Heart pearls! » Interventions

Cardiac catheterization image – 002

Dr Jayachandran Thejus MD — Tue, 04 Aug 2009 07:02:00 +0000

LMCA kissing dilation left main coronary artery percutaneous coronary intervention angioplasty

Kissing dilation with one balloon from the left main coronary artery to the left anterior descending artery and with the other balloon from the left main coronary artery to the left circumflex artery.

Cardiac catheterization image – 001

Dr Jayachandran Thejus MD — Sat, 01 Aug 2009 15:00:22 +0000

bovine type II aortic arch cardiac catheterisation catheterization interesting image

Click on the image to enlarge!

Diagnosis- Type II bovine aortic arch

Pointers- (aortogram with pigtail catheter)

1. Left common carotid is arising from the right brachicepalic artery- bovine aortic arch.

2. The right brachiocephalic artery is arising between the horizontal lines at upper and lower borders of the aortic arch- type II aortic arch. (type I- above the upper margin line, type III- below the lower margin line)

Verterbral artery obstructive disease

Dr Jayachandran Thejus MD — Thu, 30 Jul 2009 12:27:55 +0000

Humans can tolerate occlusion of one vertebral artery well.
Usual vertebral artery lesion seen is atherosclerotic stenoses of both vertebral origins.
Surgeries for vertebral artery obstruction are transection and reimplantation to subclavian or carotid, vertebral endarterectomy and vein patch angioplasty. Surgery has high morbidity.
Vertebral artery stenting gives good results in both short and long term and has lower morbidity compared to surgery. PTA alone without stenting is not done as PTA alone is accompanied by considerable recoil as the commonest site of vertebral stenosis is at its origin from the subclavian artery.

Carotid artery disease

Dr Jayachandran Thejus MD — Thu, 30 Jul 2009 12:25:36 +0000

Atherosclerotic extracranial carotid disease causes symptoms by embolism, not thrombosis.
In fewer than half of persons is circle of Willis complete.
With a TIA, chance of stroke in next 30 days is 5%.

Evaluation

Doppler ultrasound of carotids is an excellent screening tool.
MR angiography and CT angiography can give noninvasive angiography pictures.
Conventional invasive angiography with digital subtraction angiography is the gold standard, though it produces stroke in 0.5% cases.

Carotid endarterectomy

Carotid endarterectomy or CEA is the surgery for extracranial carotid artery disease. It has been shown to be better than medical management in the NASCET, ESCT, ACAS and ACST trials. It is recommended in symptoms + >50% stenosis or no symptoms + > 80% stenosis.

Carotid artery stenting or CAS

This uses self expanding stents to avoid stent compression and deformation. To protect from embolisation, protection devices are used which include distal balloon occlusion with aspiration, proximal occlusion with aspiration and distal filter.
The BEACH, ARCHeR & SECuRITY trials found that CAS is safe.
The SAPPHIRE trial compared CAS (with distal emboli protection) with CEA in patients at increased risk for CEA. It found that CAS was better than CEA (for 30 day incidence of stroke, death and MI, for cranial nerve injuries and for 1 year combined endpoint). This trial led to FDA approval of CSA with distal protection for patients at increased risk of carotid surgery.
Studies comparing CAS with CEA for patients who are not at increased surgical risk care EVA-3S and SPACE. The EVA-3S found that CEA is better than CAS while the SPACE trial did not show superiority of either strategy.
Thus, currently CAS is indicated for patients at increased risk of carotid surgery with symptoms + >50% stenosis or no symptoms + > 80% stenosis.