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73 Cards in this Set
- Front
- Back
ANATOMY: What are the Layers of the Heart from the inside out?
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Endocardium (inner)
Myocardium (middle) - muscle that helps contract the heart Epicardium (Pericardium) - double walled sac |
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ANATOMY:What are the 4 Chambers of the Heart? And what divides them?
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Left Atrium
Left Ventricle Right Atrium Right Ventricle Divided by the Septum |
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ANATOMY:What is the route that Blood Travels in the body?
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SVC/IVC Coronary Sinus
Right Atrium Tricuspid Valve Right Ventricle Pulmonary Semi-lunar Valve Pulmonary Trunk (artery w/deoxygenated blood) Lungs Pulmonary Vein Left Atrium Bicuspid/Mitral Valve Left Ventricle Semi-lunar/Aortic Valve Aorta to Systems |
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ANATOMY:What do Valves do? What are the Valves of the Heart and their locations?
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Valves permit blood to flow in one direction
Tricuspid valve - 3 leaflets between Rt atrium & Rt ventricle Mitral/Bicuspid Valve - 2 leaflets between Left Atrium & Left Ventricle Pulmonic Valve - between RV & PA (3 leaflets) Aortic Valve - between LV & Aorta (usually 3 leaflets) |
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ANATOMY:Coronary Arteries:
Right Coronary Artery Branches What section does it feed? |
Rises from coronary cusp of Aortic Valve & travels down right AV groove/sulcus on heart's posterior side
Conus Branch - feeds RVOT (where arrythmias originate) SA Nodul artery - feeds SA node and Right Atrium Divides into Rt Circumflex artery & Posterior Desc Artery |
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ANATOMY:Coronary Arteries:
Left Coronary Artery Branches Two Main Branches & their branches |
Left Anterior Descending Artery -diagonals
Left Circumflex Artery - Obtuse Marginals (OMs) |
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ANATOMY:Coronary Arteries: LAD & CIRC
Where do they rise from & feed? |
Arise from posterior sinus, runs in the AV groove between the left atrial appendage & the main trunk of the pulmonary artery
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Indications for Coronary Angiography
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CAD, new onset, unstable angina, pre-op, positive ETT
MI - post infarct, Cardiomyopathy, CHD, Heart transplant pre-op, Valvular Heart disease, Aortic Dissection |
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Contraindications for Coronary Angiography
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Uncontrolled CHF, HTN, arrhythmia, Fever of unknown origin, electrolyte imbalance, CVA within last month, patient unwilling, Medication toxicity, Pregnancy, Renal insufficiency, Hemorrhages
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Cardiac Image Acquisition:
Radiographic Image of Left Heart Failure |
Cardiac enlargement
Enlarged superior pulmonary veins Diminished inferior pulmonary veins Pleural effusions Interstitial & Alveolar Edema |
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Cardiac Image Acquisition:
Radiographic Image of Right Heart Failure |
Dilated SVC
Dilated Right Ventricle & Right Atrium Widening of the Mediastinum Elevated Right Hemi-diaphragm |
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ANATOMY:Where do the coronary arteries arise from?
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Sinus of Valsalva
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ANATOMY:What are the layers in the arteries?
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Intima (inner layer) made up of endothelial cells
Media (middle layer) smooth muscle & collagen Adventia (outer layer) smooth muscle & vasovasorium; arteriole network |
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Access Methods for Angiogram & types of closure devices
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Access through Femoral, Brachial, Radial (Allen's test)
Closure pads, angio seal (collagen plug) perclose, suture sheath |
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Contrast Administration during Angiogram
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Ample enough to substitute blood contained in coronary vessels
Too low - streaming Too high - risk of coronary dissection resulting in myocardial blushing Too long - patient at risk of bradycardia or myocardial blockade |
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Complications during an angiogram
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Bleeding at puncture site
MI or death Vascular injury: CVA, Hemmorrhage, emboli, dissection Protamine reaction Vasovagal attacks Contrast reaction Infection, CHF, Cardiac puncture, cardiac tamponade Severe arrhythmias: V-tach, V-Fib, A-Fib, SVT, Heart Block, Asystole, during angiogram |
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ANATOMY:Internal Mammary Angiography: LIMA & RIMA
Origin? Catheter used? Projection? |
LIMA: originates anteriorly from the caudal wall of the subclavian artery distal to vertebral artery. JR4 or IMA catheter for better flow characteristics, less susceptible to atherosclerosis than saphenous veins.
RIMA: less common, crosses mediastinum, right subclavian below vertebral |
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ANATOMY:Saphenous Vein Graft Angiography: Location of grafts, catheters used, helpful hints
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RCA bypass - located few cm above and anterior to RCA orifice. JR4, RCB (vertical take-off) Amplatz
LAD & diags - somewhat higher & to left. JL4, LCB, Amplatz Obtuse marginals - usually highest & furthest left. JL4, LCB Helpful to find grafts: Metallic markers or do Aortic Root contrast injection |
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Ventriculography
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Left Ventricle with cine to determine ventricular function (wall motion & ejection fraction)
Helps determine: septal defects, mitral regurg Pigtail or closed-end catheter, 30˚RAO free from spine Right Ventricle rarely done except for R to L shunting, pulm stenosis & eval pulmonary outflow, tricuspid regurg & rt ventricle dysplasia |
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Biopsy:
Indications, Complications & Bioptome Catheter |
Endomyocardial biopsy, bioptome tip catheter to right ventricle septal wall, under fluoro or echo US
Indications: used to monitor transplant for infections viral myocarditis secondary cardiomyopathy endocardial fibrosis cardiac malignancies Cardiotoxicity Contraindications: Anatomic abnormalities, anticoagulation Bioptome complications: conduction block, leaflet damage, tamponade from RV perf |
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Percutaneous Transluminal Coronary Angioplasty:PTCA What is it? Dilemma during intervention & prevention
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PTCA is revascularization of coronary arteries.
Spasm of the artery may result in total occlusion therefore Nitroglycerin is given To improve outcome: Use Laser catheters, Atherectomy catheters or intracardiac stents |
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Percutaneous Transluminal Coronary Angioplasty:PTCA
Pre-procedure Work-up |
ECG, ETT (exercise treadmill test), coronary angiography
Meds: antiplatelet aggregation - antithrombotics Sublingual nifedipine or continuous drip nitro for spasm Calcium channel blocker to help dilate smooth muscle In order: nifedipine, diltizem, verapamil |
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Percutaneous Transluminal Coronary Angioplasty:PTCA
Procedure |
Transluminal pressure during procedure
:manifolds/transducers, pressure tubing w/'y' connector (toughy), hemodynamic monitoring & recording Larger sheath to accomodate equipment |
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Percutaneous Transluminal Coronary Angioplasty:PTCA
Guiding Catheters |
Thinner wall - larger lumen: accomodates contrast & balloons, etc
'Y' connector (toughy) for balloon catheter & wire thru 1 port and contrast/flush/meds through other port |
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Percutaneous Transluminal Coronary Angioplasty:PTCA
Wires |
.014 Wires
Used once guide is in aortic root Stiffer wire for difficult stenosis or total occlusions Softer wire for tortuous vessels |
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Percutaneous Transluminal Coronary Angioplasty:PTCA
Manipulating Catheters "Backing out" |
Catheter is injected from coronary orifice to provide support needed to advance the balloon across the lesion
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Percutaneous Transluminal Coronary Angioplasty:PTCA
Manipulating Catheters "Deep Throat" |
To provide additional support when crossing a very tight stenosis, catheter goes further into vessel, used only in extreme cases to so avoid dissection
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Percutaneous Transluminal Coronary Angioplasty:PTCA
Balloon Catheters |
Inflated with Contrast (30%)
Watch patient for cardiac hemodynamic compromise (decrease in pressures, angina, arrhythmia) |
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Percutaneous Transluminal Coronary Angioplasty:PTCA
Outcome |
Positive results include:
Good angiographic flow Reduced pressures No evidence of thrombus or residual ischemia |
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Percutaneous Transluminal Coronary Angioplasty:PTCA
Debulking: Transluminal extraction catheters |
Thrombus sucked out through catheter (Angiojet or Aspiration Catheter)
Laser angioplasty: catheter with laser tip, pulsating beam of light vaporizes plaque Directional atherectomy: high speed device on tip of catheter, like a sander to remove plaque (Roto-blader) |
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Percutaneous Transluminal Coronary Angioplasty:PTCA
Stent Placement |
Scaffolding the artery wall from inside the lumen
- anticoagulation managed Implantation - distal stent placed first for multiple stents |
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Percutaneous Transluminal Coronary Angioplasty:PTCA
Thrombolysis |
Mechanical: Angiojet & Aspiration catheters
Pharmacologic: -Streptokinase, tenectplase (TPA) alleplase, releplase, urokinase -given 6-12 hours onset of MI - complications: bleeding, contraindications: stroke, hemorrhage, CVA < 1 yr, intercranial neoplasm, active bleeding, suspected aortic dissection |
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Pericardiocentesis: What is it? Indications. Risks.
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The use of a needle to remove fluid from the pericardial sac which may be evaluated for diagnostic purposes. To evaluate pericardial effusion or tamponade.
Supplies: Needle, Wire, Catheter (could be left in place for hours as a drain) Indication: Pericarditis, CHF, Cancer, Cardiac trauma Risks: Puncture of myocardium or coronary artery, pneumopericardium (air in pericardium sac), MI, infection, needle induce arrhythmia, puncture of lung, liver stomach |
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Intra-Aortic Balloon Counterpulsation (IABP)
Access point, Balloon prep Body placement Primary goal Inflations & Deflations |
Puncture 2 cm below inguinal line, negative vacuum on balloon
Placed in descending aorta with the tip distal to aortic arch (below origin of the left subclavian artery) and above renal arteries Primary goal: to increase myocardial oxygen supply & decrease myocardial oxygen demand Secondary goal: to improve CO, EF, increase coronary perfusion pressure & systemic perfusion, lower HR and PCWP Inflation with onset of diastole (t-wave dicrotic notch), deflation just prior to onset of systole (r-wave) Helium used due to low molecular weight (minimizes shuttle time & thus increases efficiency) |
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Intra-Aortic Balloon Counterpulsation (IABP)
Indications |
Indications: Refractory unstable angina, cardiogenic shock, hemodynamic compromise, high risk PTCA, V-tach because of myocardial ischemia
Left Main or 3 vessel disease, going to surgery Acute MI with mechanical impairment (mitral regurg) Left Ventricular failure |
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Intra-Aortic Balloon Counterpulsation (IABP)
Contraindications |
Aortic dissection or aneurysm
severe aortic valvular insufficiency sepsis bleeding diathesis femoral-iliac abnormalities / bypass grafts |
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Removal of Foreign Bodies
Types of objects and devices |
Dislodged stents, catheter breakage
Snare loop retrieval (safest) Basket retrieval device Forceps retrieval device Goose neck snare (surgical) |
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Hemodynamics: Ejection Fraction
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EF = SV (Stroke Volume) / EDV (End Diastolic Volume)
The % of the EDV that is ejected during systole Above 55% is normal 40-55% is moderately impaired 30-40% seriously impaired below 30% gravely impaired *Averaging 65% as 'normal' |
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Hemodynamics: Stroke Volume
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SV = EDV (End Diastolic Volume) - ESV (End Systole Volume)
Volume in mL ejected during contraction |
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Hemodynamics: Cardiac Output
Calculation, What is it? How is it measured? CI? |
CO = SV (stroke volume) X HR (heart rate)
Normal range is 4-8 L/min The amount of blood the left ventricle pumps into the aorta, an accurate indicator of cardiac function CI (cardiac index) provides a comparison between individuals' cardiac function regardless of their body size. |
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Hemodynamics : Cardiac Output Measurements
Fick Method |
Oxygen consumption method
CO = oxygen consumption/[10 (CaO2 - CvO2)] CaO2 = arterial oxygen content CvO2 = venous content |
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Percutaneous Equipment: Diagnostic Catheters
What do they do? Types of Catheters |
Catheters deliver contrast, embolizing material, meds and instruments
Types include: End Hole: stronger stream of contrast, selective Side Hole: greater contrast delivery, less recoil, used for aorta, vena cava, LV Balloon tip: angioplasty Tapered or Nontapered |
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Percutaneous Equipment: Diagnostic Catheters
Sizes, Shapes |
Sizes: measured in French (3-12F) outer diameter
-increments of .33 or 1/3 mm Shapes: various shapes for various uses |
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Percutaneous Equipment: Diagnostic Catheters Materials
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Radiolucent: to view bubbles
Radiopaque: to visualize with fluoro |
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Percutaneous Equipment: Interventional Guiding Catheters
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Thinner wall and larger lumen to allow contrast injection with balloon in place
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Percutaneous Equipment: Diagnostic Guidewires
What are they made of? |
Stainless steel core with stainless steel wrapping, coated with Teflon. Has rigid proximal end with somewhat flexible distal tip to prevent vessel wall damage
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Percutaneous Equipment: Diagnostic Guidewires
Types of coating on wires Diameters Types of cores: |
Teflon, polyurethane, polyethylene, hydrophilic (glidewires)
Diameters: .014-.045" Cores: -Fixed: for sclerotic vessels -Moveable: core moved with use of handle (madril) to length of tip (allows flexibility, increases maneuverability in vessel, 10-15cm moveable core tip) |
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Percutaneous Equipment: Diagnostic Guide wires
Sizing factors |
inner diameter of catheter
vessel size needle gauge *Wire small enough to permit blood to flow in the vessel yet large enough to prevent back flow *Keep wire taught & within sterile field! |
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Percutaneous Equipment: Interventional Guide wires
Types of Steerable Coronary Guide wires |
Stiffer wire: crossing difficult stenosis, total occlusions
Softer wire: safer for tortuous vessels |
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Percutaneous Equipment: Needles
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one-piece or single wall needle
2 piece or double wall (Seldinger, Modified Potts) 3 piece or sheath needles -Cannula, Stylet, sheath (Amplatz, Potts-Courand, Becton Dickinson or translumbar needle) Bevel up! - not to sheer wire! |
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Intravascular Devices: Intravascular Ultrasound (IVUS)
what does it do? |
Measures lumen size & true vessel size & lesion length
Helps choose proper therapy & determine optimal revascularization Give 2 dimensional eval of lumen, inside out, 360˚ view Determines vessel size, superficial calcium deposits, small artery wall tears (dissections), guide for complete stent deployment |
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Intravascular Devices: Fractional Flow Reserve (FFR)
Pressure wires What does it do? How does it work? |
maximum blood flow to the myocardium achieved in the presence of narrowing compared with the maximum blood flow possible in the theoretical absence of the narrowing
*Compares the coronary pressure prior to the lesion to the pressure distal to the lesion Wire has microsensor 3cm from tip Measures pressure as well as temperature -injection of saline at tip of guiding cath for temp meas & IV injection of adenosine for pressure measures |
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Intravascular Devices: FFR Measurements
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Pa = aortic pressure at guiding catheter
Pd = distal coronary pressure near tip of wire FFR = ratio Pd/Pa at maximum hyperemia |
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Therapeutic Devices: Balloons
Over-the-wire |
Central lumen for guidewire
Separate lumen for balloon inflation Advantages: more flexible, trackable nature, distal wire position, multiple guide wires, distal port Disadvantages: 2 people needed, larger profile |
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Therapeutic Devices: Balloons
Rapid Exchange (Singel Operator Exchange) Monorail |
To improve the ease of exchanging, single operator, guidewire exiting about 30cm from the tip
Advantages: distal wire position, enhanced visualization, lower profile, single operator, stiffer for more pushability. Disadvantages: need excellent guiding catheter support, poor tracking if not flushed |
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Therapeutic Devices: Balloons
Fixed Wire |
serves as its own guide wire, balloon mounted on steerable wire
Advantages: enhanced visualization, single operator, flexible, best for access to distal lesions, use with small guiding catheter, low profile Disadvantages: no through lumen, need to recross lesion with each removal |
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Therapeutic Devices: Balloons
Perfusion Balloons |
enables blood to perfuse across a stenosed area into the distal coronary artery when the balloon is inflated.
'bail-out' balloon for spontaneous closure (not used commonly now due to modern thrombolytics & class IIb/IIIa agents |
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Therapeutic Devices: Balloons
Compliant |
Early-generation made of polymers like polyester, were stiffer & larger than today's.
Then made polymer hybrid called polyolefin copolymer, which came to be called 'compliant' balloons. They are responsive to balloon inflation pressures, increasing in diameter with each Atm applied. They are soft flexibilty & trackability over high degree, tortuous coronary lesions. Shape to the artery as they are inflated. They may 'dog bone' which increases risk of dissection or intimal disruption |
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Therapeutic Devices: Balloons
Non-compliant (NC) |
Polyethyleneterphthalate (PET) balloons suited for long-inflation angioplasty & coronary stenting.
Holds across the length of the balloon, minimizing 'dog bone' effect. Ideal for unstable and calcified lesions Used for post-stent placement They are less able to pass through tortuous anatomy, but becoming less of an issue over time with lower profile |
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Therapeutic Devices: Balloons
Cutting Balloons |
Razor-sharp microtome blades imbedded on a hard polymer inflation balloon
As the balloon is inflated, blades are exposed and pushed out , creating microsurgical incisions into both hard and softer plaque areas Valuable for PTCA of smaller diameter vessels and bifurcation side branches. In combination with brachytherapy, favored approach for the tx of in-stent restenosis. |
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Therapeutic Devices: Stents
History |
March 28, 1986, in Toulouse France, the first coronary stent was placed in a human for the first time (first one experimented in dogs)
Wallstent; self-expanding mesh stent |
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Therapeutic Devices: Stents
Indications |
**Reduce vascular recoil, tack up intimal dissections, and increase vessel lumen diameter.
PTCA for acute infarction Restnotic lesions CTO Sub-optimal results after PTCA Saphenous vein graft disease Primary reduction in restenosis in non-restenotic focal lesions, in 3mm vessels Tx of abrupt, & prevention of threatened, coronary occlusions after balloon angioplasty |
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Therapeutic Devices: Stents
Self-expanding |
prototype is the Wallstent
Woven-wire mesh that is fused together to form a mesh tube of a specific size. Gives very good coverage, but does tend to block off side-branches (so good for SVGs or RCA) High rate of stent thrombosis & restenosis Poor radial strength Used currently more often in SVGs, peripheral vascular disease in the iliacs and femoral vessels & carotid stenting |
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Therapeutic Devices: Stents
Balloon-expandable |
Mounted on a PTCA delivery balloon & deployed in the vessel at the recommended inflation pressure
2 design types: coiled wire and slotted tube Made of surgical stainless steel, newer stents of cobalt chromium alloy, which allows struts to be made thinner, increasing flexibility |
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Therapeutic Devices: Stents
Balloon-expandable (Coiled Wire Design) |
stainless steel into a coil pattern
flexibility and radial support Some made up of a # of coils welded together Not used today |
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Therapeutic Devices: Stents
Balloon-expandable (Slotted Tube Design) |
Palmaz-Schatz stent first with a slotted tube design
Cut with a laser, made of stainless steel or cobalt chromium Offers superior radial strength over other stent designs |
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Therapeutic Devices: Stents
Drug-Eluting Stents (DES) -The 3 elements & original drug types |
Made up of 3 elements:
the stent, the drug, and the polymer that binds the drug to the stent 'Sirolimus' a cytostatic agent stops cellular proliferation just prior to this checkpoint, allowing viable cells to return to a resting state. Another drug called 'Paclitaxel' used in Taxus |
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Therapeutic Devices: Stents
Drug-Eluting Stents (DES) |
If pre-dilating, choose balloon shorter in length than the DES to be deployed to avoid trauma/dissection outside the stent
Stent reach from 'normal vessel to normal vessel' Post-dilating should be NC, shorter than stent and .25-.5mm larger than deployed DES, to ensure complete apposition to the vessel wall |
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Therapeutic Devices: Stents
Other Stent Types: AMS |
Bioabsorbable Stents (AMS) - gradually disappears within the vessel, yet the lumen area is consistently larger compared to vessels treated with conventional stents. First one done in 2003 in Belgium below the knee
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Therapeutic Devices: Stents
Other Stent Types: Bioengineered Endothelialization |
Stent has a biologically activated coating designed to attract endothelial progenitor cells (EPCs), they are captured by the coating and encapsulation begins within one hour after implantation.
This rapid endothelialization eliminates the risk of acute thrombosis & may reduce the need for antiplatelet therapies |
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Therapeutic Devices: Stents
Other Stent Types: Side-branch/Bifurcation Stents |
Stents wherein the middle section has less struts or a larger open cell, to place over side-branches.
Bifurcation stents, 'y' shaped stent mounted on 2 balloons, which are expanded simultaneously. |
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Therapeutic Devices: Stents
Other Stent Types: Covered Stents (Stent Grafts) |
Stents covered with a mesh that becomes semi-impermeable when it is exposed to blood, but porous enough to allow endothelialization.
Such as in AAA. |
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Therapeutic Devices: Atherectomy
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Non-surgical procedure to remove plaque
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