Chapter e33

Percutaneous coronary intervention (PCI) is the most widely employed coronary revascularization procedure worldwide (Chap. 246). It is now applied to patients with stable angina, acute coronary syndromes, including unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI), and as a primary treatment strategy in patients with ST-segment elevation myocardial infarction (STEMI). PCI is also applicable to patients with either single- or multi-vessel disease.

In this chapter, the use of PCI will be illustrated in a variety of commonly encountered clinical and anatomic situations such as chronic total occlusion of a coronary artery, bifurcation disease, acute STEMI, saphenous vein graft disease, left main coronary artery disease, multivessel disease, and stent thrombosis. In addition, the use of interventional techniques to treat structural heart disease will be shown, including closure of an atrial septal defect (ASD) and percutaneous aortic valve implantation; the latter is approved in Europe but is under active investigation in clinical trials in the United States and not yet approved for use.

(Videos e33-1 to e33-7)

• An 81-year-old man with angina, NYHA Class IV congestive heart failure and inferior-apical-posterior ischemia on an exercise technetium-99m scan.
• Diagnostic cardiac catheterization revealed a left dominant system with a totally occluded left circumflex (LCx) artery. The distal LCx filled via collaterals from the left anterior descending (LAD) artery, indicating chronicity of the total occlusion.

Video e33-1

Baseline left coronary angiogram shows an occluded LCx with left-to-left collaterals originating from LAD septal vessels.

Video e33-2

Attempts to cross the total occlusion in the LCx using a hydrophilic wire and an antegrade approach were not successful, with the wire tracking to the right of the trajectory.

Video e33-3

The LAD septal collateral is accessed with a guidewire and directed toward the distal LCx to cross the total occlusion retrograde.

Video e33-4

The total occlusion is crossed retrograde. The wire is snared in the guide, exteriorized, and used to provide antegrade access to the LCx.

Video e33-5

Antegrade flow in the LCx is restored after balloon inflation.

Video e33-6

Following stenting of the total occlusion, blood flow in the distal vessel is improved and a second significant stenosis is seen.

Video e33-7

Final result after LCx stenting.

• Approximately 15–30% of all patients referred for cardiac catheterization will have a chronic total occlusion (CTO) of a coronary artery.
• CTO often leads to a surgical referral for complete revascularization.
• Incomplete revascularization due to an untreated CTO is associated with ...

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