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Manual of Percutaneous Coronary Interventions
A Step-by-Step Approach
Copyright Elsevier 2020
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Manual of Percutaneous
Coronary Interventions
A Step-by-Step Approach
Emmanouil Brilakis, MD, PhD

Center for Complex Coronary Interventions,
Minneapolis Heart Institute,
Center for Coronary Artery Disease,
Minneapolis Heart Institute Foundation,
Minneapolis, MN, United States

Academic Press is an imprint of Elsevier
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Dedication
To Nicole, Stelios, and Thomas.

To my parents and my brother.


Contents
List of contributors xi 2.10 Cath lab environment 13

PCI cases online links xvii 2.11 Sterile field and equipment 13
CTO PCI cases online links xix 2.12 Equipment position within the body 14
Introduction xxiii
3. Medications 15
Part A
3.1 Sedatives and analgesics 15
The steps 1 3.2 Vasodilators 16
3.3 Contrast media 20
1. Planning 3 3.4 Anticoagulants 21
1.1 Planning 3 3.5 Antiplatelet agents 24
1.2 Monitoring 7 3.6 Vasopressors and inotropes 29
1.3 Pharmacology 7 3.7 Antiarrhythmics 31
1.4 Access 7 References 32
1.5 Engagement 8
1.6 Angiography 9
1.7 Determine target lesion(s) 9 4. Access 35
1.8 Wiring 9
1.9 Lesion preparation 9 4.1 Choosing access site 35
1.10 Stenting 9 4.2 Femoral access 36
1.11 Access closure 9 4.3 Radial access 56
1.12 Physiology 9 4.4 Other access sites 67
1.13 Imaging 9 References 68
1.14 Hemodynamic support 10
References 10
5. Coronary and graft engagement 71
5.1 Step 1. Catheter selection 71
2. Monitoring 11
5.2 Step 2. Advance guidewire to aortic root 71
2.1 Patient 11 5.3 Step 3. Advance catheter to aortic root 77
2.2 Electrocardiogram 11 5.4 Step 4. Aspirate guide catheter 82
2.3 Pressure waveform 12 5.5 Step 5. Connect with manifold 84
2.4 Oxygen saturation 12 5.6 Step 6. Ensure there is good pressure
2.5 Radiation dose—X-ray system and waveform 85
shield positioning 13 5.7 Step 7. Manipulate catheter to engage
2.6 Contrast volume 13 coronary ostia 88
2.7 Access site 13 5.8 Step 8. Ensure there is good pressure
2.8 Medication administration waveform 94
(anticoagulation—ACT, sedation, other 5.9 Step 9. Proceed with contrast injection as
medications) 13 described in 6 95
2.9 Operator and team performance 13 References 95
vii

viii Contents
6. Coronary angiography 97 9.7 Balloon angioplasty 142

9.8 Good flow? 158
6.1 Step 1. Ensure there is good pressure 9.9 Balloon expansion 158
waveform 97 9.10 Stenting 158
6.2 Step 2. Test contrast injection 97 References 158
6.3 Step 3. Administer intracoronary
nitroglycerin 98
6.4 Step 4. Optimally position patient, image
receptor, shields, and operator 99 10. Stenting 159
6.5 Step 5. Assess pressure and ECG 100 10.1 When to stent? 159
6.6 Step 6. Perform cineangiography 100 10.2 How to stent 159
6.7 Step 7. Assess pressure and ECG 102 References 166
6.8 Step 8. Angiogram interpretation 102
References 109
11. Access closure 169

7. Selecting target lesion(s) 111 11.1 Femoral access 169
11.2 Radial access 185
7.1 Stable angina - Chronic Coronary
References 188
Syndromes 111
7.2 Acute coronary syndromes 117
7.3 PCI timing 119
7.4 PCI lesion sequence selection 120 12. Coronary physiology 191
References 120
12.1 When should coronary physiology
be used? 191
12.2 How to do coronary physiologic
8. Wiring 123 assessment? 192
8.1 Step 1. Determine whether a 12.3 Physiologic assessment in various
microcatheter is needed 123 lesion and patient subsets 201
8.2 Step 2. Guidewire selection 123 References 202
8.3 Step 3. Shape the guidewire tip 124
8.4 Step 4. Insert the guidewire into the
guide catheter 125 13. Coronary intravascular imaging 205
8.5 Step 5. Advance the guidewire to the
tip of the guide catheter 126 13.1 When to do coronary intravascular
8.6 Step 6. Advance the guidewire from the imaging? 205
tip of the guide catheter to the target 13.2 Imaging modality selection 206
lesion 127 13.3 OCT step-by-step 208
8.7 Cross lesion with the guidewire 132 13.4 IVUS step-by-step 217
8.8 Advance guidewire distal to the target References 222
lesion 133
8.9 Remove microcatheter (if used) 134
8.10 Monitor wire position 138 14. Hemodynamic support 223
References 139
14.1 Hemodynamic support: when and what
device 223
14.2 Hemodynamic support: device
9. Lesion preparation 141 comparison 226
9.1 Goal 141 14.3 IABP insertion: step-by-step 226
9.2 When is lesion preparation needed? 141 14.4 Impella insertion: step-by-step 231
9.3 Confirm successful wiring 142 14.5 VA-ECMO insertion: step-by-step 237
9.4 Large thrombus 142 14.6 Tandem Heart: step-by-step 240
9.5 Severe calcification 142 14.7 Mechanical chest compression systems 241
9.6 Degenerated SVG or thrombus 142 References 241

Contents ix
Part B 19. Calcification 329

Complex lesion subsets 243 19.1 Planning 329
19.2 Monitoring 329
15. Ostial lesions 245 19.3 Medications 329
19.4 Access 329
15.1 Aorto-ostial lesions 245
19.5 Engagement 329
15.2 Branch ostial lesions 261
19.6 Angiography 330
References 266
19.7 Selecting target lesion(s) 330
19.8 Wiring 330
19.9 Lesion preparation 330
16. Bifurcations 267 19.10 Stenting 347
16.1 Bifurcation algorithm 267 19.11 Closure 348
16.2 Bifurcation PCI: step-by-step 269 19.12 Physiology 348
References 301 19.13 Imaging 348
References 348
17. Left main 303

20. Acute coronary syndromes—
17.1 Planning 303
thrombus 351
17.2 Monitoring 303
17.3 Medications 303 20.1 Planning 351
17.4 Access 303 20.2 Monitoring 351
17.5 Engagement 304 20.3 Medications 351
17.6 Angiography 304 20.4 Access 351
17.7 Selecting target lesion(s) 305 20.5 Engagement 352
17.8 Wiring 306 20.6 Angiography 352
17.9 Lesion preparation 306 20.7 Determine target lesion(s) 352
17.10 Stenting 306 20.8 Wiring 353
17.11 Closure 306 20.9 Lesion preparation 354
17.12 Physiology 306 20.10 Stenting 359
17.13 Imaging 307 20.11 Closure 359
17.14 Hemodynamic support 307 20.12 Physiology 360
References 308 20.13 Imaging 360
References 360
18. Bypass grafts—prior CABG
patients 309 21. Chronic total occlusions 363
18.1 Planning 309 21.1 Planning 363
18.2 Monitoring 311 21.2 Monitoring 363
18.3 Medications 311 21.3 Medications 364
18.4 Access 311 21.4 Arterial access 364
18.5 Engagement 311 21.5 Engagement 364
18.6 Angiography 313 21.6 Angiography 364
18.7 Selecting target lesion(s) 314 21.7 Determine target lesion(s) 366
18.8 Wiring 315 21.8 Wiring 366
18.9 Lesion preparation 322 21.9 Lesion preparation 369
18.10 Stenting 323 21.10 Stenting 369
18.11 Closure 325 21.11 Closure 369
18.12 Physiology 325 21.12 Physiology 369
18.13 Imaging 325 21.13 Imaging 369
18.14 Hemodynamic support 325 21.14 Hemodynamic support 369
References 325 References 370

x Contents
22. Other complex lesions 373 27.4 Microcatheter entrapment and fracture 456
References 457
22.1 Spontaneous coronary artery dissection 373
22.2 Stent failure 375
22.3 Small and large vessels 377
22.4 Long lesions 379
28. Other complications: hypotension,
References 380 radiation skin injury, contrast-induced
acute kidney injury 459
28.1 Hypotension 459
23. Balloon uncrossable and balloon 28.2 Radiation skin injury 462
undilatable lesions 381 28.3 Contrast-induced acute kidney injury 468
23.1 Balloon uncrossable lesions 381 References 470
23.2 Balloon undilatable lesions 389
References 394
29. Vascular access complications 471
29.1 Femoral access complications 471
24. Complex patient subgroups 397 29.2 Radial access complications 480
24.1 TAVR patients 397 References 484
24.2 Cardiogenic shock patients 402
References 405
Part D
Equipment 485
Part C 30. Equipment 487
Complications 407 Introduction 487
30.1 Sheaths 489
25. Acute vessel closure 409 30.2 Catheters 492
25.1 Maintain guidewire position 409 30.3 Guide catheter extensions 499
25.2 Determine the cause of acute vessel 30.4 Support catheters 511
closure and treat accordingly 409 30.5 Y-connectors with hemostatic valves 513
25.3 Hemodynamic support 419 30.6 Microcatheters 514
References 419 30.7 Guidewires 534
30.8 Embolic protection devices 541
30.9 Balloons 542
26. Perforation 421 30.10 Atherectomy 548
30.11 Laser 556
26.1 Perforation classification, causes, and 30.12 Thrombectomy devices 556
prevention 421 30.13 Aorto-ostial lesion equipment 558
26.2 General treatment of perforations 421 30.14 Stents 559
26.3 Large vessel perforation 424 30.15 Vascular closure devices 559
26.4 Distal vessel perforation 425 30.16 CTO PCI dissection/reentry
26.5 Collateral vessel perforation 436 equipment 561
26.6 Perforation in patients with prior 30.17 Intravascular imaging 562
coronary artery bypass graft surgery 30.18 Complication management 562
carries very high risk 436 30.19 Radiation protection 569
References 436 30.20 Hemodynamic support devices 571
30.21 Contrast management 571
30.22 Brachytherapy 571
27. Equipment loss and entrapment 439 30.23 The “CTOComplex PCI cart” 571
References 571
27.1 Stent loss or entrapment 439
27.2 Guidewire entrapment and fracture 445
Index 575
27.3 Balloon entrapment and fracture 450

List of contributors
J. Dawn Abbott Warren Alpert Medical School at Kenneth Baran Minneapolis Heart Institute,
Brown University, Providence, RI, United States Minneapolis, MN, United States
Nidal Abi Rafeh St. George Hospital University Medical Mir Babar Basir Henry Ford Health System, Detroit,
Center, Beirut, Lebanon MI, United States
Mazen Abu Fadel Oklahoma Heart Hospital North Nicolas Boudou Clinique Saint Augustin, Bordeaux, France
Campus, Oklahoma City, OK, United States; Konstantinos Dean Boudoulas The Ohio State
University of Oklahoma Cardiovascular Institute, University, Columbus, OH, United States
Oklahoma City, OK, United States Christos V. Bourantas Barts Heart Centre, Barts Health
Pierfrancesco Agostoni HartCentrum, Ziekenhuis Netwerk NHS Trust, London, United Kingdom; Institute of
Antwerpen (ZNA) Middelheim, Antwerp, Belgium Cardiovascular Sciences, University College London,
London, United Kingdom
Sukru Akyuz University of Health Sciences, Dr. Siyami
Ersek Thoracic and Cardiovascular Surgery Training and Nenad Ž. Božinović University Clinical Center Nis, Niš,
Research Hospital, Istanbul, Turkey Serbia
Leszek Bryniarski Department of Cardiology and
Khaldoon Alaswad Henry Ford Hospital, Detroit, MI,
Cardiovascular Interventions, University Hospital,
United States
Institute of Cardiology, Jagiellonian University
Dimitrios Alexopoulos National and Kapodistrian Medical College, Cracow, Poland
University of Athens Medical School, Athens, Greece; Alexander Bufe Heartcentre Niederrhein, Helios
Attikon University Hospital, Athens, Greece Clinic Krefeld, University Witten/Herdecke, Germany
Dominick J. Angiolillo University of Florida College of M. Nicholas Burke Minneapolis Heart Institute and
Medicine-Jacksonville, Jacksonville, FL, United States Minneapolis Heart Institute Foundation, Minneapolis
Herbert D. Aronow Alpert Medical School of Brown MN, United States
University, Providence, RI, United States; Lifespan Heinz Joachim Büttner Department of Cardiology and
Cardiovascular Institute, Providence, RI, United Angiology II University Heart Center Freiburg Bad
States; Rhode Island and The Miriam Hospitals, Krozingen, Bad Krozingen, Germany
Providence, RI, United States
Pedro Pinto Cardoso Cardiology Division, Heart and
Alexandre Avran Clinique Pasteur, Essey-lès-nancy, France Vessels Department, University Hospital, CHULN,
Lorenzo Azzalini Division of Cardiology, VCU Health Lisboa, Portugal; Faculty of Medicine, Universidade
Pauley Heart Center, Virginia Commonwealth de Lisboa, Centro Cardiovascular da Universidade de
University, Richmond, VA, United States Lisboa, Lisboa, Portugal
Avtandil M. Babunashvili Department of Mauro Carlino Interventional Cardiology Unit, Cardio-
Cardiovascular Surgery, Center for Endosurgery and Thoracic-Vascular Department, IRCCS San Raffaele
Lithotripsy, Moscow, Russian Federation Scientific Institute, Milan, Italy
Jayant Bagai Vanderbilt University Medical Center, Jeff Chambers Metropolitan Heart and Vascular Institute,
Nashville, TN, United States Mercy Hospital, Minneapolis, MN, United States
Subhash Banerjee VA North Texas Health Care System Konstantinos Charitakis University of Texas Health
and UT Southwestern Medical School, Dallas, TX, Science Center at Houston, Houston, TX, United
United States States
xi

xii List of contributors
Yiannis S. Chatzizisis Cardiovascular Division, Dmitriy N. Feldman Greenberg Division of Cardiology,

University of Nebraska Medical Center, Omaha, NE, Department of Medicine, New York Presbyterian
United States Hospital, Weill Cornell Medical College, New York,
Ivan J. Chavez Minneapolis Heart Institute at Abbott NY, United States
Northwestern Hospital and Minneapolis Heart Institute Sergey Furkalo National Institute Surgery and
Foundation, Minneapolis, MN, United States Transplantology NAMS, Kiev, Ukraine
James W. Choi Baylor Scott & White Heart and Andrea Gagnor Maria Vittoria Hospital, Turin, Italy
Vascular Hospital, Dallas, TX, United States; Texas
A&M College of Medicine, Bryan, TX, United Alfredo R. Galassi Department of Health Promotion,
States Mother and Child Care, Internal Medicine, and
Medical Specialties (PROMISE), University of
Evald Høj Christiansen Department of Cardiology,
Palermo, Palermo, Italy
Aarhus University Hospital, Aarhus, Denmark
Mauricio G. Cohen Cardiovascular Division, Roberto Garbo San Giovanni Bosco Hospital, Turin, Italy
Department of Medicine, Elaine and Sydney Sussman Santiago Garcia Minneapolis Heart Institute and
Cardiac Catheterization Laboratory, University of Minneapolis Heart Institute Foundation, Minneapolis,
Miami Hospital and Clinics, Miami, FL, United States MN, United States
Francesco Costa Policlinico G. Martino, University of Gabriele L. Gasparini Humanitas Clinical and Research
Messina, Messina, Italy Hospital, Rozzano, Milan, Italy
Felix Damas de los Santos Interventional Cardiology
Anthony H. Gershlick University Hospitals of Leicester
Department, National Institute of Cardiology Ignacio
(UHL), University of Leicester and Leicester Biomedical
Chávez, México City, Mexico
Research Centre, Leicester, United Kingdom
Rustem Dautov Heart and Lung Institute, The Prince
Charles Hospital, Brisbane, QLD, Australia; Mario Goessl Minneapolis Heart Institute and
University of Queensland, Brisbane, QLD, Australia Minneapolis Heart Institute Foundation, Minneapolis,
MN, United States
Tony De Martini SIU School of Medicine, Memorial
Medical Center, Springfield, IL, United States Luca Grancini Centro Cardiologico Monzino, IRCCS,
Milan, Italy
Ali E. Denktas Baylor College of Medicine, Houston,
TX, United States Abdul Hakeem Rutgers Robert Wood Johnson University
Hospital, New Brunswick, NJ, United States
Joseph Dens Department of Cardiology, Ziekenhuis Oost
Limburg, Genk, Belgium Allison B. Hall Eastern Health/Memorial University of
Newfoundland, St. John’s, NL, Canada
Zisis Dimitriadis Cardiology I, University Medical
Centre, Johannes Gutenberg University Mainz, Mainz, Stefan Harb University Heart Center Graz, Medical
Germany University of Graz, Graz, Austria
Anthony Doing University of Colorado Health, Medical Raja Hatem Hôpital du Sacré-Coeur de Montréal,
Université de Montréal, Montreal, QC, Canada
Center of the Rockies, Loveland, CO, United States
Jose P.S. Henriques Department of Cardiology,
Mohaned Egred Freeman Hospital, Newcastle
University of Amsterdam, Amsterdam UMC,
University, Newcastle upon Tyne, United Kingdom
Amsterdam, The Netherlands
Basem Elbarouni University of Manitoba, Winnipeg,
Yangsoo Jang Severance Hospital, Yonsei University
MB, Canada; St. Boniface Hospital, Winnipeg, MB,
College of Medicine, Seoul, Korea
Canada
Risto Jussila Helsinki Heart Hospital, Helsinki, Finland
Ahmed M. El Guindy Department of Cardiology,
Aswan Heart Centre, Magdi Yacoub Foundation, Artis Kalnins Clinic of Cardiovascular diseases, Riga
Cairo, Egypt East University hospital, Riga, Latvia
Abdallah El Sabbagh Mayo Clinic, Jacksonville, FL, Arun Kalyanasundaram Promed Hospital, Chennai,
United States India
Panayotis Fasseas Division of Cardiovascular Medicine, Paul Hsien-Li Kao Cardiovascular Center, Cardiology
Medical College of Wisconsin, Milwaukee, WI, Division, Department of Medicine, National Taiwan
United States University Hospital, Taipei City, Taiwan

List of contributors xiii
Judit Karacsonyi Division of Invasive Cardiology, Konstantinos Marmagkiolis University of Texas MD

Second Department of Internal Medicine and Cardiology Anderson Cancer Center, Houston, TX, United States;
Center, University of Szeged, Szeged, Hungary; HCA Northside Hospital, St. Petersburg, FL, United
Minneapolis Heart Institute and Minneapolis Heart States
Institute Foundation, Minneapolis, MN, United States Kambis Mashayekhi University Heart Center Freiburg
Lampros Karagounis Director, A Cardiology Bad Krozingen, Bad Krozingen, Germany
Department, European Interbalkan Medical Center,
Kreton Mavromatis Atlanta VA Health Care System,
Thessaloniki, Greece
Emory University School of Medicine, Atlanta, GA,
Antonios Karanasos First Department of Cardiology, United States
University of Athens, Hippokration Hospital, Athens,
Greece Michael Megaly Minneapolis Heart Institute and
Minneapolis Heart Institute Foundation, Minneapolis,
Dimitri Karmpaliotis Columbia University, New York, MN, United States
NY, United States
Owen Mogabgab Cardiovascular Institute of the South,
Houman Khalili Florida Atlantic University and Delray Houma, LA, United States
Medical Center, Delray Beach, FL, United States
Michael R. Mooney Minneapolis Heart Institute and
Jaikirshan J. Khatri Director of Complex Coronary Minneapolis Heart Institute Foundation, Minneapolis,
Intervention, Department of Cardiovascular Medicine, MN, United States
Cleveland Clinic Lerner College of Medicine of Case
Western Reserve University, Cleveland, OH, United Jeffrey W. Moses Columbia University Medical Center,
States New York, NY, United States; St. Francis Heart
Center, New York, NY, United States
Dmitrii Khelimskii E.N. Meshalkin National Medical
Research Center Bilal Murad Minneapolis Heart Institute, United
Hospital, St. Paul, MN, United States
Byeong-Keuk Kim Division of Cardiology, Severance
Cardiovascular Hospital, Yonsei University College of Alexander Nap Amsterdam University Medical Center,
Medicine, Seoul, Korea Amsterdam, The Netherlands
Louis P. Kohl Division of Cardiology, Hennepin William Nicholson Emory University, Atlanta, GA,
Healthcare (HCMC) and University of Minnesota United States
Medical School, Minneapolis, MN, United States Dimitrios N. Nikas 1st Cardiology Department, Ioannina
Daniel M. Kolansky Hospital of the University of University Hospital, Ioannina Greece
Pennsylvania, Philadelphia, PA, United States
Ilias Nikolakopoulos Minneapolis Heart Institute
Michalis Koutouzis Red Cross Hospital of Athens, Foundation, Minneapolis, MN, United States
Athens, Greece
Goran Olivecrona Department of Cardiology, Lund
Oleg Krestyaninov Meshalkin Novosibrisk Research University/Skåne University Hospital, Lund, Sweden
Institute, Novosibirsk, Russia
Mohamed A. Omer Minneapolis Heart Institute and
Faisal Latif University of Oklahoma, Oklahoma City, Minneapolis Heart Institute Foundation, Minneapolis,
OK, United States; SSM Health St. Anthony Hospital, MN, United States
Oklahoma City, OK, United States
Jacopo Andrea Oreglia De Gasperis Cardio Center,
Seung-Whan Lee Department of Cardiology, Asan
Niguarda Hospital, Milan, Italy
Medical Center, University of Ulsan College of
Medicine, Seoul, Korea Lucio Padilla Department of Interventional Cardiology
and Endovascular Therapeutics, ICBA, Instituto
Thierry Lefevre ICPS Hôpital Privé Jacques Cartier,
Cardiovascular, Buenos Aires, Argentina
Massy, France
Ioannis Paizis Department of Cardiology, LAIKO
Nicholas J. Lembo Columbia University Medical Center,
General Hospital, Athens, Greece
New York-Presbyterian Hospital, Cardiovascular
Research Foundation, New York, NY, United States Carmelo Panetta UMP/University of Minnesota,
Ehtisham Mahmud UCSD Cardiovascular Institute- Minneapolis, MN, United States
Medicine, University of California, San Diego, CA, Mitul Patel UCSD Cardiovascular Institute, University of
United States California, San Diego, CA, United States

xiv List of contributors
Ashish Pershad Banner-University Medical Center, System Director, Cardiovascular Interventional

Phoenix, AZ, United States Center, University Hospitals, Cleveland, Ohio
Marin Postu IECVD “C.C.Ilescu”, Bucharest, Romania Evan Shlofmitz MedStar Washington Hospital Center,
Srini Potluri Cardiac Catheterization Laboratory, Baylor Washington, DC, United States
Scott & White Heart Hospital, Plano, TX, United Richard Shlofmitz St. Francis Hospital, Roslyn, NY,
States United States
Anil Poulose Minneapolis Heart Institute and Paul Sorajja Minneapolis Heart Institute and
Minneapolis Heart Institute Foundation, Minneapolis, Minneapolis Heart Institute Foundation, Minneapolis,
MN, United States MN, United States
Stylianos Pyxaras Landshut-Achdorf Hospital, Anthony Spaedy Cardiac Catheterization Laboratories,
Landshut, Germany Boone Hospital Center, Columbia, MO, United States
Sunil V. Rao Duke University Medical Center, Durham, Peter Tajti Division of Invasive Cardiology, Second
NC, United States; Durham VA Medical Center, Department of Internal Medicine and Cardiology
Durham, NC, United States Center, University of Szeged, Szeged, Hungary
Sudhir Rathore Frimley Health NHS Foundation Trust, Jacqueline E. Tamis-Holland Division of Cardiology,
Surrey, United Kingdom Department of Medicine, Mount Sinai Mount Sinai
Morningside, New York, NY, United States
Amir Ravandi University of Manitoba, Winnipeg, MB,
Canada; St. Boniface General Hospital, Winnipeg, Aurel Toma Medical University of Vienna, Vienna, Austria
MB, Canada; Bergen Cardiac Care Centre, Winnipeg, Konstantinos Toutouzas First Department of
MB, Canada Cardiology, Athens Medical School, Athens, Greece
Nicolaus Reifart Main Taunus Heart Institute, Bad Jay H. Traverse Minneapolis Heart Institute Foundation,
Soden, Germany Abbott Northwestern Hospital, Minneapolis, MN,
Robert F. Riley Complex Coronary Therapeutics United States; Cardiovascular Division, University of
Program, The Christ Hospital Health Network, Minnesota School of Medicine, Minneapolis, MN,
Cincinnati, OH, United States United States
Stephane Rinfret McGill University Health Center, Huu Tam Truong Loma Linda VA Healthcare System,
Montreal, QC, Canada Loma Linda, CA, United States; Loma Linda
University, Loma Linda, CA, United States
Gurpreet S. Sandhu Department of Cardiovascular
Medicine, Mayo Clinic, Rochester, MN, United Sotiris Tsalamandris First Department of Cardiology,
States University of Athens, Hippokration Hospital, Athens,
Greece
Yader Sandoval Department of Cardiovascular
Medicine, Mayo Clinic, Rochester, MN, United States Ioannis Tsiafoutis Interventional Cardiologist, Red
Cross Hospital, Athens, Greece
Elias Sanidas Department of Cardiology, LAIKO
General Hospital, Athens, Greece Imre Ungi University of Szeged, Szeged, Hungary
Ricardo Santiago Trinidad PCI Cardiology Group, San Emmanouil Vavouranakis First Department of
Juan, Puerto Rico Cardiology, Medical School, University of Athens,
Hippokration Hospital, Athens, Greece
Jeffrey M. Schussler Baylor Scott & White Heart and
Evangelia Vemmou Minneapolis Heart Institute
Vascular Hospital, Dallas, TX, United States
Foundation, Minneapolis, MN, United States
Arnold Seto Long Beach VA Medical Center, Long Minh N. Vo Mazankowski Royal Columbian Hospital,
Beach, CA, United States; University of California, BC, Canada
Irvine, CA, United States
Vassilis Voudris Division of Interventional Cardiology,
Alok Sharma Minneapolis VA Medical Center, Chairman Cardiology Department, Onassis Cardiac
Minneapolis, MN, United States Surgery Center, Athens, Greece
Arslan Shaukat Phelps Health, Rolla, MO, United States Yale Wang Minneapolis Heart Institute and Minneapolis
Mehdi H. Shishehbor Professor of Medicine, Case Heart Institute Foundation, Minneapolis, MN, United
Western Reserve University School of Medicine; States

List of contributors xv
Jarosław Wójcik Hospital of Invasive Cardiology Department of Cardiology, Attikon University

“IKARDIA”, Nałe˛czów/Lublin, Poland Hospital, National and Kapodistrian University of
Jason Wollmuth Providence Heart and Vascular Athens Medical School, Athens, Greece
Institute, Portland, Oregon, United States Masahisa Yamane Saitama Sekishinkai Hospital,
Eugene B. Wu Prince of Wales Hospital, Chinese Saitama, Japan
University, Hong Kong Luiz Fernando Ybarra London Health Sciences Centre,
Iosif Xenogiannis Minneapolis Heart Institute Schulich School of Medicine & Dentistry, Western
Foundation, Minneapolis, MN, United States; Second University, London, ON, Canada


PCI cases online links
Case Number YOUTUBE link

1 https://www.youtube.com/watch?v 5 Z4-lZ0GmGbY
2 https://www.youtube.com/watch?v 5 SSBMDshfnx4
3 https://www.youtube.com/watch?v 5 R1qMbS8d-f4
4 https://www.youtube.com/watch?v 5 laYXNLAERKo
5 https://www.youtube.com/watch?v 5 Yu5KR7gJMNk
6 https://www.youtube.com/watch?v 5 5QqwesnusBk
7 https://www.youtube.com/watch?v 5 7YXTePUN8A8
8 https://www.youtube.com/watch?v 5 9eSeLtQXeYs
9 https://www.youtube.com/watch?v 5 YsddPIhti-c
10 https://www.youtube.com/watch?v 5 uzEJi7SWAbc
11 https://www.youtube.com/watch?v 5 TrSZnIN19BY
12 https://www.youtube.com/watch?v 5 C9mDQlp6wBc
13 https://www.youtube.com/watch?v 5 5x0gJ5hULQ8
14 https://youtu.be/AHteTspH3R8
15 https://www.youtube.com/watch?v 5 g0IfIsNsops
16 https://www.youtube.com/watch?v 5 9ZaHJZKhoC0
17 https://www.youtube.com/watch?v 5 9fEVRRVOLME
18 https://www.youtube.com/watch?v 5 NTNEQzVJINk
19 https://www.youtube.com/watch?v 5 eV1blkBd2bQ
20 https://www.youtube.com/watch?v 5 RQiFrT47WXw&t 5 3s
21 https://www.youtube.com/watch?v 5 TDyKZW2fTPA
22 https://www.youtube.com/watch?v 5 nRNwpgV8ORI&t 5 1s
23 https://www.youtube.com/watch?v 5 lrMbTP0Ou-g
24 https://www.youtube.com/watch?v 5 -ah-rtCbOfw
25 https://www.youtube.com/watch?v 5 CX7GS19TTcQ
26 https://www.youtube.com/watch?v 5 cQMEvu7RavQ
27 https://www.youtube.com/watch?v 5 x9bB5Hab9A0
28 https://www.youtube.com/watch?v 5 Wmw8eE8LSuw
29 https://www.youtube.com/watch?v 5 COqySRTm7h4
30 https://www.youtube.com/watch?v 5 fxceb437LF0
31 https://youtu.be/cHvPrxoV2-Y
32 https://youtu.be/8EQsasVWJRU
33 https://www.youtube.com/watch?v 5 1TwMn7SMhc8
34 https://youtu.be/KRqZDDQ6E3g
35 https://www.youtube.com/watch?v 5 zDyWd7fNPmw
36 https://www.youtube.com/watch?v 5 pIdQ-P8Ekpc
37 https://www.youtube.com/watch?v 5 SdRSb8Oh-0Q
38 https://www.youtube.com/watch?v 5 ARrFtw473ek
39 https://www.youtube.com/watch?v 5 JNKqsEVl0VE
40 https://www.youtube.com/watch?v 5 hWVWe9dTqVk
41 https://www.youtube.com/watch?v 5 eZgX4jMJ158
42 https://www.youtube.com/watch?v 5 RVcqwU8qhWw
43 https://www.youtube.com/watch?v 5 tXtTiivM1Kc
44 https://www.youtube.com/watch?v 5 4ntheQqS_Lc
45 https://www.youtube.com/watch?v 5 Ta_qwiFS2-Y
46 https://youtu.be/rQrbOi7-eSE
47 https://www.youtube.com/watch?v 5 9HdZn5iI-bE
48 https://www.youtube.com/watch?v 5 _gNLUyKe-Xg
49 https://www.youtube.com/watch?v 5 l8NIYCW_oXk
50 https://youtu.be/fbVoKuTdVEg
xvii

xviii PCI cases online links
51 https://www.youtube.com/watch?v 5 NuLm5WUX0ew
52 https://youtu.be/4bZFdJ7POlg
53 https://www.youtube.com/watch?v 5 qpJnSzpR1kA
54 https://www.youtube.com/watch?v 5 C-kTk1hv1Nc
55 https://youtu.be/1tCL0HepoqY
56 https://youtu.be/3sGSkQ6hoQ0
57 https://youtu.be/3xTOxrhH3Us
58 https://www.youtube.com/watch?v 5 36JzHvjGfLE
59 https://youtu.be/9SL7BnPzFvw
60 https://youtu.be/TNDK5DwtVxo
61 https://www.youtube.com/watch?v 5 LtWpzX1Mi3g
62 https://youtu.be/mk3HMGICYo4
63 https://youtu.be/mnqzShZ89zE
64 https://youtu.be/z-z76bS3WhY
65 https://youtu.be/qOlOdLF28Gc
66 https://youtu.be/D2QhNbShgj4
67 https://www.youtube.com/watch?v 5 TsqRwqZju4s
68 https://youtu.be/v3eNPECCPi8
69 https://www.youtube.com/watch?v 5 ZX-AJEpXeHI
70 https://youtu.be/9sU4RnQbetM
71 https://youtu.be/9qoF_RzfWSc
72 https://youtu.be/6Ne-6W_7h_A
73 https://youtu.be/NndEwAX61hI
74 https://www.youtube.com/watch?v 5 MTR9XnRyqds
75 https://www.youtube.com/watch?v 5 XhTQl5mQCdE
76 https://www.youtube.com/watch?v 5 mUffP1PUD_s
77 https://www.youtube.com/watch?v 5 MG8W3F3qGa8
78 https://youtu.be/XZoGURFaUkI
79 https://youtu.be/jG01KcZ176w
80 https://www.youtube.com/watch?v 5 l-kjzOrk8Gg
81 https://www.youtube.com/watch?v 5 Ql3BHNGVYQA
82 https://youtu.be/lMKovIIh8os
83 https://youtu.be/Wfuh1r4siPQ
84 https://youtu.be/iCpjeqOSXDk
85 https://youtu.be/CBFtofcFw5E
86 https://youtu.be/IzQ-wpYTUMw
87 https://youtu.be/VRqERXKp-rU
88 https://youtu.be/eglCD3rzKLQ
89 https://youtu.be/RNxl_wf9B2Q
90 https://youtu.be/8ezaVo9zSQc
91 https://youtu.be/Zyrf3qbZuxE
92 https://youtu.be/Bd6eqk8aEnw
93 https://youtu.be/U7kaCF14SM4
94 https://youtu.be/_2Yn8td_d9Y
95 https://youtu.be/Q6gLRyyF0jI
96 https://youtu.be/MQO5G8yGy80
97 https://youtu.be/maPX2si7W8k
98 https://youtu.be/uQifXrA_a9w
99 https://youtu.be/qePK1aOyzsc
100 https://youtu.be/zsUIRkRvgHM

CTO PCI cases online links
Case Number YOUTUBE link

1 https://youtu.be/65ch3syR_6Q
2 https://www.youtube.com/watch?v 5 l8CavAxZ0fM
3 https://www.youtube.com/watch?v 5 T1_C4bRPKvQ
4 https://www.youtube.com/watch?v 5 STjnaCqBWB4
5 https://youtu.be/l1ZJbZPIBoc
6 https://youtu.be/5QqwesnusBk
7 https://www.youtube.com/watch?v 5 Psln9Ounl1Y
8 https://youtu.be/9eSeLtQXeYs
9 https://www.youtube.com/watch?v 5 2s8oMdjgipM
10 https://www.youtube.com/watch?v 5 p5nnVIbUmTQ
11 https://www.youtube.com/watch?v 5 rgaCjz26JYQ
12 https://youtu.be/i7e2r7yizng
13 https://www.youtube.com/watch?v 5 r0-3m3S_Hdg
14 https://www.youtube.com/watch?v 5 o4aLXc7q-ps
15 https://www.youtube.com/watch?v 5 0LssoY7q8WM
16 https://youtu.be/7jMltlY2UBk
17 https://youtu.be/tidtCbQm114
18 https://youtu.be/9ge8x7rwP6Q
19 https://www.youtube.com/watch?v 5 oedZujPSUGQ
20 https://www.youtube.com/watch?v 5 xfhkfyxq_I4
21 https://youtu.be/TDyKZW2fTPA
22 https://youtu.be/nRNwpgV8ORI
23 https://www.youtube.com/watch?v 5 9ivAdJfB-b8&t 5 2s
24 https://youtu.be/-ah-rtCbOfw
25 https://www.youtube.com/watch?v 5 sFRi-CgeBic
26 https://www.youtube.com/watch?v 5 rw648MhLzLc
27 https://youtu.be/lmSokEj0kVI
28 https://www.youtube.com/watch?v 5 MZMGqr3AOho
29 https://www.youtube.com/watch?v 5 L6lKm8VZy4w
30 https://www.youtube.com/watch?v 5 9bLDQT_orbU
31 https://www.youtube.com/watch?v 5 2zi7Aw0Wj_4
32 https://youtu.be/8EQsasVWJRU
33 https://www.youtube.com/watch?v 5 90t2J_yzfMc
34 https://www.youtube.com/watch?v 5 4lthDgjfR-w
35 https://www.youtube.com/watch?v 5 xXoedns1SG0
36 https://www.youtube.com/watch?v 5 FM8MagxwF7o
37 https://www.youtube.com/watch?v 5 xkH5OC_c380
38 https://www.youtube.com/watch?v 5 u9FljysaPUA
39 https://youtu.be/OKyuSQ_D210
40 https://youtu.be/8Ky6aWpqxkU
41 https://www.youtube.com/watch?v 5 mRczj1MoxTI
42 https://youtu.be/xGnPiXb_J50
43 https://youtu.be/8gb7uIS2lZI
44 https://www.youtube.com/watch?v 5 8o_XFj_WTKg
45 https://youtu.be/Ta_qwiFS2-Y
46 https://youtu.be/zhsZGoKvRW4
47 https://youtu.be/9HdZn5iI-bE
48 https://www.youtube.com/watch?v 5 Jo7-n9GoLsI
49 https://youtu.be/lhco4_iLQKk
50 https://youtu.be/43OqbC8u2-c
xix

xx CTO PCI cases online links
51 https://www.youtube.com/watch?v 5 PBeKhiXqE68
52 https://www.youtube.com/watch?v 5 Ar6w7Fn7Mq0
53 https://www.youtube.com/watch?v 5 gHT5CbpPlFg
54 https://www.youtube.com/watch?v 5 Wq_twcGCq_s
55 https://www.youtube.com/watch?v 5 CQ2uuHPsPp8
56 https://www.youtube.com/watch?v 5 ksFrCcrtbJs
57 https://www.youtube.com/watch?v 5 RIfDfE-e6cM
58 https://www.youtube.com/watch?v 5 CkyoRDR2Ogc
59 https://www.youtube.com/watch?v 5 cHCllDaWTZc
60 https://youtu.be/TNDK5DwtVxo
61 https://www.youtube.com/watch?v 5 3FyjYP9ckxQ
62 https://youtu.be/mk3HMGICYo4
63 https://www.youtube.com/watch?v 5 52wrenRLL1I
64 https://youtu.be/z-z76bS3WhY
65 https://www.youtube.com/watch?v 5 XfGhPJRgQCE
66 https://www.youtube.com/watch?v 5 T5TzHmVfqBM
67 https://www.youtube.com/watch?v 5 8EVIE9opOy0
68 https://www.youtube.com/watch?v 5 _fqwBJmvxLU
69 https://www.youtube.com/watch?v 5 BB9IHRpqJvM
70 https://www.youtube.com/watch?v 5 VeIAYjBnGrs
71 https://youtu.be/9qoF_RzfWSc
72 https://www.youtube.com/watch?v 5 LyQUzBOmNiw
73 https://www.youtube.com/watch?v 5 xAtFXE3hQU8
74 https://www.youtube.com/watch?v 5 Jh455839rnU
75 https://www.youtube.com/watch?v 5 qls66s5pfHA
76 https://www.youtube.com/watch?v 5 MwhcUMGy8iw
77 https://www.youtube.com/watch?v 5 UXZSq2Sp4a8
78 https://www.youtube.com/watch?v 5 rGzG5fL7RBQ
79 https://www.youtube.com/watch?v 5 L2TTclGPUuk
80 https://www.youtube.com/watch?v 5 F4_qKy5YqdE
81 https://www.youtube.com/watch?v 5 pHqerc81ZQY
82 https://www.youtube.com/watch?v 5 MNA2VgMEVjs
83 https://www.youtube.com/watch?v 5 q4ZpFmmGR50
84 https://www.youtube.com/watch?v 5 MDGum3jgQVE
85 https://youtu.be/8hOo5Jawjq4
86 https://www.youtube.com/watch?v 5 Bs0TGvVfQXM
87 https://www.youtube.com/watch?v 5 FLsKZonQDjA
88 https://www.youtube.com/watch?v 5 xMcMSepKMoc
89 https://www.youtube.com/watch?v 5 x5XDGGgdhSI
90 https://www.youtube.com/watch?v 5 HOJFgzkH3vA
91 https://www.youtube.com/watch?v 5 _BZ91Uv4k3o
92 https://www.youtube.com/watch?v 5 cg9HzbLPr3g
93 https://www.youtube.com/watch?v 5 yRUiHDRB-6w
94 https://www.youtube.com/watch?v 5 U5jS_YpCio0
95 https://www.youtube.com/watch?v 5 a84JZGJvzt4
96 https://www.youtube.com/watch?v 5 IZxNw2C58Gw
97 https://www.youtube.com/watch?v 5 MMb9gjbweWc
98 https://www.youtube.com/watch?v 5 ZYg8asrY4bo
99 https://www.youtube.com/watch?v 5 G013TP0s5Es
100 https://www.youtube.com/watch?v 5 aeKvhLs4cww
101 https://www.youtube.com/watch?v 5 JHNJeYyeCJY
102 https://www.youtube.com/watch?v 5 a3Z8orfDvPU
103 https://www.youtube.com/watch?v 5 ipHabyQ0GA8
104 https://www.youtube.com/watch?v 5 2mYe2Q9_ls0
105 https://www.youtube.com/watch?v 5 8dacJb36GzY
106 https://www.youtube.com/watch?v 5 _Wvej1tV5Sc
107 https://www.youtube.com/watch?v 5 _jo3zFqt588
108 https://www.youtube.com/watch?v 5 t_oVUGZKmsI
109 https://www.youtube.com/watch?v 5 MUEdLGTcj8A
110 https://www.youtube.com/watch?v 5 CvRFlo-4CIA
111 https://www.youtube.com/watch?v 5 -MNXJJFMxWo
112 https://youtu.be/xICEE9KOJrI
113 https://www.youtube.com/watch?v 5 uZ8MjQbKaUE
114 https://www.youtube.com/watch?v 5 veeK8Nd9fUc

CTO PCI cases online links | xxi
115 https://www.youtube.com/watch?v 5 q8w-xhW_GX8

116 https://www.youtube.com/watch?v 5 GeorLGfR3TA
117 https://www.youtube.com/watch?v 5 9BzyVbd54pc
118 https://www.youtube.com/watch?v 5 -bawP8CXlo0
119 https://www.youtube.com/watch?v 5 ckE99t9akPA
120 https://www.youtube.com/watch?v 5 4QrEFV1yj2c
121 https://youtu.be/8iULlNvTBw8
122 https://www.youtube.com/watch?v 5 Sq2RlA7mp9U
123 https://www.youtube.com/watch?v 5 WG3LWNtqAwc
124 https://youtu.be/Y2SceKlvTrw
125 https://youtu.be/HXevHVmVGFI
126 https://youtu.be/KV38cR0kgNY
127 https://youtu.be/Mda9W1Nlzms
128 https://youtu.be/Ta1MbCgzgCg
129 https://www.youtube.com/watch?v 5 3pBA3EppWpc
130 https://youtu.be/dfoJh8bWtaM
131 https://youtu.be/fBR3p6DBcy4
132 https://youtu.be/8S7bFFfdivM
133 https://youtu.be/91Ty31QL0X8
134 https://youtu.be/7TVoY_HaWXc
135 https://youtu.be/06vvD96kZ7A
136 https://youtu.be/NS719aZYv50
137 https://youtu.be/q6tDMXd8l98
138 https://youtu.be/QANysW9vIE0
139 https://youtu.be/MMkLpsinnis
140 https://youtu.be/4dhjCS9bp1s
141 https://youtu.be/gexEyhnT4Ts
142 https://youtu.be/KABiHnf4G80
143 https://youtu.be/RXdTo1v45MI
144 https://youtu.be/78bi9BATCLQ
145 https://youtu.be/razVovMt8lU
146 https://youtu.be/KUeV7oDLBpg
147 https://youtu.be/leI_YNdil1s
148 https://youtu.be/rlo0VDuu-lY
149 https://youtu.be/657O4WnyN7Q
150 https://youtu.be/XzWU4SptnzQ


Introduction
The goal of percutaneous coronary intervention (PCI) is to restore unimpeded blood flow in epicardial coronary arteries
without causing complications.
PCI is performed using the following 14 steps (Fig. 1).
PCI: the process FIGURE 1 The 14 steps of percutaneous coro-

nary intervention.
1. Planning
2. Monitoring
3 Pharmacology
4. Access
5. Engagement
6. Angiography
7. Determine target lesion(s)
8. Guidewire
Balloon angioplasty
Orbital atherectomy
Rotational atherectomy
9. Lesion Preparation
Laser
10. Stent(s) Thrombectomy
Intravascular lithotripsy
11. Closure
12. Physiology
13. Imaging
14. Hemodynamic support
time
The following steps are performed in all PCI cases:

G Planning (Chapter 1: Planning).
G Monitoring (Chapter 2: Monitoring).
G Medications (Chapter 3: Medications).
G Access (Chapter 4: Access).
G Engagement (Chapter 5: Coronary and Graft Engagement).
G Angiography (with the exception of the “zero contrast PCI,” although the latter still requires a prior angiogram)
(Chapter 6: Coronary Angiography).
G Determine target lesion(s) (Chapter 7: Selecting Target Lesion(s)).
G Wiring (Chapter 8: Wiring).
G Vascular closure (Chapter 11: Access Closure).
The following steps are not always performed:
G Lesion preparation (sometimes direct stenting is performed without predilation, although this is generally discour-
aged) (Chapter 9: Lesion Preparation).
xxiii

xxiv Introduction
G Stenting (sometimes balloon angioplasty, including drug-coated balloons, or thrombectomy only is performed)
(Chapter 10: Stenting).
G Physiology (Chapter 12: Coronary Physiology).
G Imaging (Chapter 13: Coronary Intravascular Imaging).
G Hemodynamic support (Chapter 14: Hemodynamic Support).
The Manual of PCI breaks down the PCI procedure into 14 sequential stages. The steps of each stage are then dis-
cussed, using the following template:
1. Goal (why?),
2. How?
3. Challenges, and
4. What can go wrong (complications)?
The same format (goal, how, challenges, what can go wrong) is used for the steps of each specialized technique,
such as atherectomy and thrombectomy. For each challenge and potential complication, we discuss: (1) potential
causes; (2) prevention; and (3) treatment strategies.
The first 14 chapters review in-depth each stage of PCI (part A). The subsequent 10 chapters review performance of
those steps in specific clinical and angiographic subgroups (part B). Chapters 2529, review complications (part C),
and Chapter 30 reviews equipment (part D).
Planning is the first stage of any procedure, including PCI, and is a key step. Plans can (and should) change depend-
ing on new information that becomes available during the procedure, but creating a plan before starting is invaluable.
The Manual of PCI aims to help each operator develop rich, accurate mental representations of what does or can
happen during PCI. Developing such mental representations is key to achieving expert performance [1].
The algorithms contained in this book are not the only or necessarily the best algorithms for these procedures. These
are algorithms used by the authors, but there will always be room for improvement. Please send feedback on how these
algorithms (and the book) can be improved.
Reading this manual (or any book for that matter) will not make you an expert interventionalist. Developing exper-
tise in PCI requires practice—not naı̈ve practice, but deliberate practice (working to improve areas of deficiency with a
teacher) [1].
“Always improving” what we do, so that the best possible outcome can be achieved for each patient, is the ultimate
goal of this book. We envision a future where all algorithms for all PCI procedures will be freely available to all and
continually improved upon.
Reference
[1] Ericsson A, Pool R. Peak: secrets from the new science of expertise. Boston: Houghton Mifflin Harcout Publishing Company; 2016.

Part A
The steps


Chapter 1
Planning
If you fail to plan you are planning to fail.

Benjamin Franklin.
Planning is essential for every procedure, including percutaneous coronary intervention (PCI). Thoughtful planning
and appropriate preparation before performing PCI improves the safety, efficiency, outcome, and cost of the procedure.
The following items should be checked, that correspond to each of the 14 steps of the procedure. While planning is
in itself the first of the 14 steps, it also serves as a preview of what will occur during each of the subsequent steps
(Table 1.1).
1.1 Planning
Consent obtained
G Consent needs to be obtained and documented prior to the procedure. Discussion about the risks and benefits of ad
hoc PCI is critical, in patients without a prior angiogram.
History:
G Clinical presentation (stable angina, acute coronary syndromes (ACS), other).
G If stable coronary artery disease, is indication for procedure appropriate? (Review appropriate use criteria [2]).
G Ongoing chest pain?
G Prior cardiac catheterization or other procedure requiring fluoroscopy? If yes, are the prior images and reports
available?
G Prior coronary artery bypass graft surgery (CABG)? If yes, is surgical report available?
G Current medications (see Section 1.3).
G Comorbidities
G Valvular heart disease
G Congestive heart failure
G Arrhythmias
G Peripheral arterial disease (PAD)
G Renal failure
G Significant lung disease
G Obstructive sleep apnea
G Bleeding disorders
G Back pain or other musculoskeletal disorders that can affect lying flat on the cardiac catheterization table
G Diabetes mellitus
G Advanced age
G Is the patient likely to be noncompliant with medications or require noncardiac surgery in the upcoming 612
months? If yes, PCI may be best avoided to minimize the risk of stent thrombosis (due to the surgery and the early
discontinuation of dual antiplatelet therapy). Medical therapy only or CABG may be preferred.
G In patients with renal failure or those who are anticoagulated, it may be best to stage non-emergent PCI; ultra low or
zero contrast PCI, if feasible, may be beneficial in patients with advanced kidney disease.
G Contrast or latex allergy?
Manual of Percutaneous Coronary Interventions. DOI: https://doi.org/10.1016/B978-0-12-819367-9.00001-9

© 2021 Elsevier Inc. All rights reserved. 3

4 PART | A The steps
TABLE 1.1 Preprocedure checklist for cardiac catheterization and PCI.

Patient Name: ______________________ MRN: ______________ Procedure Date:_________
1. History
*NPO GUIDELINE RECOMMENDATIONS (by the American Society of Anesthesiologists

(ASA)
2 hours prior to scheduled Clear Liquids, including clear/hard candies and
procedure time drinks without pulp or dairy
6 hours prior to scheduled Light solids, including toast/oatmeal/granola bar,
procedure time liquids with dairy, hard candies, pulp, and infant
formula
8 hours prior to scheduled Regular Diet
procedure time
Chewing tobacco No chewing tobacco 6 hours prior to procedure
Candidacy for stenting:
4. Is patient on chronic anticoagulation
Allergies
use
(Continued )

Planning Chapter | 1 5
TABLE 1.1 (Continued)

Medications
Informed Consent
(DNR= do not resuscitate, DNI=do not intubate)
Sedation, Anesthesia and Analgesia
2. Physical Examination
(Continued )

TABLE 1.1 (Continued)
3. Labs and Imaging
(CBC=complete blood count): Hemoglobin: ______ WBC: ______ Platelets: ______

Potassium: ______
Creatinine: _____
GFR: _____
INR:____
Beta hCG:____
Was EKG
If available, echocardiogram
If available, coronary CTA
If available, prior angiogram(s)

If yes, assess the following:
Location of femoral bifurcation: ______
Peripheral arterial disease: ______
Extent of vessel and coronary calcification: ______
Prior stents: ______
Old severe lesions which were untreated: ______
Access issues-crossover: ______
Groin scar: ______
Kissing iliac stents or stenosis: ______
Radial loops: ______
Subclavian stenosis or tortuosity: ______
Need for a long sheath: ______
Anomalous origin of left or right coronary artery: ______

Issues with LIMA or other graft engagement: ______
Diagnostic and guide catheters used [and whether these provided optimal support based on report and
angiographic images]: ______
Guidewires used: ______
Issues with stent delivery: ______
Atherectomy was needed: ______

Physical examination:
G Radiation skin injury on the back (Fig. 28.3)? If yes, may need to postpone or modify procedure to avoid repeat
radiation of the affected area.
G Cardiovascular examination that includes all pulses in upper and lower extremities.
G Signs of congestive heart failure (pulmonary rales, high jugular venous pressure, lower extremity edema).
Labs:
G Hemoglobin
G White blood cell count
G Platelet count
G International normalized ratio (INR)
G Potassium level
G Creatinine 1 estimated glomerular filtration rate (GFR) (limit contrast to # 3.7 3 GFR for patients at increased risk
for contrast nephropathy, such as patients with chronic kidney disease, Section 28.3)
G Pregnancy test (for women of childbearing potential).
Prior imaging:
G Review prior coronary angiograms and PCIs.
G Review noninvasive testing results (echocardiography, magnetic resonance imaging [MRI], stress testing).
G In patients with recent diagnostic angiography or coronary computed tomography angiography (CTA), the target
lesion(s) can be determined prior to the procedure.
1.2 Monitoring
G Assess baseline ECG and heart rate.
G Assess patient’s baseline vital signs and pulse oximetry.
1.3 Pharmacology
G Allergies?
G Has patient received aspirin?
G For patients with a well-documented aspirin allergy: have they been desensitized?
G For patients allergic to contrast: have they been premedicated (Section 3.3)?
G For planned PCI or for patients with ST-segment elevation acute myocardial infarction (STEMI): have they received
a P2Y12 inhibitor?
G On metformin: in patients with chronic kidney disease hold metformin the day of the procedure and do not restart
until at least 48 hours after the procedure. In patients without chronic kidney disease metformin does not necessarily
need to be discontinued; instead renal function can be checked after the procedure and metformin withheld if renal
function deteriorates.
G On insulin: reduce insulin to adjust for fasting status before the procedure.
G On warfarin: discontinue 5 days prior to elective procedures and check the INR on the day of the procedure. Radial
access is preferred in anticoagulated patients.
G On direct oral anticoagulants (DOAC): discontinue prior to elective procedures, as outlined in Table 1.2.
1.4 Access
History:
G Prior radial artery harvesting for CABG?
G Arteriovenous (AV) fistula for dialysis? Avoid using this arm for cardiac catheterization.
G Access site(s) used for any prior procedures? Has a closure device been used? Consider using contralateral femoral
or radial access if an Angioseal was used within 90 days.
G Prior access site complications? If yes, what was the complication and how was it managed? If yes, avoid using the
same access site.

TABLE 1.2 How long to stop a DOAC before a cardiac catheterization procedure.
Direct factor Xa inhibitors Days to hold

Apixaban (Eliquis) 2 days
Edoxaban (Savaysa)
Creatinine clearance 5095 mL/min 2 days
Rivaroxaban (Xarelto)
Creatinine clearance $ 50 mL/min 2 days
Direct thrombin factor IIa inhibitor Days to hold

Dabigatran (Pradaxa)
Creatinine clearance . 80 mL/min 2 days
Creatinine clearance calculator: http://www.mdcalc.com/creatinine-clearance-cockcroft-gault-equation/.
G History of PAD? Access through severely diseased or occluded iliofemoral or subclavian arteries should be avoided.
G Clinical presentation: radial access is especially favored in STEMI patients.
G On warfarin or DOAC: radial access is preferred.
G High risk of bleeding: radial access is preferred.
G Patient preference (patients who work extensively with their hands/arms or use them for support may prefer femoral
approach).
G Good distal pulses?
G Morbid obesity? (Favors radial access)
Labs: high INR and low platelet count favor radial access.
Prior imaging:
G Review prior cardiac and/or peripheral catheterization films: disease or tortuosity in aortoiliac and upper extremity
vessels?
G Computed tomography (CT) of the chest:
G Anomalous aortic arch anatomy?
G Size of iliac/subclavian vessels and presence of disease.
G Arteria lusoria? (Anomalous origin of right subclavian from the aortic arch.) Arteria lusoria favors use of left
radial or femoral access.
G CT of the abdomen/pelvis: location of common femoral artery bifurcation and disease in iliofemoral vessels.
G Ultrasound of peripheral arteries.
Desired outcome: Decide on access site and size/length of the sheath.
1.5 Engagement
G Prior CABG: what is the anatomy (surgical report, prior coronary angiograms)?
G Catheters used in prior coronary angiograms/PCIs? If significant difficulty or inability to engage the coronary arter-
ies well from one access site was encountered, you should switch to a different access site (such as femoral).
G Aortic CT angiography: aortic dilation? Anomalous coronary arteries?
G Aortic stenosis or regurgitation (associated with dilated ascending aorta that may require larger catheters for coro-
nary engagement)?

1.6 Angiography
G Renal failure? If yes:
G Limit contrast volume, by using biplane angiography if available, limiting cine angiographic projections, using
intravascular ultrasound (IVUS), and potentially using contrast savings systems, such as the DyeVert Plus
(Osprey Medical) (Section 29.3).
G Consider using isoosmolar contrast agents (Section 29.3).
G Administer preprocedural and postprocedural hydration (13 mL /kg/h of normal saline).
G Prior radiation skin injury? If yes: Limit number of cineangiography runs and avoid including the previously
affected area within the radiation beam.
1.7 Determine target lesion(s)

History: The presence and severity of symptoms can help determine the need for PCI.
Prior imaging: Prior noninvasive testing can help determine potential culprit lesions. Review of prior angiograms is
essential for determining whether any interval changes have occurred.
1.8 Wiring
History:
G Prior challenges wiring the target lesion(s)?
1.9 Lesion preparation

History:
G Prior challenges expanding the target lesion(s)?
Prior imaging:
G Severe calcification: consider atherectomy, laser, and intravascular lithotripsy. if available (Chapter 19: Calcification).
G Large thrombus: consider antithrombotic treatment and thrombectomy (Chapter 20: Acute Coronary Syndromes—Thrombus).
1.10 Stenting
History:
G Able to take dual antiplatelet therapy (DAPT)? (History of bleeding or high risk of bleeding, compliance with medications)
1.11 Access closure

History:
G Active infection or immunocompromised? May be best to avoid use of vascular closure devices to minimize the risk
for infection.
1.12 Physiology
History: If symptoms are equivocal and there is no preprocedural noninvasive testing showing ischemia, physiologic
coronary assessment can be useful.
G Prior adverse reaction or contraindication to intracoronary vasodilators such as adenosine?
1.13 Imaging
History:
G Prior PCI of the target lesion(s) strongly favors performing intravascular imaging.

1.14 Hemodynamic support

History:
G Congestive heart failure symptoms.
G Low ejection fraction.
G Elevated jugular venous pressure.
G Lower extremity edema.
G Lung crackles.
G Femoral and radial pulses.
Labs:
G Beta natriuretic peptide (BNP).
G Lactate in patients with cardiogenic shock.
Prior imaging:
G Echocardiography (ejection fraction, left and right ventricular size, valvular abnormalities).
G Access site imaging to determine feasibility of hemodynamic support.
Hemodynamics:
G Right heart catheterization measurements, if available (high right atrial, pulmonary artery, or pulmonary artery capil-
lary wedge pressure, low cardiac output, low cardiac power output, low pulmonary artery pulsatility index [PAPI]).
Consider hemodynamic support in patients with reduced ejection fraction, poor hemodynamics, and/or complex or
high-risk planned interventions (Chapter 14: Hemodynamic Support).
References
[1] Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to
Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative
Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 2017;126:37693.
[2] Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 appropriate use criteria for coronary revasculari-
zation in patients with stable ischemic heart disease: a report of the American College of Cardiology Appropriate Use Criteria Task Force,
American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear
Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of
Thoracic Surgeons. J Am Coll Cardiol 2017;69:221241.

Chapter 2
Monitoring
Monitoring the patient should be continually performed from the beginning to the end of the case, so that potential com-
plications are promptly identified and corrected. The following parameters are assessed (Fig. 2.1).
2.1 Patient
1. Patient comfort level: patient discomfort can lead to movement, potentially leading to complications. It can also
lead to tachycardia and tachypnea, which may in turn worsen ischemia.
2. Chest pain, abdominal pain, groin pain? Is the pain anticipated based on the procedure or is it unexpected? The pain
could be due to ischemia, perforation, or other complications.
3. Level of consciousness and breathing. Is breathing assistance needed (BiPAP or intubation)?
4. Ability to move all extremities (no stroke) or conversely excessive movements that may hinder performance of the
procedure.
5. Signs of allergic reactions: skin rash; itching and hives; swelling of the lips, tongue, or throat; hypotension.
2.2 Electrocardiogram
The ECG morphology and heart rate should be evaluated at the beginning of the case, so that subsequent ECG changes
can be promptly identified.
Electrocardiographic changes of concern include:
1. New ST segment depression.
2. New ST segment elevation (Fig. 2.2).
FIGURE 2.1 What to monitor dur-

5. Radiation dose 2. ECG
X-ray system and ing cardiac catheterization.
3. Pressure
shield position 4. O2
10. Environment
saturation
1. Patient
9. Operators
12. Equipment
position within body
8. Anticoagulation
–ACT 7. Access
Sedation site
Medication 11. Sterile field
6.Contrast
volume


3mmHg
(A) (B)
FIGURE 2.2 Electrocardiographic and pressure waveform changes during CTO PCI. (A) Baseline. (B) ST-segment elevation (arrows) and develop-
ment of 35 mmHg pulsus paradoxus after a distal vessel perforation in a patient with prior coronary artery bypass graft surgery. Reproduced with per-
mission from the Manual of CTO Interventions, 2nd ed. (Figure 3.35). Copyright Elsevier.
3. Bradycardia.
4. Tachycardia.
5. QRS widening.
6. Ventricular premature beats during wire manipulations.
7. Ventricular fibrillation.
2.3 Pressure waveform

The arterial pressure should be continuously monitored.
Pressure waveform changes of concern include:
1. Hypotension (see Section 28.1)
2. Pulsus paradoxus (Fig. 2.2)
3. Hypertension
4. Pressure waveform dampening or disappearance (see Section 28.1.1.1.) that may reflect the true aortic pressure, or
may be due to:
a. Deep guide catheter engagement or engagement of coronary arteries with ostial lesions. Injections should not be
performed while the pressure waveform is dampened, as they can lead to coronary or aorto-coronary dissection
and/or air embolism.
b. Air entrainment within the guide catheter (e.g., when using the trapping technique for equipment exchange).
c. Thrombus formation within the catheter. Injecting in such cases can lead to coronary or systemic thromboembolism.
d. Guide catheter kinking.
e. Insertion of equipment: for example, inserting an aspiration catheter, such as the Export into a 6 French guide
catheter may lead to pressure dampening.
f. Disconnection of the pressure transducer.
In patients who develop hypotension and in heart failure or shock patients, placement of a Swan Ganz catheter
can facilitate decision making regarding hemodynamic support and also help detect any new hemodynamic changes
(Section 28.1.1).
2.4 Oxygen saturation

Oxygen desaturation may be due to hypoventilation due to heavy sedation, but it can also be due to early pulmonary
edema, artifact, or other causes. Full arterial blood gas can provide more comprehensive information about the patient’s
oxygenation and metabolic status.

Monitoring Chapter | 2 13
2.5 Radiation dose—X-ray system and shield positioning

The cumulative air kerma and DAP radiation dose should be continuously monitored. Usually the procedure is stopped if
the air kerma dose exceeds 57 Gray. An air kerma radiation dose higher than 15 Gray is a sentinel event (Section 28.2).
The dose rate is another dynamic parameter that can be tracked.
There are also continuous operator dose monitoring devices (such as the DoseAware, Philips) that can alert to high
operator doses in real time, alerting the operator to the need for changes to reduce high radiation dose.
The position of the various shields and the image receptor should be continually monitored and adjusted to minimize
patient and operator radiation dose.
2.6 Contrast volume

This can be tracked automatically by some systems (such as the ACIST injector and the DyeVert Plus system). The pro-
cedure should generally be stopped before reaching a contrast volume $ 3.7 3 GFR, although a lower threshold is
preferable in patients with chronic kidney disease or single kidney (Section 28.3). Recent contrast administration (for
example in patients who had contrast computed tomography) should be taken into consideration when determining the
contrast threshold.
2.7 Access site

The pulses at the access site and distally should be assessed at the beginning and the end of the case.
Bleeding and hematoma formation can occur at the access site(s)—continuous inspection and palpation can help in
early identification (Chapter 4: Access).
2.8 Medication administration (anticoagulation—ACT, sedation, other medications)

Sedation (Section 3.1) is given in nearly all patients and should be titrated to achieve acceptable patient comfort without
compromising respiratory or hemodynamic status.
Anticoagulation (Section 3.4) is achieved with unfractionated heparin in most procedures and monitored using ACT
(activated clotting time). Goal ACT (Hemochron device) for PCI is 300350 seconds for most procedures or .350 sec-
onds for retrograde CTO PCI. When glycoprotein IIb/IIIa inhibitors or cangrelor (Section 3.5) are given, goal ACT is
200250 seconds.
Other medications may be required, such as vasopressors (Section 3.6), atropine (Section 3.7.2), etc.
2.9 Operator and team performance

Paying attention to the operators’ and team’s operational state can help identify conditions that may lead to suboptimal
outcomes, such as excessive fatigue.
2.10 Cath lab environment

Avoiding excessive noise and distractions is important for better outcomes.
A rule analogous to the “sterile cockpit rule” for flying should be implemented during the critical parts of the proce-
dure. The “sterile cockpit rule” is an informal name for the Federal Aviation Administration regulation stating that
pilots shall not require, nor may any flight crewmember perform, any duties during a critical phase of flight, except
those duties required for the safe operation of the aircraft.
2.11 Sterile field and equipment

Keeping the equipment and table organized will facilitate equipment identification and use.
Dried blood and contrast can make the operator gloves and various types of equipment (guidewires, catheters, bal-
loons, stents, etc.) “sticky” and could also create risk of embolism if debris enters the manifold. Regularly wiping the
gloves and equipment and flushing the catheters with heparinized saline will facilitate equipment handling and reduce
the risk of complications.

2.12 Equipment position within the body

The position of equipment inserted into the body (such as sheaths, guide catheters, guidewires, balloons, stents, etc.)
should be constantly monitored for both efficacy and safety.
A classic example is guide disengagement while attempting to deliver balloons and stents, when the operator often
focuses on the equipment that needs to be delivered (such as the stent) and does not pay attention to the guide catheter,
which may become completely disengaged leading to loss of guide and guidewire position. Conversely, deep guide
engagement may result in dissection and acute vessel closure (Section 25.2.1), especially if contrast is injected.
Another example is not monitoring the location of the guidewire tip (especially when collimation is used to mini-
mize radiation dose), which may enter into small branches and result in distal vessel perforation (Section 26.4).
Who is assessing the above parameters:

1. The primary and secondary operators.
2. The cath lab technician (traditionally a technician is constantly monitoring the ECG and pressure tracings).
3. The cath lab RN (who monitors the ECG, pressure, and O2 saturation). The cath lab RN is usually administering the
various medications (sedation, anticoagulation, antiplatelet agents, etc.).

Chapter 3
Medications
In this chapter we discuss the following classes of medications that are commonly used in the cardiac catheterization
laboratory:
1. Sedatives and analgesics
2. Vasodilators
3. Contrast media
4. Anticoagulants
5. Antiplatelet agents
6. Vasopressors and inotropes
7. Antiarrhythmics
3.1 Sedatives and analgesics

3.1.1 Goals
G Improve patient comfort.
3.1.2 How?
G Midazolam (Versed): 0.51 mg intravenous (IV)—can be repeated. Duration of action: 1580 minutes.
G Fentanyl: 25100 mcg IV—can be repeated. Duration of action: 3060 minutes. Other opioids, such as morphine
can also be used.
3.1.3 What can go wrong?

3.1.3.1 Respiratory failure—hypopnea
Causes:
G Excessive sedation may suppress respiratory drive.
Prevention:
G Avoid excessive sedation.
G Monitor oxygen saturation throughout the procedure.
Treatment:
G Stop administering sedation.
G Flumazenil (Romazicon) for reversing midazolam: 0.2 mg IV over 15 seconds. If there is no response after 45 sec-
onds, administer 0.2 mg again over 1 minute. Can repeat at 1-minute intervals up to a total of 1 mg.
G Naloxone (Narcan) for reversing opioids (Fentanyl, morphine, etc.): 0.10.2 mg intravenously; can repeat at 2- to 3-
minute intervals until the desired degree of reversal is achieved.
G Intubation may be required for severe respiratory depression.


3.1.3.2 Delayed response to oral P2Y12 inhibitors which may lead to thrombotic complications
Causes:
G Opioids delay gastric empting and slow-down drug adsorption, such as P2Y12 inhibitor absorption.
Prevention:
G Avoid opioids use in STEMI if not deemed necessary.
Treatment:
G Use intravenous antiplatelet agents (e.g., cangrelor or GP IIb/IIIa inhibitors).
3.2 Vasodilators
Medications that cause vasodilation can be categorized into those causing mainly large vessel vasodilation (nitroglyc-
erin) and those causing mainly small vessel vasodilation (nicardipine, nitroprusside, adenosine).
3.2.1 Nitroglycerin
3.2.1.1 Goals
G Dilate coronary arteries (intracoronary nitroglycerin should be routinely administered before coronary angiography,
to prevent coronary spasm and allow accurate interpretation of coronary anatomy).
G Treat hypertension.
G Treat pulmonary edema.
3.2.1.2 How?
G Intracoronary/intragraft: 100300 mcg.
G Intravenous: nitroglycerin drip is usually started at 10 mcg/min and increased by 10 mcg/min at 5-minute intervals
until the desired effect is achieved and systolic blood pressure remains above 100 mmHg. Maximum dose is
200 mcg/min.
G Sublingual: 0.4 mg.
3.2.1.3 What can go wrong?

3.2.1.3.1 Hypotension
Causes:
G Excessive dilatation of peripheral veins, reducing blood return to the heart (decreased preload). Also excessive dila-
tation of peripheral arteries (decreased afterload).
G Coadministration of nitroglycerin and phosphodiesterase type 5 (PDE-5) inhibitors, such as avanafil, sildenafil, var-
denafil, and tadalafil.
G Hypertrophic obstructive cardiomyopathy (HOCM): nitroglycerin worsens left ventricular outflow obstruction by
decreasing both preload and afterload.
Prevention:
G Avoid high and multiple doses of nitroglycerin.
G Do not administer in patients with hypotension or patients with right ventricular infarction.
G Do not administer in patients who have recently received a PDE-5 inhibitor, such as avanafil (Stendra, within prior
24 hours), sildenafil (Viagra, within prior 24 hours), vardenafil (Levitra, within prior 24 hours), and tadalafil (Cialis,
within prior 48 hours).
G Do not administer to patients with hypertrophic obstructive cardiomyopathy (HOCM).
Treatment:
G Do not administer additional doses of nitroglycerin. Nitroglycerin’s half-life ranges from 1.5 to 7.5 minutes.
G Administer normal saline.
G Waiting (hypotension often resolves after a few minutes).
G Administer vasopressors (such as norepinephrine or phenylephrine) in cases of extreme or persistent hypotension. If
hypotension persists, also assess for other potential causes, such as bleeding.

Medications Chapter | 3 17
3.2.1.3.2 Headache, flushing, dizziness

Headache may occur after nitroglycerin administration due to dilation of intracranial arteries. Dizziness can occur due
to the hypotensive effect of nitroglycerin.
3.2.1.3.3 Tachycardia
Reflex tachycardia may result from the hypotensive effect of nitroglycerin.
3.2.2 Nicardipine
3.2.2.1 Goals
G Prevent and treat no reflow. Nicardipine is a calcium channel blocker that can be used intracoronary to achieve vasodila-
tion of small arteries. Nicardipine is the preferred agent for treating or preventing no reflow (Section 25.2.3.2), for
example, during atherectomy (Section 19.3) and during saphenous vein graft PCI (Section 18.9.2), as it has less hypo-
tensive effect compared with nitroprusside and verapamil and also has shorter duration of action.
3.2.2.2 How?
G Intracoronary: 100300 mcg.

This is treated as described in Section 3.2.1.3.1.
3.2.3 Nitroprusside
3.2.3.1 Goals
G Prevent and treat no reflow.
3.2.3.2 How?
G Intracoronary: 100300 mcg.

3.2.4 Verapamil
3.2.4.1 Goals
G Prevent radial spasm.
3.2.4.2 How?
G Radial artery: 23 mg.
G Intracoronary: 1 mg intracoronary over 2 minutes.

3.2.5 Adenosine
3.2.5.1 Goals
G Cause vasodilation during physiologic testing (Section 12.2.6).

3.2.5.2 How?
G Intracoronary: RCA: 50100 mcg.
G Intracoronary left main: 100200 mcg—several thousand mcg could be administered (slowly) in case of no reflow.
G Intragraft: 100200 mcg.
G Intravenous: 140 mcg/kg/min, administered through a central vein or a large peripheral vein.
G Regadenoson or papaverine (papaverine is not available in the United States) can also be administered for inducing
vasodilation. Regadenoson is costly and papaverine may cause ventricular fibrillation.

3.2.5.3.1 Heart block
Causes:
G Adenosine’s effect on atrioventricular node.
G This is most likely to occur with injection in the right coronary artery.
Prevention:
G Avoid high doses of adenosine in the right coronary artery.
G Slow adenosine administration.
G Aminophylline administration (250300 mg intravenously over 10 minutes) may be used to prevent bradycardia [1]
during atherectomy of the right coronary artery. Aminophylline is an A1 adenosine receptor antagonist (Section 19.3).
Treatment:
G Watchful waiting (adenosine has short half-life).
3.2.5.3.2 Atrial fibrillation

Atrial fibrillation is the most commonly documented adenosine-induced arrhythmia (2.7% after intravenous administra-
tion) [2] and is usually well-tolerated except in patients with accessory pathways [3].
Causes:
G Premature ventricular beats occurring during adenosine administration, sometimes during periods of AV block
(Figs. 3.1 and 3.2) [4].
FIGURE 3.1 Atrial fibrillation occurring after adenosine administration. Adenosine caused ST-segment depression (arrowheads). A premature ven-
tricular beat (arrow) subsequently triggered atrial fibrillation.

Medications Chapter | 3 19
(A) (B)
Complete heart block
Adenosine administration
(C) (D)
Atrial fibrillation
FIGURE 3.2 Coronary angiography demonstrating an in-stent restenotic lesion of the mid right coronary artery (A). Intracoronary adenosine admin-
istration through the right coronary artery (40 mcg) resulted in complete heart block (B), followed by development of atrial fibrillation (C). After stent-
ing the right coronary artery lesion resolved. Sinus rhythm was restored with cardioversion at the end of the procedure. Reproduced with permission
from Mahmood A, Papayannis AC, Brilakis ES. Pro-arrhythmic effects of intracoronary adenosine administration. Hellenic J Cardiol 2011;52:3523
(Figure 2). Copyright Elsevier.
Prevention:
G Same as for heart block above.
Treatment:
G DC cardioversion. If cardioversion is not desired, antiarrhythmics, such as amiodarone, and AV nodal blocking
agents, such as beta blockers or calcium channel blockers could be used.
3.2.5.3.3 Ventricular fibrillation

Causes:
G Torsades des pointes or ventricular fibrillation can be triggered by adenosine administration, usually after a ventricu-
lar pause due to the R on T phenomenon (Fig. 3.3), but may also occur without a pause [5].
Prevention:
G Same as for heart block above.
Treatment:
G Ask patient to cough, as forceful coughing could generate sufficient blood flow to the brain to maintain conscious-
ness until definitive treatment (defibrillation) can be administered.
G Defibrillation.

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Plein d orgueil, il trébuche et va mourir plus loin...
LES VOLUPTUEUX
Les laquais ont servi les sorbets à la rose

Et les voluptueux ont pris de tendres poses
Pour écouter l’orchestre invisible à travers
Les tentures de soie étrange aux tons de chair.
On voit le parc charmant par les portes vitrées
Et l’air tiède est rempli d’une ambre évaporée
Mêlée artistement aux aromes des fleurs...
Avec son voile vert dépouillant ses pudeurs
La jeune fille au corps parfait s’est mise nue
Pour que les jeunes gens et les femmes venues
Pour la beauté, parmi les bouquets et les ors,
Jouissent par l’esprit des lignes de son corps.
Ils n’ont pas entendu les pas dans les arbustes.
Ils n’ont pas vu surgir les faces et les bustes
Du peuple, des affreux escaladant les murs
Pour profaner le parc où fleurit l’art impur.
La foule est là, obèse, extravagante, énorme...
Et le dégénéré à tête un peu difforme,
Au cou trop long, aux yeux rougis d’avoir trop lu,
Qui sait des joueurs grecs les secrets disparus,
Prend la lyre et, chétif, devant l’horrible horde,
Fait merveilleusement résonner les sept cordes.
Le peuple grimaçant grogne, grince des dents
Et n’ayant pas compris s’éloigne cependant.
Mais les voluptueux à peine une seconde
Dérangés par le bruit qu’a fait la vie immonde,
Se recouchent dans l’épaisseur des coussins d’or,
Savourant les sorbets, les vers et les beaux corps.
LE DERNIER SPASME
Comme ils avaient compris le sens de la comète,

De l’épaisseur de l’air et du trouble des eaux
Les jeunes gens, hantés de luxures secrètes,
Entrèrent en courant dans le parc du château.
Déjà des craquements sortaient du creux des arbres,

Les lévriers pâmés hurlaient sur les gazons...
La chaleur partageait les vasques et les marbres
Et la mort répandait sa forte exhalaison...
Ils sautèrent soudain sur les trois jeunes filles,

Ils les prirent contre eux avec de fortes mains
Et foulant le parterre et franchissant la grille
Bondirent à cheval en les tenant aux reins.
L’horreur embellissait les trois nobles visages,

La lutte dessinait la ligne des corps purs.
Sur les portes, des gens criaient à leur passage...
Mais déjà des éclairs zébraient d’or les azurs...
La cavalcade alla jusqu’aux forêts prochaines.

Là, les déshabillant, leur broyant les genoux,
Les hommes en fureur sous les ombres des chênes
Prirent les trois enfants aux corps minces et doux.
Car ils ne voulaient pas entrer dans le silence

Sans percer de leur cri de plaisir les cieux lourds.
Ils désiraient connaître en mourant la puissance
De la vie, éclater de jeunesse et d’amour.
Mais déjà les oiseaux tombaient comme des pierres,

Les chevaux étaient morts debout, tous les tocsins
Hurlaient dans la soirée aux verdâtres lumières...
Eux, pensaient seulement à la forme des seins...
Ils apprenaient le rythme essentiel du monde.
Le plaisir à présent devenait mutuel
Et la terre en cassant ses vertèbres profondes
Leur donnait un nouvel aliment sexuel.
Les jeunes filles par l’étreinte ravagées

Gémissaient et serraient les hommes sur leurs flancs.
Les dents marquaient les cous et les lèvres mangées
Entre elles se buvaient intarissablement.
La mer se souleva, les montagnes flambèrent

Le ventre de la terre eut des bruits de canon...
Sortis des profondeurs des monstres émergèrent
Les peuples affolés devinrent des charbons...
De hauts vaisseaux lancés par des ras de marée

Allèrent s’enfoncer au milieu des labours...
Le fleuve fou roula sur la ville égarée...
Les amants demeuraient l’un sur l’autre toujours...
La lune se fendit dans le ciel de désastre...

Des geysers de feu par milliers jaillissaient...
Mais sous la lave en flamme et sous les morceaux d’astre,
Les amants enlacés toujours se possédaient...
Et plus haut que le jet des volcans gigantesques,

Dans le chaos et les éthers carbonisés,
Arrêtant les soleils dans leur folle arabesque
Monta le dernier spasme et le dernier baiser...
LA MESSE DE L’ANE A CORNES
L’âne à cornes se peint, se maquille avec soin.

Ses mignons près de lui se tiennent les pieds joints,
Prêts à lui présenter un corps qu’il aime à mordre.
Ses femmes sont sur des divans, guettant ses ordres.
Mais quand il a vêtu l’étole de brocart
Et la mitre, il les quitte en faisant des écarts,
Il sort de son palais et s’en va vers les bouges.
Il cogne les judas avec sa patte rouge
Et pelée, et fait voir son mufle monstrueux.
A son cri, le rebut de tous les mauvais lieux,
Les matrones, les procureurs et les ribaudes
Viennent vers lui, dansant de joie, chantant des laudes,
Et l’un porte un ciboire et l’autre un ostensoir,
L’autre lève en riant deux cierges dans le soir.
Alors, sur un autel formé d’un dos de femme,
Des nains chauves servant d’enfants de chœur infâmes,
Et sous la cathédrale immense du ciel bas,
L’âne bénit, étend son étole grenat
Et semble célébrer une messe grotesque.
Et quand avec sa patte il trace une arabesque,
Frappant la femme-autel du sabot à grands coups,
Le peuple agenouillé roule sur les cailloux
Parmi les détritus et les choses impures.
L’un étreint le ruisseau, l’autre baise l’ordure,
Un autre mord au cierge et mange avidement,
Et tous, les yeux soudain grandis stupidement,
T’adorent dans la nuit de plus en plus profonde,
Ane à cornes galeux qui règnes sur le monde!...
LES RENCONTRES DANS LE PORT
VIEUX
LE LONG DU PORT VIEUX
Le long du port vieux on fait des rencontres,
Un bateau pourrit auprès d’un fanal.
Près du parapet, un noyé se montre,
Et dans la ruelle, au bord du canal
La misère est là comme un vaste étal.
Le long du port vieux on voit des fenêtres

Qui semblent pleurer les morts qu’on aimait.
Le long du port vieux on croise des êtres
Comme nulle part on n’en vit jamais,
Et les uns sont bons, les autres mauvais.
Le long du port vieux, l’on boit et l’on chante,

Et la chair est faible et le lit affreux.
Là, des égarés et des repentantes
Parfois voudraient fuir le long du port vieux.
Mais le couteau luit, la vie est méchante.
Est-ce ici, seigneur, que trinquent des frères?

Pourrais-je m’asseoir, je viens de si loin!
Et m’aimera-t-on, j’en ai tant besoin!
A tous les carreaux meurent les lumières.
C’est un peu plus loin... C’est toujours plus loin...
Le long du port vieux, la boue est fétide.

Parmi les filets je fais des détours,
Heurtant des anneaux, des barriques vides,
Sans trouver jamais une ombre d’amour,
Le long du port vieux, je marche toujours.
Le long du port vieux, que de formes bougent,

Que de chants d’ivrogne et de cris de faim!
Le long du port vieux où je vais en vain
Avec ton seuil noir et tes carreaux rouges,
Maison de pitié, te verrai-je enfin?
L’ENFANT MORT
Auprès du lupanar repose un enfant mort.

En peignoir rose, en peignoir mauve, dans la rue
Avec des cris elles sont toutes accourues.
Le gros numéro tremble au vent qui vient du port...
L’être est dans le ruisseau sous des linges immondes,

Il a les yeux vitreux, il est jaune et gonflé.
L’absence de pitié, la tristesse du monde,
Monte sinistrement du port ensorcelé.
La nuit est lourde et chaude ainsi qu’une fournaise...

Les femmes crient et la patronne s’avançant,
Avec son ventre énorme et sa face mauvaise
Prend l’enfant et lui dit «petit» en le berçant.
Et lorsqu’elle baisa sur le front l’être jaune,

Son visage carré de marchande de chair
Devint plus beau que le visage des madones
Et la lune en montant lui fit un nimbe clair.
L’épicière du coin apporta quatre cierges,

Les quatre adieux du mal et de la pauvreté.
Les filles de maison pareilles à des vierges
Levaient ces feux sur les ordures des cités.
Pierreuses et voyous formèrent un cortège,

Car l’enfant du ruisseau était bien de leur sang.
Un marin ivre ainsi qu’un prêtre sacrilège
Promenait sur ce peuple un ostensoir absent.
Ils allèrent ainsi, méditant dans leur âme

Et ceux qu’ils rencontraient, suivaient, ayant compris.
Et près de l’enfant mort les pitiés porte-flamme
Par les peignoirs ouverts montraient leurs seins flétris...
Les bouges, gorges d’ombres, exhalaient leurs haleines,
Le peuple sentait mieux le malheur éternel.
Au loin se dessinaient comme des bras de haine,
Des mâtures de rêve au fantastique ciel.
Ils allèrent ainsi de ruelle en ruelle,

Vers le bassin qui sert de dépotoir au port,
Où se déversent les égouts où s’amoncellent
Les coques pourrissant auprès des pontons morts.
Il semblait que c’était la faute originelle

Qui courbait tous les dos en arc de désespoir
Et la patronne alors de ses mains solennelles
Leva l’enfant et le jeta dans le flot noir.
«Seigneur, accueille au fond des clémentes ordures,

Loin du soleil injuste et des hommes mauvais,
Dans cette tombe affreuse et pour nous la plus pure
Ce pauvre paria, pour qu’il dorme à jamais.
«Et puisque tu n’as pu lui donner en partage

Que le coin de la rue et le lit du ruisseau,
Qu’au moins notre pitié plus profonde et plus sage
Le couche malgré toi dans le meilleur berceau.»
L’ARBRE DE CHAIR
Je suis l’arbre de chair qui pourrit dans la nuit,

Je cache des poisons dans le suc de mes fruits
Et sous le rougeoiment de feu des soirs de paie,
Comme une bête en rut l’homme boit à mes plaies.
Il ne me parle pas, il n’a pas de pitié,
Il déchire mes draps des clous de ses souliers,
Il se vautre à loisir, il me possède, il crie
Et retourne aussitôt à l’ombre de sa vie.
Ainsi que les forçats je porte un numéro.
Le malheur dans mon lit comme dans un terreau
Malsain s’épanouit sur ceux qui me besognent,
Sur des sommeils de pauvre et des réveils d’ivrogne.
Mes amours sont toujours précédés d’un débat
Sur le prix, pour adieux je reçois des crachats.
Je vois se refléter dans ma glace ternie
L’image de l’horreur et de l’ignominie
Et pourtant comme un mort dressé hors du cercueil,
Je me tiens droite sur ma porte avec orgueil.
Si, de ses bons travaux il faut faire la somme,
Mon apport vaudra bien celui des autres hommes.
J’offrirai comme un feu d’amour, comme une fleur,
Mon sexe fatigué d’innombrables labeurs.
Parmi les êtres purs j’élèverai ma face,
Où l’alcool et la maladie ont mis leurs traces,
Mon front chauve où l’on voit le crâne blanchissant
Sous la peau et branlant ma mâchoire sans dents
Je montrerai mon mal, ses trous, ses boursouflures,
Disant: je l’ai transmis à mille créatures!
S’il est un châtiment, je l’ai connu déjà.
Et s’il est un pardon, qui me le donnera?
L’ORGIE PAUVRE
Le garni fastueux se farde et se parfume

Comme une courtisane avide de plaisir.
Par les pores fanés des vieux rideaux il hume
L’odeur des corps humains d’où montent les désirs.
Il s’étale sous le crépuscule des lampes

Qui pare ses fauteuils d’une vague splendeur.
Dans le miroir malade aux reflets faussés rampe
L’encens qu’on a brûlé dans une assiette à fleurs.
La descente de lit est toute parsemée

De bouquets bon marché effeuillés avec soin.
Des coussins d’orient et des robes lamées,
D’un clinquant de bazar animent chaque coin.
La tête renversée, une jambe pendante,

Une femme se pâme hors des draps rejetés,
Une autre la caresse et de sa main tremblante
Peuple ce ciel de chair d’éclairs de volupté.
Une autre, fauve et lourde, en gémissant s’affale,

Se crucifie et meurt sur le divan crevé.
Plus loin, les yeux brillants et la face animale,
L’homme est comme un forçat à son spasme rivé.
Le champagne et l’éther coulent et se mélangent.

Près d’une tache d’huile un genou trop épais
Prend dans le demi-jour une importance étrange,
Le tapis est usé, les sièges contrefaits...
Mais soudain, au milieu de ces caricatures

De la magnificence absente de l’amour,
Un souffle délicat descend des moisissures
Du plafond, sort des trous des draps et des velours.
Et malgré l’espoir vain, la détresse profonde,
Malgré l’odeur humaine et les relents du mal,
Un frisson de beauté circule une seconde
Dans ce rez-de-chaussée où vomit l’idéal...
JE VOUDRAIS BIEN ENTRER...
Je voudrais bien entrer dans cette maison-là...

Je vois le corridor baigné d’un vague éclat...
Mais tu me prends la main en disant: Pas encore!
Ta robe en tissu de chagrin se décolore
Et la rue est si longue et mon cœur a si mal.
Arrêtons-nous. J’entends comme le bruit d’un bal
Étouffé... Mais tu dis: Plus loin! Pas cette danse
Ni ces danseurs plaintifs qui tournent en silence...
—J’ai tellement besoin de rêver quelque part
Au jeune adieu qui pleure auprès du vieux départ.
Il pleut et ta figure est tellement voilée!...
La bonne porte luit au fond de cette allée...
Tu vois, on m’a fait signe... Et tu dis: Pas encor!
—Je serre contre moi le lis noir du remords...
On voit les flaques d’eau étinceler par terre...
Ah! que les bonheurs morts renferment de mystère!
LA JEUNE FILLE AU LUPANAR
Au judas, apparaît un visage de plâtre.

Devant la maison louche, aux clartés du fanal,
Luisent les diamants et les bagues bleuâtres
De la femme mi-nue en sa robe de bal.
Un coin de son hermine est pendant dans la boue.

La ruelle s’éclaire et fait ressortir mieux
Le blé de ses cheveux, la rose de sa joue,
L’ivoire de ses seins, le métal de ses yeux.
L’ivresse du plaisir tend comme un arc sa forme.

Elle rit en faisant claquer ses jeunes dents.
Ses perles effleurant une matrone énorme
Éblouissent le seuil de leur luxe impudent...
Elle embrase en passant le corridor sinistre

De la flamme en satin qui double son manteau.
Sa prunelle aux tons mats que ne cercle aucun bistre
Écorche les miroirs comme un feu de couteau.
Le troupeau, comme une eau malade se déverse

Dans le salon, timide, hébété, paresseux...
Elle, dans les sofas se pâme et se renverse,
Montrant sa jambe fine et son torse nerveux.
L’aspect des corps lassés attise sa luxure,

Elle écrase les seins tombant entre ses doigts,
Se moque insolemment des pauvres chevelures,
De la rape des peaux et du graillon des voix.
Elle les fait danser, se coucher sur son ordre,

Ainsi qu’une dompteuse exquise aux yeux d’acier,
Domptant des animaux qui voudraient bien la mordre,
Mais courbent leur échine et lui lèchent les pieds.
Le piano faussé résonne et le vin coule...
Parfois elle égratigne avec son ongle peint
Le dos vaincu d’une des femmes qui s’écroule,
Ou la cingle du coup de fouet de son dédain.
Sous l’électricité les visages se creusent.

L’alcool est plus puissant, les tapis plus profonds,
Un halo de splendeur baigne la visiteuse,
L’envie et le malheur descendent du plafond...
Et soudain, sans un mot, tout le bétail se dresse

Avec un goût de sang, des regards d’assassin.
Elles se penchent, haletantes de l’ivresse
De broyer à la fois ses bijoux et ses seins.
Elles voudraient casser cette main frêle et rude,

Crever cette peau fine avec ses diamants,
Ce corps trop ferme insulte à leur décrépitude,
Et vaincre ce cynisme orgueilleux de vingt ans...
Or, debout, l’autre s’est campée au milieu d’elles

Et se grise du voisinage de la mort,
L’air de crime la fait plus perverse et plus belle,
Hors la robe, elle tend exprès son jeune corps.
Et le couteau pâlit devant l’éclair bleuâtre

Des bijoux, toutes les tigresses en fureur
Ne sont plus qu’un troupeau de chiennes qu’il faut battre,
Pour leur air malheureux de femelles en pleurs...
Mais la petite reine, avec une allumette

Qu’elle frotte sur son soulier de satin blanc,
Rallume alors indolemment sa cigarette
Pour leur souffler au nez sa fumée en riant...
LE SECRET PERDU

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Manual of Percutaneous Coronary

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Emmanouil Brilakis, MD, PhD

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British Library Cataloguing-in-Publication Data

Publisher: Stacy Masucci

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To Nicole, Stelios, and Thomas.

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List of contributors xi 2.10 Cath lab environment 13

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6. Coronary angiography 97 9.7 Balloon angioplasty 142

11. Access closure 169

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Part B 19. Calcification 329

17. Left main 303

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Yiannis S. Chatzizisis Cardiovascular Division, Dmitriy N. Feldman Greenberg Division of Cardiology,

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Judit Karacsonyi Division of Invasive Cardiology, Konstantinos Marmagkiolis University of Texas MD

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Ashish Pershad Banner-University Medical Center, System Director, Cardiovascular Interventional

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Jarosław Wójcik Hospital of Invasive Cardiology Department of Cardiology, Attikon University

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Case Number YOUTUBE link

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Case Number YOUTUBE link

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115 https://www.youtube.com/watch?v 5 q8w-xhW_GX8

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PCI: the process FIGURE 1 The 14 steps of percutaneous coro-

7. Determine target lesion(s)

10. Stent(s) Thrombectomy

14. Hemodynamic support

The following steps are performed in all PCI cases:

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If you fail to plan you are planning to fail.

Manual of Percutaneous Coronary Interventions. DOI: https://doi.org/10.1016/B978-0-12-819367-9.00001-9

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TABLE 1.1 Preprocedure checklist for cardiac catheterization and PCI.

*NPO GUIDELINE RECOMMENDATIONS (by the American Society of Anesthesiologists

Candidacy for stenting:

4. Is patient on chronic anticoagulation

(CBC=complete blood count): Hemoglobin: WBC: Platelets: __