure
- Aetiology of acute vessel closure
- Definition of coronary dissection
- Classification of dissection by cause
- Type F dissection
- Classification systems for coronary artery dissection
- Classification systems for coronary artery dissection (continued)
- Prevention of coronary dissection
- Wire handling to avoid dissection
- Immediate management of coronary dissection
- Choosing conservative versus stent management
- Stenting technique for dissection
- Distal right coronary artery dissection sealed with a stent
- Regaining the true lumen after wire-induced dissection
- Difficult and refractory dissections
Iatrogenic aorto-coronary dissection
- Definition of iatrogenic aorto-coronary dissection
- Distinguishing IAD from aortic dissection
- Incidence of iatrogenic aorto-coronary dissection
- Prevention of aorto-coronary dissection
- Guide extension and injection technique
- Aorto-ostial dissection of the right coronary artery
- Management of aorto-coronary dissection
- Indications for surgery in aorto-coronary dissection
- Follow-up imaging after aorto-coronary dissection
- Definition of intramural haematoma
- Recognition of intramural haematoma
- Intramural haematoma of the distal left main on IVUS
- Management of intramural haematoma
Embolisation and no-reflow
- Recognition of coronary embolisation
- Air embolism during PCI
- Thrombus and plaque embolisation
- Management of thrombotic embolisation
- Definition of the no-reflow phenomenon
- Settings in which no-reflow occurs
- Management of no-reflow
- No-reflow and its resolution after targeted drug delivery
Equipment entrapment and loss
- Mechanism of equipment entrapment
- Guidewire entrapment in bifurcation PCI
- Management of a fractured guidewire fragment
- Rotablator burr entrapment
- Freeing an entrapped rotablator burr
- Epidemiology of stent loss
- Consequences of stent loss
- Prevention of stent loss
- Further precautions during stent delivery
- Algorithm for the management of stent loss
- Deciding where a lost stent needs treatment
- Percutaneous retrieval techniques for a lost stent
- When retrieval fails
- Stent loss, migration and management by crushing
Coronary artery perforation
- Definition of iatrogenic coronary artery perforation
- Risk factors for coronary perforation
- Incidence and outcome of coronary perforation
- Ellis classification of coronary perforation
- Frequency and cause by perforation type
- Angiographic recognition of perforation
- C-CAT sign and imaging-guided prevention
- Balloon and device factors in perforation
- Guidewire precautions in CTO intervention
- Anatomical classification of perforation site
- Perforation after atherectomy and lithotripsy in a calcified lesion
- First steps in managing coronary perforation
- Algorithm for the management of coronary perforation
- Conservative management of small perforations
- Management of large-vessel perforation
- Ping-pong guide technique
- Covered stents for large-vessel perforation
- Comparative overview of major covered coronary stents
- Comparative overview of major covered coronary stents (continued)
- GraftMaster Rx deployment technique
- PK Papyrus and comparative outcomes
- After covered stent deployment
- Detection of distal-vessel perforation
- Management of suspected distal wire perforation
- Embolisation for distal-vessel perforation
- Distal perforation of the ramus intermedius treated with coils
- When embolisation is not feasible
- Timing of pericardiocentesis
- Drainage and transfusion in tamponade
- Reversal of anticoagulation after perforation
- Refractory perforation and surgical repair
Human factors and error management
- Human error as a source of PCI complications
- Error frameworks applied to the cath lab
- Layers underlying a visible complication
- Threat and Error Management
- Application of threat and error management in PCI
- Application of threat and error management in PCI (continued)
- Future directions in PCI safety
Summary
- Key principles of complication prevention
- Key principles of complication management
- Key figures in acute PCI complications
References
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- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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