Practical Handbook of Advanced Interventional Cardiology

Tips and Tricks

Thach N. Nguyen, Shao Liang Chen, Moo-Hyun Kim, Duane S. Pinto, Cindy L. Grines, C. Michael Gibson, Ernest F. Talarico, Thach N. Nguyen, Shao Liang Chen, Moo-Hyun Kim, Duane S. Pinto, Cindy L. Grines, C. Michael Gibson, Ernest F. Talarico

• Publisher: Wiley-Blackwell
• Year: 2020
• ISBN:
  9781119382676
• Edition: 5
• Topic: Medicine
• Subtopic: Cardiology

A concise and convenient pocket guide to interventional cardiology's latest procedures and technologies

Interventional cardiology is growing more and more integral to the modern-day management of cardiovascular problems. Indeed, trainees are taught interventional methods as a matter of course. With a widening range of options open to them, however, the practicing cardiologist must be diligent and discerning when selecting the appropriate course of action for each patient, adapting their strategy as circumstance demands. Developing the skills and experience necessary to make these key judgments can be a challenging and lengthy process.

Bringing together the knowledge of an international group of over 50 experts, this fifth edition of the Practical Handbook of Advanced Interventional Cardiology helps cardiologists of all levels to find interventional solutions to a wide range of problems. Its revised contents cover topics including new devices, valve procedures, and venous and atrial occlusion, and also feature new chapters on bioresorbable vascular scaffolds, protected percutaneous coronary intervention, coronary atherectomy, pulmonary embolism, and more. This essential companion:

• Offers clear, easy-to-follow guidance for cardiology practitioners of all levels of skill and experience
• Grades each strategic or tactical action by level of complexity
• Includes full-color clinical images and illustrations
• Covers all key interventional procedures and techniques
• Provides practical tips and tricks for handling difficult clinical scenarios and complications

The Practical Handbook of Advanced Interventional Cardiology is an invaluable resource for both practitioners and trainees in interventional cardiology and all related areas of cardiovascular medicine.

CHAPTER 1
Vascular Access

Thach N. Nguyen, Nguyen Hong Phat, Phuoc T. Nguyen, and Tri Pham

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• Challenges
• Femoral Approach
  • Gameplay: Ideal Location of Femoral Access
  • Best Players: aka Standard of Technical Excellence in Femoral Approach
  • Real‐time Actions
  • Ultrasound‐guided puncture
  • Tricks and Tips
  • ***Selection of the area for puncture under ultrasound
  • **Difficulty in cannulating the arterial sheath
  • Real‐time Actions
  • Fluoroscopically guided micropuncture access
  • Large sheath
  • Dedicated Equipment
  • Tricks and Tips
  • **Angiography to check the location of femoral entry through a dilator
  • *Preparations in obese patients
  • *Directing the needle
  • *If the wire cannot be inserted
  • *Sequential order for arterial and venous puncture
  • **Kinked wire
  • **Puncture of pulseless femoral artery
  • Confronting the Challenges
  • **Two catheters inserted with single puncture technique
  • **Insertion of intra‐aortic balloon pump (IABP) through a diseased iliac artery
  • Puncture of femoral bypass graft
  • Real‐time Actions
  • Bypass graft puncture
  • Confronting the Challenges
  • ***Parallel technique
• Antegrade Puncture
  • Real‐time Actions
  • Common femoral artery antegrade puncture
  • Tricks and Tips
  • **Manipulation of the wire
  • **Puncture of CFA with high bifurcation 11
  • **Puncture with abduction and external rotation of the thigh
• Brachial Approach
• Axillary Puncture
• Right Heart Catheterization in Patients Undergoing Procedure with Radial Approach
• Closure Devices
  • Collagen Plug Device: MYNX^®
  • Clip Device: StarClose^®
  • Real‐time Actions
  • The Perclose
  • Preclosure of large arterial access
  • Preclosure of large venous access
  • Tricks and Tips
  • ***Differences in technical details for preclosure of venous access
  • ***Double Angio‐Seal™ closure for 10‐Fr vascular access
  • ***Double MYNX closure for a 14‐Fr arterial access
  • Discriminating Differences
  • Which vascular closure devices for which patients?
  • Confronting the Challenges
  • Suspecting intra‐arterial deployment of collagen plug
  • ***Management of intra‐arterial deployment of collagen plug
• Complications
  • Hematoma
  • Arteriovenous Fistula (AVF)
  • Acute Arterial Thrombosis
  • Confronting the Challenges
  • Mechanical thrombectomy for acute thrombosis
  • Limb Ischemia
  • Confronting the Challenges
  • ***Temporary relief of iatrogenic ischemic limb: percutaneous technique for in vivo femoral artery bypass
  • Preventing limb ischemia
  • Retroperitoneal Hematoma
    • Mechanism of clinical symptoms
  • Discriminating Differences
  • Medical and surgical management of retroperitoneal hemorrhage
  • Tricks and Tips
  • **How to detect retroperitoneal hematoma in a 1‐second maneuver
  • Real‐time Actions
  • How to seal a perforation with a balloon
  • How to close a perforation with a microcoil or injection of thrombin
  • Perforation
  • Real‐time Actions
  • How to seal a perforation with a covered stent
  • Pseudo‐aneurysm
  • Tactical Move: Best options for exclusion of femoral pseudo‐aneurysm
  • Femoral Dissection
  • Case Report: Retrograde Abdominal and Thoracic Dissection from the Iliac Artery

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CHALLENGES

Gaining vascular access without early or late bleeding at the access site is a major challenge for every operator carrying out diagnostic or interventional cardiovascular procedures.

FEMORAL APPROACH

GAMEPLAY

Ideal Location of Femoral Access

Usually the femoral artery is palpated below the inguinal ligament that runs from the anterior superior iliac spine to the pubic tubercle. The true position of the inguinal ligament is 1–2 cm below that line. An ideal “landing zone” is defined by vascular entry above the femoral bifurcation and below an upper margin conservatively defined as several centimeters below the inferior excursion of the inferior epigastric artery (IEA). The IEA descends to, but does not cross, distal to the inguinal ligament; thus, entry above the lowest point of the course of this vessel, which typically then turns cranial to supply circulation to the epigastrium, can be used to define an unequivocally high puncture [1] (Figure 1.1).

Figure 1.1 Ideal location for puncture of the femoral artery.

Reproduced with permission of Wiley.

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BEST PLAYERS

aka Standard of Technical Excellence in Femoral Approach

The technique employs visualization of the femoral head under fluoroscopy in a posterior–anterior projection. The skin puncture starts at the level of the lower border of the head of femur with the eventual goal of arterial cannulation at the mid‐third of the head of femur. However, even with this technique, punctures below the bifurcation of the common femoral artery (CFA) cannot be completely avoided. This is due to variability in the site of the femoral artery bifurcation in reference to the femoral head. Although in a majority of cases (approximately 77%) the bifurcation is below the level of the femoral head, in approximately 2...