Debulking in Cardiovascular Interventions and Revascularization Strategies

Between a Rock and the Heart

1st Edition - January 21, 2022
Editor: On Topaz
Language: English
Paperback ISBN:
9 7 8 - 0 - 1 2 - 8 2 1 4 5 1 - 0
eBook ISBN:
9 7 8 - 0 - 1 2 - 8 2 1 4 6 2 - 6

Debulking in Cardiovascular Interventions and Revascularization Strategies: Between a Rock and the Heart aims to provide a comprehensive overview on the diagnostic and therapeut… Read more

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Debulking in Cardiovascular Interventions and Revascularization Strategies: Between a Rock and the Heart aims to provide a comprehensive overview on the diagnostic and therapeutic aspects of resistant lesions as well as tailored debulking processes in revascularization strategies. Cardiovascular interventionalists and surgeons alike frequently encounter technical challenges and increased risk when attempting to diagnose and treat resistant cardiovascular lesions, bio-tissues and vessels. Calcified plaques, fibrotic or thrombotic lesions, total occlusions, degenerative plaques, complex lesions and vessels impose morphologic obstacles to the safe and effective delivery and deployment of balloons and stents. In such instances, a debulking strategy involving the actual drilling and extraction of the targeted plaque/bio-tissue constitutes a unique option that ensures safe and efficacious subsequent balloon dilatations and stenting.

A range of topics is included in the book, from the characteristics and constituents of various resistant targets and bio-tissues, to the corresponding options of debulking methods, and finally the technologic and pharmacologic means available for application.

The book also provides an up-to-date description of related management solutions and tools, exploring the medical issues pertaining to the patients with these targets; procedural results and clinical outcomes as related to debulking strategies and associated diagnostic and therapeutic technology and revascularization options.

Cover image
Title page
Table of Contents
Copyright
Dedication
Contributors
Foreword
Preface
Introduction—a fortiori
Chapter 1. The impact of biological factors, anatomy, and mechanical forces on calcification and fibrosis of cardiac and vascular structures
Introduction
Vascular microanatomy
Vascular biological factors
Mechanical signaling in cardiovascular disease
Conclusions
Chapter 2. The resistant atherosclerotic plaques: pathologic features and their impact on revascularization
Coronary plaques resistant to intervention
Crystals and plaque formation
Plaque rupture and cholesterol crystals
Cholesterol crystals and calcification
Intravascular imaging of formidable plaques
Percutaneous coronary intervention
Conclusion
Chapter 3. Application and interpretation of fractional flow reserve in heavily calcified coronary arteries
Overview of FFR
Coronary artery calcium
The role of Pd/Pa and FFR in calcified arteries
Mechanisms by which coronary artery calcium could influence FFR
Summary
Chapter 4. Abrasion, grinding, pulverization, vaporization, and extraction: debulking options for percutaneous coronary interventions of calcified coronary lesions
PCI and calcified coronary lesions
Cutting and scoring balloons
Coronary lithotripsy
Rotational atherectomy
Orbital atherectomy
Laser atherectomy
Conclusion
Chapter 5. Percutaneous coronary interventions in calcified coronary lesions: imaging, tools, and outcomes
Introduction
Calcified coronary lesions
Pathophysiology
Detection of CAC during PCI
CAC and the effect on PCI outcome
PCI toolbox for dealing with CAC lesions
Calcium modification algorithm
Conclusions
Chapter 6. Effectiveness of debulking strategies in coronary and endovascular interventions: targets and tools
Coronary atherectomy
Peripheral atherectomy
Special considerations
Chapter 7. Revascularization of complex coronary lesions: the importance of vessel and plaque preparation strategies
Introduction
Historical perspective to lesion preparation
Direct stenting versus prestenting lesion preparation
The risk of inadequate lesion preparation before stent deployment
Predictors of the need for lesion preparation in complex lesions
Importance of calcium and the concept of calcium modification
Calcification phenotypes
Role of coronary imaging in guiding lesion preparation
Tools and strategies for lesion preparation
Atherectomy
Vessel preparation in specific lesion types
Summary
Chapter 8. Debulking rock hard coronary lesions: “real-world” experience in a tertiary care medical center
Introduction
Cutting and scoring balloon atherectomy
Rotational atherectomy
Orbital atherectomy
Laser atherectomy
Selected cases illustrating the utilization of coronary debulking
Summary
Chapter 9. Atherectomy debulking of calcified left main coronary lesions: strategies and technologies
Introduction
How to define “calcified lesions” of the LMCA?
Imaging approaches for LMCA PCI
Best strategies for qualified LMCA lesions: forward ablating techniques versus lateral fracture devices
Choice of ablating tool (Table 9.1)
How aggressively should you ablate calcified LMCA lesions?
Shortcomings of atherectomy as primary procedure
Special scenarios of calcified LMCA
Precautions: mitigating heating, stalling, and wire fatigue
Cost
Chapter 10. Laser debulking of complex and resistant atherosclerotic plaques in acute coronary syndromes
Introduction
Pathophysiology of acute coronary syndrome and the role of PCI
Characteristics of coronary laser systems
Laser—plaque interaction
Lasing technique in ACS interventions
Laser revascularization in ACS
Clinical outcome of laser debulking in ACS
Laser revascularization in acute coronary syndrome with calcified lesions
Laser role in treating suboptimal stent deployment or nondilatable stent in calcified lesions
Complications associated with the use of laser in ACS
Summary
Chapter 11. Intravascular lithotripsy: plaque modification in preparation for stenting
Heavily calcified coronary stenosis—an unmet need of effective treatment
Intravascular lithotripsy—mechanism and technology
What have we learned from peripheral IVL
Intracoronary lithotripsy
IVL for underexpanded stent
Intravascular imaging of IVL
Summary and thoughts for the future
Chapter 12. Complications of percutaneous coronary interventions in calcified lesions: causes, recognition, management, and how to avoid
Underappreciation of coronary calcification
Fundamentals during PCI of heavily calcified lesions
Complications during ablation of coronary calcification
Arrhythmia complications during debulking
Intracoronary imaging during coronary plaque modification
Summary
Chapter 13. Calcified lesions: the interplay between imaging, revascularization effects, role of select debulking technologies and related outcomes
Introduction
Summary
Chapter 14. The usefulness and limitations of the current American college of cardiology/American heart association and European society of cardiology guidelines for debulking of calcified and fibrotic lesions
Introduction
The role of practice guidelines
Specific debulking devices
Summary
Chapter 15. Coronary calcifications: effect on coronary artery bypass graft surgery
Overview
Diagnosis
Management
Chapter 16. Debulking strategies in revascularization of diseased saphenous vein bypass grafts
Introduction
Unique targets for SVG debulking
Integration of stents in SVG debulking
Debulking strategy incorporating dedicated stent platforms for thrombus capturing
Pericardium-covered stents
Adjunct pharmacotherapy in SVG debulking
2b/3a glycoprotein receptor inhibitors
Vasodilators
Anticoagulants
Summary
Chapter 17. Chronic total occlusion: biology and revascularization
Introduction
Human CTO studies
Animal models of arterial chronic total occlusions
Lessons from experimental studies
New approach to CTO PCI: biologic modification of chronic total occlusions
CTO revascularization: why bother?
Summary
Chapter 18. Chronic total occlusions: the impact of calcific deposits on the performance and outcomes of percutaneous coronary interventions
Introduction
Impact of calcium in the outcomes of CTO PCI
Calcium in CTO scoring systems
Technical aspects
Conclusions
Chapter 19. Percutaneous coronary interventions in resistant chronic total occlusions: the utilization of debulking strategy—a Japanese perspective
Rationale behind the need to use a debulking strategy for select CTO patients
Japanese guidelines and recommendations for CTO revascularization and debulking options
CTO revascularization strategy
Chapter 20. Thrombus debulking in revascularization of atherosclerotic chronic total occlusions
CTO formation: histopathologic processes
The angiographic and structural features of CTO
Clinical considerations of CTO revascularization
Technical consideration in revascularization of CTO
CTO in peripheral arterial disease
Summary
Chapter 21. Cardiac allograft vasculopathy in transplanted hearts: perspectives on the disease and revascularization options
Recognition of the condition
Impact of CAV on OHT outcome
Potential mechanisms of CAV
Identification and measurement
Vasodilators
Antioxidant vitamins
Immunosuppressant therapy
Retransplantation
Future directions
Chapter 22. The impact of chronic kidney disease on coronary revascularization
Introduction
Vascular and coronary artery calcification in CKD patients
Contrast nephropathy in revascularization of CKD patients
Vascular access challenges in revascularization of CKD patients
Coronary revascularization in CKD patients
Summary
Chapter 23. Debulking challenging large volume intracardiac and intravascular thrombus with the AngioVac system
Introduction—vascular and intracardiac thrombosis
Treatment paradigm
AngioVac aspiration thrombectomy
Conclusion
Chapter 24. Thrombectomy with the FlowTriever device in the treatment of massive and high submassive acute pulmonary embolism
Background
Interventional approaches for the treatment of PE
Procedural aspects of percutaneous aspiration thrombectomy
The unique potential of aspiration thrombectomy
Summary
Chapter 25. Cardiac magnetic resonance imaging: the role of an essential imaging modality in cardiac assessment before surgical debulking
Introduction
Conclusions
List of abbreviations
Chapter 26. Cardiac surgery for constrictive pericarditis
Overview
Pathogenesis
Clinical manifestations
Diagnosis
Management
Prognosis
Chapter 27. Contemporary perspective on the role of vascular and endovascular surgery in the treatment of severe obstructive peripheral arterial disease
Introduction—the challenge
Severe obstructive peripheral arterial disease
Surgical, endovascular, or hybrid revascularization?
Different vascular beds
Summary
Chapter 28. Utilization of debulking strategies in endovascular interventions in peripheral arterial disease
Introduction
Directional atherectomy
Rotational atherectomy
Laser atherectomy
Specialty balloons
Intravascular lithotripsy
Chapter 29. Design and ablative properties of peripheral atherectomy lasers with a special emphasis on the Auryon system
Introduction
The physics of lasers
Commonly used laser devices
Preclinical and clinical data for the Auryon system
Potential future applications of Auryon
Conclusion
Chapter 30. The “nitinol-constrained” Chocolate balloon angioplasty: clinical applications in patients with severe atherosclerotic peripheral arterial disease
Introduction
Outcomes and mechanisms of balloon angioplasty
Limitations of stent implantation
Chocolate PTA balloon catheter
Chocolate BAR clinical study results
Chocolate PTA Case studies
Conclusions
Chapter 31. Complex aortic plaque: clinical manifestations, diagnosis, and management strategies
Introduction
Pathology
Disease prevalence
Disease entities by location of aortic calcification
Porcelain aorta
Clinical implications of aortic calcification
Medical therapy for aortic calcification
Aortic atheroma
Calcification and abdominal aortic aneurysms
Complex aortic calcification (coral reef aorta)
Summary
Key points
Chapter 32. Perspectives on the rationale and utilization of embolic protection systems in aortic interventions
Introduction
Conclusion
Chapter 33. The impact of calcified aortic and mitral valves on clinical presentations and related structural heart interventions
Introduction
Aortic valve disease
Mitral valve disease
Conclusions
Chapter 34. Transcatheter aortic valve failure: the impact of calcification
Introduction
Current definition and clinical data regarding structural valve deterioration
Comparison of durability between SAVR and TAVR bioprosthesis
The durability of TAVR bioprosthesis from long-term registries
The durability of SAVR bioprosthesis
Leaflet calcification
Structural changes (leaflet tears)
Infective endocarditis
Leaflet thrombosis
Neointimal coverage and pannus formation
Conclusion
Chapter 35. Challenges in revascularization of the venous circulation: deep vein thrombosis, venous disorders, and the role of deep venous stenting
Introduction
Clinical presentations
Strategies to revascularize the vein
Venous stenting
Summary
Chapter 36. Strategies for extraction of implantable electronic device leads: the impact of calcified and fibrotic tissues
Overview of pacing system history
Transvenous pacing/defibrillator lead types and materials
Histologic changes in vascular and myocardial endothelium
History of lead extraction
Safety enhancement protocols and risk assessment
Future
Chapter 37. Perspectives on the role of chelation therapy in the treatment of atherosclerosis: principles of application, clinical results, and practical implications
Introduction
Mechanism
TACT
Adverse effects
Chapter 38. Percutaneous management of challenging complex resistive targets in interventional pediatric cardiology
Calcified valves
Pulmonary artery conduits
Systemic venous obstructions
Fontan obstructions
Pulmonary artery obstructions
Pulmonary vein obstructions
Pulmonary valve atresia and intact ventricular septum
Index

On Topaz

Professor On Topaz received the MD degree in 1979 from the Sackler School of Medicine, Tel-Aviv University and completed residencies in Internal Medicine and Cardiology at the Beilinson and Meir hospitals, Israel. He is a graduate of 3 clinical and research US fellowships including Cardiovascular Pathology at the University of Minnesota [1983-1984], adult Cardiology at the University of Miami [1986-1989] and Interventional Cardiology at the Medical College of Virginia[1989-1990]. Following this extensive training he became an Assistant Professor at Case Western Reserve University and then at the University of Minnesota. In 1993 he joined the division of cardiology, Medical College of Virginia/Virginia Commonwealth University in Richmond, Virginia with a rank of Associate Professor serving as the director of interventional cardiology of the McGuire Veterans Affairs Medical Center . He was a member of the admissions committee of this school of medicine for 11 years . In 2001 he received the rank of Professor of Medicine and in 2002 received as well as a rank of Professor of Pathology. In 2010 he was nominated the chief of the division of Cardiology of Charles George Veterans Affairs Medical Center in Asheville, North Carolina with a rank of Professor of Medicine at the Duke University School of Medicine. Professor Topaz’s main clinical specialty is percutaneous interventions for complex lesion subsets in challenging coronary and peripheral vascular targets. He specializes in treatment of patients with critical lesions in the presence of depressed LVEF, severe left main disease, old saphenous vein grafts, chronic total occlusions, stent thrombosis and heart transplant allograft disease . He has special interest in revascularization of severe renal artery stenosis and severe subclavian artery occlusions. Professor Topaz is the inventor of several percutaneous revascularization techniques with advanced debulking technology for plaque extraction and thrombus removal. He is also a national and international proctor of FDA approved plaque debulking and thrombectomy devices such as laser and rheolytic thrombectomy. Professor Topaz’s clinical investigations and basic research focus on cardiovascular thrombus including pathology and exploration and development of dedicated revascularization strategies for management of thrombus and its constituents during various phases of coronary and peripheral ischemic syndromes . He has gained global recognition for contribution to the understanding and the treatment of thrombotic lesions in acute ischemic/ thrombotic coronary and peripheral syndromes and authored the chapter on The thrombus containing lesion for several editions of the Textbook of Interventional Cardiology ,edited by Topol and Teirstein and published by Elsevier. Professor Topaz is a world authority on cardiovascular lasers whereby he pioneered the contemporary coronary lasing techniques and introduced the utilization of laser revascularization in acute myocardial infarction. In addition, he developed laser application for treatment of congenital heart conditions such as pulmonic atresia. Professor Topaz conducts basic research on the effects of laser irradiation on cardiac and vascular bio-tissue with special focus on the interaction of laser energy with thrombus and platelets. He discovered the unique phenomena of laser- induced enhancement of thrombolytic agents activity and laser induced suppression of platelet aggregation. Clinically , he investigates the therapeutic outcomes of various cardiovascular lasers. Professor Topaz is a recognized researcher and scholar of cardiovascular pathology and vascular anatomy. In 2010 he discovered in several patients the existence of a previously unknown, peripheral artery which constitutes origin of both inferior phrenic arteries as a vascular trunk from the right renal artery. The importance of this discovery was further emphasized as this vessel supplies unique, also newly discovered trans diaphragmatic cardiac collaterals. Recently, he and colleagues introduced an important paradigm shift in the diagnosis and management of symptomatic chronic mesenteric ischemia with emphasis on the performance of endovascular interventions in the inferior mesenteric artery. Professor Topaz served on special study sections of the NIH and NSF and is a fellow of the American College of Cardiology, the American College of Physicians, the Society for Cardiac Angiography and Interventions, the American Society of Laser Medicine and Surgery, the Society of Vascular Medicine and a member of numerous cardiovascular societies and organizations. Professor Topaz is an invited faculty of leading international conferences in the field of interventional cardiology, whereby he participates as live case operator, lecturer, moderator , discussant and session chairperson . He has lectured, proctored and performed live coronary and peripheral interventions in many countries around the world. Between 1998 and 2005 he served as the North American Editor- in- Chief of the journal Laser in Medical Sciences, the clinical publication of the European Laser Association. He is the recipient of an NIH national research service award, the Winthrop interventional award and several teaching awards. In 2010 the McGuire Veterans Affairs medical center of Virginia Commonwealth University established the “On Topaz MD award”, presented annually to their best interventional cardiology fellow . To date, Professor Topaz has published 137 peer-reviewed articles; the textbook “Lasers in Cardiovascular interventions [Springer, UK, 2016]; the textbook "Cardiovascular Thrombus" [Elsevier, Philadelphia, USA, 2018]; 31 book chapters and a member of 18 peer-reviewed journals.23 book chapters and 56 abstracts. He is a reviewer and editorial board member of 16 peer-reviewed journals and a member of medical advisory boards.

Affiliations and expertise

Professor of Medicine, School of Medicine, Duke University, Cardiologist, Division of Cardiology, Charles George Veterans Affairs Medical Center, Asheville, NC, USA

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