PAtho pys in SVG. arrowing
smooth muscle cell proliferation and intimaly hyperplasion, then eventusal atherosclerosis–> usually ists intimal hyperplasioa
pathophys of most graft failure is what?
size of distal vess less than this at risk for early svg closure
neointimal hyperplasia
late graft failure is more hat pathophys
athereoma and fibriosis
- wp of SVG are occlused at 1 year
- IMA at 1 yr
- RF for graft occlusion
- SVG metanalysis dapt
- Naitive vs. SVG PCI?
- mace events compared to normal
- No reflow with svg pci
- post dil w/ svg
- 19%, 26% in another study.
- 5%
- pt factors - younger age pt, EF <30%, HLD, No ASA, enoscopic harves. smoking
Graft - older grft, smaller target diameter, large graft, smaller runoff, distal anastomasolis < 2.0
- metaanlaysus shoed DAPT higher patency of SVG and loer mort at 1 year compared to asa alone. but higher bleeding and no diferince in bleeding.
- favor naitive mantra
- MACE rate compared to normal… 2x
- 5-30%
- try to avoid
- no reflow w/ svg intervention death rate
- SVG PCI IIb/IIIA
- what else doesnt help
- doages for medicined for no reflow -
- push verapamil need to think about what?
- 5-15%–> shoc and heart block (10 x infold) “wake up and smell the flowers”…
- placebo is better.
- NTG, CABG, lytics, IIBIIIA dont dilate
- doages for medicined for no reflo adenosine 10-60 Uc IC, nitroprusside 100, nicard 100verap 100 (everything 100!, except adenosine a little less) everyting is microgram too.
- TVP
embolic protection
- SAFER trial
- SAFER predictors of MACE
- “david cox” great saying about distal protection.
4. problem
5. fire studyy
6. GL rec for SVG
- Baloon distal - non q ave, mace was less,
- No EPD yse, SVG degenration score, plaque volume
- when do you not wear your seatbelt. \
- need a 20 mm landing zone. filter can clog. can get stuck
- filter vs. gaurdwire same safter
- CLASS I
- DIVA trial SVG
- no difference 12 months. equivalent outcomes at 12 months.
STAR and ministar
ADR length requirement
Best channes in order for retrograde approach
basiclally knucl then re-enter, minstar is just to go sub I in the CTO segment.
need 20 mm at least and no major branches
SVG>septal> epcicardial
Hybrid algorhtym 4 coponents with duals to look at
ambigous prox cap
poor distal target
good IC collaterals
Major sidebrach at distal cap
3 major RCTS for CTO
Decision CTO - Park jorea, no difference in mort, too much cross over and many did not achieve - changed enpoint and sample size, negative SAQ
EUROCTO - 2:1 randomization, omt 2 anginal medications. improved QOL (spetus)
impactor CTO - omt v. pci ischemia burden sig reduced and phyica; limitation also improved
gudie you need SKS and 1.75 burr jo meds
7fr,
wire componts
- core
- tip style
- coating
- tip stiffness give some stiff wires
- determines stiffenss of wire and taper and length of taper is impt for steep curves
2, core to tip transition may improve torque compared to shaping ribbon.
- hydrophilic coating
- miracle bros, confianza
watermelon seed means
slipping
key for stents wokking better than poba
more acute gain and less lumen loss for net gain….
LSD
longatdual stent deformation - ostium
provisional vs. 2 stent
provisional is favored. and reduction in All causem mortality
rule of thumb for sizing
which cell do you ant
murrary and finets law
2/3 sum added together will be proxima.
distal most cell.
size of angle for T stent or TAP
3 bailout stent techniques
70 degrees.
TAP, reverse crush, and Cullotte
Plaque modification
burr size bsed one
burr guide reference
50% of index vesel diameter
- 25 and 1.5 6fr
- 75 7fr
- 0 8fr
- 15 8fr
- 25 9fr
- 5 10 fr
CIN definition 3 stages
stage 1 increase by 25% or absolute of >0.3
stage 2 increase >2-3 fold
stage 3 > 3 fold or cr > 4 ith an acute increase of at least 0.5
occurs 48-72 hrs and normalizes 7-10days peaks at a week
Metformin hen to dc
at time of procedure if normal renal function and 48 hours if not.
duration of dual antiplatet therapy
12 vs. 30 mo therpay after mi –> no difference in mort trend to higher at 1 year. 1% of increased risk of major bleeding. this i why dapt didnt change anything.
North american update on triple therapy
high thrombotic risk triple rx x 1 month then drop asa
low thrombotic risk drop asa just after procedure.
strength of abbrievated regimine on gl in SIHD 3 month and 6 mo ACS
IIb
