Percutaneous coronary

angiography and angioplasty:

indication and technique
I. Elements of coronary anatomy
with clinical and angiographic
resonance
 Origin in Valsalva sinuses
Three main coronary arteries:
Left coronary artery (left main steam)
❑ Left anterior descending artery
(LAD)
❑ Left circumflex artery (LCx)
Right coronay artery
Subepicardial trajection
Capacitance vessels with elastic structure
predominantly
Pu
LAD RCA

LM Ao
Tri
Cx
Mi
 Left anterior
descending artery
It is considered the main coronary
vessel
It descends within the anterior
interventricular groove
It supplies the antero-lateral wall
of the LV and anterior 2/3 of the
interventricular septum
Branches:
Septal branches
Diagonal branches
Three segments:
Proximal
Medium
Distal
Left circumflex
artery
It is placed in the left coronary
groove

It supplies the lateral and posterior

wall of the LV

Branches:

➢ Obtuse marginals

➢ Postero-lateral branches

➢ Branch for the sinus node (40%

of cases)

➢ Posterior descending artery

(PDA) = left dominance (10-15%
of cases)
Right coronary artery
It descends in the right coronary groove
It supplies the RV, the inferior and
postero-lateral wall of the LV and the
posterior 1/3 part of the interventricular
septum
Branches:
❑ Acute marginals for the RV
❑ Posterior descending artery
❑ Postero-lateral branch
❑ Branches for the excito-conductor
system:
▪ Sinus node (60% of cases)
▪ AV node (90% of cases)
In 10-15% of cases it is hypoplastic: non-
dominant (it doesn’t supply the postero-
inferior wall)
Coronary circulation
 II. Diagnostic coronarography
Definition:
• The selective opacification of the coronary arteries with contrast dye under
radiologic field, aiming for the evaluation of the coronary artery disease
▪ Stenosis > 50%; localization : proximal and medium segments

▪ Number of affected vessels: uni-, bi- or three-vascular disease

▪ Therapeutic decision making: medical therapy, percutaneous, surgical

Necessary –personnel and material:

• Cath lab
• Specific materials: ex. diagnostic catheters
• Highly trained interventional cardiologist
Arterial access:
• Radial, ulnar
• Femural , popliteal
• Brachial, axilar
Catheters for coronarography and ventriculography

Diagnostic Judkins catheters kit

The necessity of using performant catheters
 Cath lab
▪ Radiologic equipment for
fluoroscopy/cine and digital
recording of images
• Mobile table
• Mobile X-ray source

▪ Radiologic equipment
protection
▪ Hemodynamic status: ECG
and invasive BP monitoring
▪ High pressure syringe
▪ Another diagnostic
systems:
• oximetry
• IVUS
• “Pressure-wire”
• Coagulation monitoring
(ACT, aPTT)
 Basic angiography projections for the left
coronary artery

Right anterior oblique caudate Right anterior oblique cranial

 Basic angiography projections for the left
coronary artery

Left anterior oblique cranial Left anterior oblique caudate

Basic angiography projections for the right
coronary artery

Left anterior oblique Left anterior oblique cranial

Ventriculography and aortography
Complications and adverse reactions
▪ Complications at the access point (0.4%):
• Hematomas
• Arterio-venous fistulas
• Pseudoaneurysms
• Dissection and acute artery occlusion
• Local infections
 Complications and adverse
reactions
▪ Cardiac complications :
• Dissection of the coronary ostium

• Coronary embolization

• AMI

• AV block or branch block

• Coronary perforation with acute

tamponade

• Atrial and ventricular arrhythmias

• Acute pulmonary edema

▪ Systemic complications:
• Vagal reactions

• Systemic embolization (CVA !!!)

• Renal dye contrast toxicity

• Allergic reactions
 Mortality risk associated with diagnostic
coronarography is 0.1-0.2%
▪ High risk subgroups for mortality:

• Left main stenosis > 50% (mortality

0.5%)

• LVEF < 30% (0.2%)

• NYHA III/IV HF (0.2%)

• age> 60 years (0.1%); >80 years

mortality 0.8%

• Aortic valvular lesions (0.1%)

• Coronary three vessels disease

(0.1%)
Diagnostic coronarography indications chronic coronary
syndromes:

Inconclusive non-invasive testing (functional or anatomic)

Exceptionally, in patient with particular professions (regulatory issues)

Patients with a high clinical likelihood of CAD

• Symptoms unresponsive to medical therapy

• Typical angina at low level of exercise

• When initial clinical evaluation indicates a high event risk

 Starting angiography

Coronary
angiography :
“lumenography”

Less accuracy for the

identification
of the instable plaque!

4 months later
Little WC et al. Circulation 1988;78:1157-66.
 Angiography cannot detect
significant unstable plaques !!!

An unstable plaque, which is angiographic insignificant is responsible for the ACS.

The plaque proved to be critical at IVUS.
IVUS is more viable for the identification of the
significant plaques than coronarography !!!
Optical coherence
tomography

Fibrotic Lipid core Calcified

❑ laser technique

❑ Resolution 2-10 μm,

but it decreases in

depth (<1mm)

❑ it necessitates

vessel free of blood

homogenous, Scratchy, Scratchy,
Signal  Vague margins Precise margins
Non-invasive techniques for heart disease detection
Multi-slice CT

Angio RMN

Kim WY et al. Circulation 2002;106;296-9.

 III. Percutaneous coronary intervention

▪ After diagnostic coronarography PCI is made under radiologic control with

local anesthesia
▪ Definition:
• Technique for coronary angioplasty
• Stenosis are dilated with a balloon catheter
• 99% of cases end up with stent implantation (DES)
▪ It can be associated with other interventional devices and techniques:
• Rotational and directional atherectomy
• Thrombospiration
• Antiembolic devices
• Shockwave intravascular lithotripsy
• Laser angioplasty
 Pioneers

Dotter CT. Zeitler EJ.

Judkins MP. Vasa 1973;2:401.
Circulation 1964;30:654.

Gruentzig AR et al.
Circulation 1976;54(suppl II):II-81.
 Gruentzig AR, Senning A, Siegenthaler WE.
Nonoperative dilatation of coronary artery stenosis:
percutaneous transluminal coronary angioplasty.
N Engl J Med 1979;301:61– 8.

Primary PCI in acute myocardial infarction

Hartzler GO et al. PTCA with and without thrombolytic therapy for treatment of

acute myocardial infarction. Am Heart J 1983;106:965-73

 When is PCI indicated?
▪ Uni-, bi- or three coronary atherosclerotic stenosis > 50% with positive
FFR/iFR
▪ Chronic total occlusion (CTO)-positive viability test
▪ Degenerated venous (not occluded) or arterial grafts
▪ Coronary complex lesions:
• Unprotected LMS stenosis
• Ostial stenosis
• Bifurcation stenosis
▪ COURAGE; ORBITA;ISCHEMIA-in coronary chronic syndromes
▪ Acute coronary syndromes:
• Instable angina
• STEMI and NSTEMI
 Coronary stents

Magic Wallstent JOSTENT

Crossflex NIR

Graft stent

AVE GFX
 Coronary angioplasty technique

1. Identification of the lesion 2. Predilatation with a balloon catheter

 Coronary angioplasty technique

3. 3.5x23 mm stent implantation 4. Checking the result

Processes affecting stents-restenosis

▪ Restenosis (32-55% of all angioplasties-

POBA and PCI)
- 17-41% for BMS
- <10% for second generation DES
- hours to years
- need for reintervention CABG or re-PCI
(target lesion revascularisation)
- depending factors: patient, device,
technique
“The dark side of the balloon”

restenosis
Drug eluting stents reduce restenosis rates after PCI

Simple
stent

Sirolimus stent
 In-stent restenosis
• The three major pathogenic mechanisms that underlie restenosis are:
1. Early elastic return (recoil)
2. Vascular remodelling
3. Neointimal hyperplasia
The first and the second mechanisms are typical of “old-style” angioplasty before
the stent era.
The presence of metallic struts promotes a new mechanism called neointimal
hyperplasia

• Mehran classification of in-stent restenosis:

Type I: focal (≤10 mm)
Type II: diffuse (>10 mm within the stent)
Type III: proliferative (>10 mm outside the stent)
Type IV: occlusive
DES becoming BMS
 Processes affecting stents-thrombosis
• High-risk complication of PCI frequently manifested as ACS
or cardiac death
• 2% of all PCI in stent-era
• Frequently in the first month
• Classified as:
- acute: <24 h
- subacute: 24 h to 30 days
- late: 30 days to 12 months
- very late: >12 months
*Intraprocedural during PCI (1%)
• Related factors: patient, device, technique
Processes affecting stents-neoatheroslerosis

• Long term phenomenon that transform the stent neointima

from normal neointima to an atherosclerotic lesion (minimum
2 years)

• Clinical presentation as: stable disease or ACS

• The most frequent cause for long term failure of PCI

• Related factors: patient, device, technique

European Heart Journal (2018) 00, 1–96.
Indications for STEMI revascularisation-2017
 Severity criteria in instable angina and NSTEMI

Wijns W et al. Eur Heart J 2015;31:2501-55.

Wijns W et al. Eur Heart J 2015;31:2501-55.
 MINOCA/NOCAD
• Diagnostic criteria for myocardial infarction with non-obstructive
coronary arteries (13% of cases):
- universal AMI criteria
- Non-obstructive coronary arteries disease on angiography, defined as no
coronary artery stenosis ≥50% in any potential infarct-related artery
- No clinically overt specific cause for the acute presentation
Possible causes: vasospasm, spontaneous reperfusion, myocarditis, stress
cardiomyopathy, microvascular disfunction, myocardial bridging

• NOCAD: non-obstructive coronary arteries disease

ESC/EACTS guidelines for myocardial revascularization
Indications for revascularization in chronic coronary syndromes

European Heart Journal (2018) 00, 1–96

 FFR-fractional flow reserve

DEFER: Revascularisation of stenoses with FFR >0.75 can safely be deferred.

Revascularisation was performed with bare metal stents.
FAME: Limiting revascularisation to stenoses with FFR ≤0.80 is not inferior to
revascularisation of all stenoses >50 % diameter reduction. Multivessel disease,
revascularisation with drug-eluting stents.
FAME-2: Stenoses with FFR ≤0.80 benefit from revascularisation. Single-vessel
or multivessel disease, revascularisation with drug-eluting stents
 iFR-instantaneous wave-free ratio
*cut-off is iFR≤89
 coronary flow reserve (CFR)

• Ratio of maximum hyperaemic

flow to resting flow
• X2-5 is normal
• Epicardial stenosis>60% limits
maximal coronary flow in
rest&work
• Epicardial stenosis >80% impairs
resting blood flow
 Criteria for the choice between CABG vs PCI

• Assessment of surgical risk

- STS score for in-hospital mortality, 30-day mortality and in-hospital
morbidity after CABG (I B)
- EuroSCORE II for in-hospital mortality after CABG (IIb B)
- SYNTAX II Score for PCI
- SYNTAX II Score for CABG

• Assessment of coronary artery disease complexity

- SYNTAX Score

• Completeness of revascularization should be

prioritized
Periprocedural prognostic factors in coronary intervention-
retrospective study
NCDR / Inappropriate Revascularization

ACUTE PCIs 1.1%

11.6% NON-ACUTE PCIs
 Peri-operative Stent Thrombosis: Risk Factors

Timing: 6 weeks BMS, 3 lesions

months DES
Bifurcation and ostial
Advanced age lesions
Diabetes mellitus Suboptimal stent
Renal dysfunction deployment/apposition
Low LVEF Overlapping stents
ACS at presentation
Stenting of long/multiple

Circulation 2007, 116:e378-e382

Ideal case: primary
PCI after 5 hours

Timp “door to balloon” = 25 min

▪ 48 years, male
▪ Retrosternal pain
▪ ECG changes show large antero-lateral AMI
▪ Cardiogenic shock
▪ Emergency coronarography 3 h
after pain starting

Critical mid-shaft LMS stenosis

PCI with NIR stent
4.5 x 13 mm at the LMS
ostium

▪ optimal angiographic result

▪ shock signs relief

▪ good clinical evolution until day 5

▪ day 6: left hemiparesis → ECHO

 Repeated arteriography at day 7 shows
type A acute aortic dissection

Final diagnosis: type A aortic dissection with extension at LMS and large
anterior myocardial infarction with cardiogenic shock;
CVA at day 6 (cerebral CT)
63 years, male
HTA: 180/100 mmHg
Addmited at 3 h Anterior AMI
Killip III class
 Primary PCI 5 hours from starting
▪ TIMI 3; blush grade 2
▪ LVEF: 37% post PCI → 47% at discharge
Thrombolysis contraindications :
postero-inferior AMI and active cavernous TBC
on treatment; 4 hours from starting
Primary PCI with two stents
(3.5 x 18 mm and 3.5 x 12 mm), 4 hours
after starting
 Late primary PCI (14 hours after
starting); RBBB + gr I AV block ;
Intraprocedure total AV block

diagnostic

No reflow
TIMI 0 TIMI 3 flow 5 days after PCI
TIMI 3 flow after efficient thrombolysis,
severe residual stenosis

Direct stenting on LAD

at 7 days after thrombolysis
 Procedural aims of primary PCI
Final TIMI 3 flow
Grade III myocardial blush
Residual stenosis < 10%
No dissections at stent margins

Smith SC et al. Circulation 2006;113:156-75. Antman ME et al. Circulation 2004;110:588-636.

 Future/present in interventional cardiology:
interventions in structural CV disease

Long term non-surgical correction of valvular disease:

Aortic and pulmonary stenosis (CoreValve, Edwards Sapien)

Mitral regurgitation (MitraClip)

Endovascular exclusion of the left auricle

Endovascular correction of abdominal and thoracic aortic aneurisms

Endovascular closure of PFO, ASD and PDA

Alcoholization ablation of septales in HCM

TAVI – CoreValve 29 x 2: “valve in valve”
febr 2013
TAVI – CoreValve 29 x 2: “valve in valve”
TAVI – CoreValve 29 x 2: “valve in valve”
febr 2013
TAVI – CoreValve 29 x 2: “valve in valve”
febr 2013
TAVI
TAVI – CoreValve 29; 13 sept 2013
final result