Handbook Of Complex Percutaneous Carotid Intervention

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It has been referred in Medline since The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years. CiteScore measures average citations received per document published.


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Read more. SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact. SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field. The field of three-dimensional printing applied to patient-specific simulation is evolving as a tool to enhance intervention results.

We report the first case of a fully simulated percutaneous coronary intervention in a three-dimensional patient-specific model to guide treatment.. An year-old female presented with symptomatic in-stent restenosis in the ostial circumflex and was scheduled for percutaneous coronary intervention. Considering the complexity of the anatomy, patient setting and intervention technique, we elected to replicate the coronary anatomy using a three-dimensional model.

In this way, we simulated the intervention procedure beforehand in the catheterization laboratory using standard materials. The procedure was guided by optical coherence tomography, with pre-dilatation of the lesion, implantation of a single drug-eluting stent in the ostial circumflex and kissing balloon inflation to the left anterior descending artery and circumflex.

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Procedural steps were replicated in the real patient's treatment, with remarkable parallelism in angiographic outcome and luminal gain at intracoronary imaging.. In this proof-of-concept report, we show that patient-specific simulation is feasible to guide the treatment strategy of complex coronary artery disease. It enables the surgical team to plan and practice the procedure beforehand, and possibly predict complications and gain confidence..

An year-old female came in to the outpatient clinic for a follow-up visit complaining of a two-month history of typical chest pain on exertion grade II-III according to the Canadian Cardiovascular Society classification and progressive dyspnea. Her cardiovascular risk factors included hypertension, dyslipidemia and obesity.

Past medical history was significant for coronary artery disease with hospitalization for unstable angina three years before.


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  • At that time, ejection fraction was normal and coronary angiography showed mild distal left main disease and severe diffuse stenosis of the right coronary artery RCA. After hospital discharge she was doing well, without any symptoms. Treatment included acetylsalicylic acid mg, lisinopril 20 mg, nebivolol 5 mg and pitavastatin 2 mg daily.

    A nitroglycerin transdermal patch was added to her usual therapeutic regimen and she was scheduled for invasive stratification. At coronary angiography, mild diffuse restenosis of the RCA stents was found. An intermediate lesion was detected in the distal left main LM coronary artery affecting the circumflex Cx ostium.

    There was also severe calcification of the left anterior descending LAD artery with intermediate lesions in the proximal and mid segments. Therefore, we decided to perform focal percutaneous coronary intervention PCI of that lesion. The procedure was complicated by distal LM dissection propagating to the Cx, probably induced by deep engagement of the extra backup guiding catheter.

    Handbook of Complex Percutaneous Carotid Intervention : Jacqueline Saw :

    The patient was hypotensive, but flow was restored after kissing balloon dilation in the distal LM bifurcation. After that, we used a two-stent mini-crush technique considering Cx as a side branch using a 3. Kissing balloon inflation was followed by the proximal optimization technique of LM with a 5-mm balloon. There was good stent expansion and apposition on IVUS, as well as good angiographic result. The patient remained stable during hospital stay and was discharged with double antiplatelet therapy.. After four months, the patient presented with recurrent angina on exertion. At that point, we decided to stage the procedure in order to plan the treatment strategy..

    As our group has experience in cardiac three-dimensional 3D printing and simulation, we decided to test the treatment strategy for this complex PCI beforehand with the use of a 3D patient-specific simulator. The coronary anatomy was then printed in 3D using a stereolithography printer 1 in order to obtain a final patient-specific coronary artery model made of custom hybrid flexible material, with a dual-layered design and filled with fluid. Its main features include 3D-printed vascular anatomy, as well as radial and femoral access sites that enable the use of actual diagnostic and interventional devices with realistic haptics feedback Figure The steps for creating a patient-specific 3D coronary model for simulation are depicted.

    The images on the bottom show the ostial circumflex stenosis model on visual inspection left and the post-intervention result after stent placement right.. The right radial access was used to engage the left main with a 6 Fr extra backup guiding catheter.

    Then, the ostial Cx stenosis was pre-dilated with 2. Then kissing balloon inflation was used to better shape the carina. Final OCT images showed good stent expansion with a small number of struts protruding to the LM, which was considered a good result for the predefined primary treatment strategy.

    The angiographic and OCT images of the simulated procedure are depicted in the left-hand boxes in Figure 2.

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    Also, at the right bottom part of Figure 1 , the result of stent implantation can be seen by directly inspecting the transparent, flexible patient-specific 3D print.. Side-by-side display of matched angiographic appearance Panel A and OCT imaging Panel B of patient-specific simulated procedure and actual procedure for comparative purposes.

    Panel A Angiographic images depicting the sequential procedural steps from diagnosis to final surgical result. Panel B OCT still frames of minimal luminal area before intervention and the final result after stent implantation.. The following day, we performed the actual procedure on the patient, keeping in mind the planned steps from the simulation. However, the right radial pulse was absent and, therefore, we used the right femoral arterial access. OCT imaging showed that the mechanism of restenosis was stent under-expansion at the Cx ostium where there was significant plaque burden that may have had limited expansion previously.

    Therefore, we considered that another stent was needed to reshape the vessel and minimize the recurrence of restenosis. We used a similar selection of interventional material and carried out the same sequence of steps to perform this PCI as tested the day before, achieving a good result both angiographically Figure 2 , Panel A and on OCT imaging Figure 2 , Panel B.

    The procedure was uneventful and the patient was discharged the next day. Figure 2 compares the simulation and actual procedures. The parallelism in angiographic outcomes and also the similarities in luminal gain in OCT are noteworthy.. Simulation has evolved as a learning tool and has been shown to be effective for teaching both novice and experienced learners. Interventional cardiology learning curves and the volume-outcome relationship suggest that simulation may be used to potentially improve clinical results.

    However, several hurdles prevented it from being widely adopted in the past. Submit Search. Successfully reported this slideshow. We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime. Upcoming SlideShare.

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