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Chapter 19: Myocardial Revascularization with Percutaneous Devices

James M. Wilson; James T. Willerson

INTRODUCTION

At its height, the success of surgical coronary revascularization spurred improvement in catheter-based technology—first for imaging quality, and later for attempted therapy. In 1974, Andreas Gruentzig completed the development of a double-lumen balloon catheter that was miniaturized for use in coronary arteries. Soon afterward, techniques for percutaneous transluminal coronary angioplasty (PTCA) expanded as technical breakthroughs were applied to subselective catheters, devices, guidewires, balloon materials, coronary stents, and circulatory support. Currently, trial evidence attests that percutaneous therapy is useful as a treatment in patients with poorly controlled angina whose anatomy does not imply a survival benefit from revascularization, and for emergency revascularization during ST-segment elevation myocardial infarction (MI). Surgical and percutaneous revascularization, however, cannot be considered equivalent.1

BALLOON ANGIOPLASTY

Principles

In the early balloon angioplasty era, several technical limitations restricted the use of percutaneous techniques to low-risk patients with proximal, discrete coronary artery stenoses, and procedural outcomes lacked predictability. As advances in tools and techniques were developed, higher-risk patients became candidates for percutaneous therapy. Over time, several principles for safety and success were recognized (Table 19-1).

TABLE 19-1:Principles of Percutaneous Coronary Intervention
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TABLE 19-1: Principles of Percutaneous Coronary Intervention

  1. The patient’s outcome is a function of age, comorbidity, and coronary morphology

  2. The procedure’s outcome is a function of coronary morphology and proper planning (ie, sequence and equipment choices, such as guidewires and device)

  3. Proximal and distal control of the treated vessel must be maintained

    1. Choose proper guide catheter support

    2. Maintain distal wire position

    3. Keep the guide, device, and distal wire tip visible during any movement of any device

  4. The needs and limits to treatment options such as devices, adjuvant medical therapy, contrast use, and circulatory support are determined by

    1. vascular access

    2. the patient’s condition (eg, stable angina or acute myocardial infarction)

    3. ventricular function

    4. comorbidities such as diabetes mellitus, renal insufficiency

  5. The following factors can lead to failure:

    1. Incomplete understanding of the three-dimensional anatomy of the course to be taken and lesion to be treated

    2. Unrealistic interpretation of

      1. the capacity of available techniques to achieve success

      2. the amenability of specific anatomy to percutaneous manipulation

    3. Ignorance of or inattention to technique in subselective device movement

    4. Inattention to anticoagulation

    5. Inattention to catheter hygiene (minimizing blood and contrast stagnation within the guiding catheter or other devices)

Tools

GUIDING CATHETERS

Guiding catheters differ from diagnostic catheters in that a wire braid supports a thin catheter wall, allowing for a larger central lumen and providing enough rigidity to support the advance of subselective catheters to the distal regions of the coronary bed. The anatomy of the ascending aorta and the origin of the treated coronary artery determine which shape of guiding catheter will provide the most secure positioning (Fig. 19-1). The choice of guiding ...

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