Radiation Safety Abbott Vascular. All rights reserved.

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1 Radiation Safety

2 More and more complex cases are performed Complexity Index and Fluoroscopy Time 2

3 3

4 Collimators / Distances The intensity of scattered radiation is a function of exposed field size Use collimator Doubling the beam area doubles the scatter dose rates 4

5 Coronary angulations 5

6 Operator passive protection 6

7 Time Progression of PTCA Injury: 7

8 Quick Self Assessment 8

9 Which is the most irradiating coronary angulation: a) RAO angulation b) LAO angulation c) Cranial angulation d) Caudal angulation 9

10 Which is the most irradiating coronary angulation: a) RAO angulation b) LAO angulation c) Cranial angulation d) Caudal angulation 10

11 Which is not operator passive protection: a) Upper Shield b) Glasses c) Facial Mask d) Lower Shield 11

12 Which is not operator passive protection: a) Upper Shield b) Glasses c) Facial Mask d) Lower Shield 12

13 Optimizing Angiographic Views 13

14 Anatomy of the Heart: 4 Cavities TOP LEFT RIGHT ATRIUM ATRIUM Mitral Valve LEFT RIGHT Tricuspide Valve RIGHT LEFT VENTRICLE Inter-ventricular Plane Atrio-ventricular Plane VENTRICLE BOTTOM APEX 14

15 Circle and Loop Method 15

16 Decision Tree THE CRITICAL POINTS ARE 1. PERPENDICULARITY 2. ORTHOGONAL VIEWS 16

17 Decision Tree LESION LOCATION 2 BEST «USUAL» PROJECTIONS* LAD PROXIMAL RAO 30/CAUD 25 LAO 45/CRAN 25 MID RAO 20/CRAN 20 LAO 40/CRAN 20 DISTAL RAO 10/CRAN 25 LAO 90 DIAGONAL Brch RAO 10/CRAN 25 - LAO 45/CRAN 25 LCX PROXIMAL RAO 25/CAUD 25 - LAO 45/CAUD 20 DISTAL RAO 25/CAUD 25 - LAO 60/CAUD 20 MARGINAL Brch RAO 25/CAUD 25 - LAO 60 RCA PROXIMAL LAO 45 - LAO 30/CAUD 30 MID LAO 60/CRAN 25 - RAO 30 DISTAL LAO 45 CRAN 30 * +/

18 Left Coronary Artery Projections 18

19 Left Coronary Artery Projections 19

20 Right coronary projections LAO 45 RAO 30 Right 20 dominant

21 D.H.G. 77-y-o man LAO 90, CRAN 0 RAO 31, CAUD 23 LAO 9, CRAN 30 21

22 D.H.G. 77-y-o man LAO 90, CRAN 0 RAO 31, CRAN 10 RAO 23, CAUD 21 22

23 Quick Self Assessment 23

24 Which is/are the best view(s) to confirm coaxial alignment between the catheter tip and Left Main : LAO/ 30 caudal or 5 RAO/ 20 caudal LAO/ 50 cranial RAO RAO/ 50 cranial or 90 LAO 24

25 Which is/are the best view(s) to confirm coaxial alignment between the catheter tip and Left Main : LAO/ 30 caudal or 5 RAO/ 20 caudal LAO/ 50 cranial RAO RAO/ 50 cranial or 90 LAO 25

26 Which is/are the best view(s) to confirm coaxial alignment between the catheter tip and the ostium of the RCA : LAO LAO/ 50 cranial RAO LAO/ 50 caudal 26

27 Which is/are the best view(s) to confirm coaxial alignment between the catheter tip and the ostium of the RCA : LAO LAO/ 50 cranial RAO LAO/ 50 caudal 27

28 Match the following angiographic views with the corresponding coronary artery segments : LAO/ 25 caudal RAO/ 20 cranial RAO/ 25 caudal LAO/ 25 cranial a. Prox Left Main, Prox LAD, Prox LCX b. Lcx and Marginal branches c. Mid and distal LAD and diagonal branches d. Mid RCA, the origin and course of patent ductus arteriosus (PDA) 28

29 Match the following angiographic views with the corresponding coronary artery segments : LAO/ 25 caudal a RAO/ 20 cranial c RAO/ 25 caudal b LAO/ 25 cranial d. a. Prox Left Main, Prox LAD, Prox LCX b. Lcx and Marginal branches c. Mid and distal LAD and diagonal branches d. Mid RCA, the origin and course of patent ductus arteriosus (PDA) 29

30 Match each of the following anatomic variants with the appropriate guide catheter : 1. RCA superior orientation ( sheperd s crook ) 2. RCA inferior orientation 3. Tortuous LCX a. Hockey stick b. Extra backup (EBU) c. Multipurpose d. Castillo 30

31 Match each of the following anatomic variants with the appropriate guide catheter : 1. RCA superior orientation ( sheperd s crook ) a. 2. RCA inferior orientation c. 3. Tortuous LCX b. a. Hockey stick b. Extra backup (EBU) c. Multipurpose d. Castillo 31

32 The following statements regarding the left lateral Projection (LAO 90 ) are all true EXCEPT : a. The mid portion of the RCA can be seen well without the excessive motion of a straight RAO b. The anastomosis of the LIMA to mid or distal LAD is seen very well in this view c. Proximal and distal LAD and proximal LCX can be well visualized d. The Left Main ostium can be frequently seen in this projection 32

33 The following statements regarding the left lateral Projection (LAO 90 ) are all true EXCEPT : a. The mid portion of the RCA can be seen well without the excessive motion of a straight RAO b. The anastomosis of the LIMA to mid or distal LAD is seen very well in this view c. Proximal and distal LAD and proximal LCX can be well visualized d. The Left Main ostium can be frequently seen in this projection 33

34 Lesion Morphology 34

35 Objectives Describe types of coronary lesions Identify clinical concerns related to intervention Acute success Complications Long-term outcomes 35

36 Lesion Assessment Angiography Intravascular ultrasound (IVUS) Optical coherence tomography (OCT) 36

37 Morphology/Composition Eccentric vs. Concentric Eccentric Concentric 37

38 Limitations of Coronary Angiography 38

39 Morphology/Composition Fibrotic vs. Lipid Fibrotic Lipid 39

40 Morphology/Composition Thrombus Thrombus 40

41 Morphology/Composition Calcified Calcified Calcium 41

42 Lesion Location Proximal/ostial Distal Bifurcation Bifurcation Proximal Distal 42

43 Lesion Location Bypass graft Tortuosity Tortuous SVG 43

44 Lesion Classification A, B1, B2, C Current ACC/AHA Classification Low risk Moderate risk High risk 44

45 45

46 Clinical Concerns Acute / procedural success Potential complications Long-term results 46

47 Key Lesion Types & Morphologies Thrombus Bifurcations Tortuosity & Angulation Calcification Ostial Lesions Long Lesions Chronic Total Occlusions Saphenous Vein Grafts (SVG) In-Stent Restenosis 47

48 Thrombus Challenges / Concerns Major adverse cardiac events Thrombotic occlusion Distal embolization 48

49 Thrombus Technical Considerations Procedure staging Reduction of thrombus burden Prevention of further thrombus organization Device selection and deployment 49

50 Bifurcation Lesions Challenges / Concerns Plaque location Side branch occlusion Adverse events related to branch occlusion Adequate lumen enlargement 50

51 Bifurcation Lesions Technical Considerations Sufficient ID guiding catheter Branch protection with 2nd guide wire Balloon material and markers 51

52 Tortuosity & Angulation Challenges / Concerns Device deliverability Dissection Abrupt closure 52

53 Tortuosity & Angulation Technical Considerations Guiding catheter support Guide wire trackability and support Device trackability and conformability Dilatation catheter compliance 53

54 Calcification Challenges / Concerns Device deliverability Location and degree of calcium Lesion resistance Dissection at interface of plaque/vessel 54

55 Ostial Lesions Challenges / Concerns Device positioning Vessel recoil / aortic elasticity Lesion rigidity Dissection Restenosis 55

56 Ostial Lesions Technical Considerations Guiding catheter positioning/support Balloon characteristics Precise placement Stent radial strength Debulking options 56

57 Long Lesions Challenges / Concerns Treatment of entire diseased segment Dissection Abrupt closure Death, MI, TLR Increased restenosis rate 57

58 Long Lesions Technical Considerations Deliverability of longer devices Device performance Increased device utilization 58

59 Chronic Total Occlusion Challenges / Concerns Lesion access Lesion complexity Myocardium viability Distal disease 59

60 Chronic Total Occlusion Technical Considerations Significant guiding catheter support Crossing lesion with guide wire Dilatation catheter selection 60

61 Saphenous Vein Grafts Challenges / Concerns Friable plaque Distal embolization No-Reflow Abrupt closure Increased restenosis rates 61

62 Saphenous Vein Grafts Technical Considerations Guiding catheter access Guide wire characteristics Availability of distal protection Balloon material Stent metal-to-artery ratio 62

63 In-Stent Restenosis Challenges / Concerns New disease process Initial stent deployment assessment Patterns of in-stent restenosis 63

64 In-Stent Restenosis Patterns In-stent Peri-stent In-segment 64

65 Focal In-Stent Restenosis: Angiographic Classification Unscaffolded (Articulation or gap) Body Margin Multi-focal Classification proposed by Mehran et al. Circulation 1999; 100:

66 Diffuse In-Stent Restenosis: Angiographic Classification Intra-Stent Proliferative Total Occlusion Classification proposed by Mehran et al. Circulation 1999; 100:

67 In-Stent Restenosis Technical Considerations IVUS availability Debullking of restenotic tissue Guide catheter performance/id Guidewire characteristics Dog-boning Watermelon seeding 67

68 Conclusions Lesion scenarios often occur in combination Variables in the clinical picture can affect treatment strategy Evaluate lesion, clinical, and vessel factors on a case-by-case basis 68

69 Quick Self Assessment 69

70 Lesion morphology assessment can be done with (all true EXCEPT): 1. Angiography 2. Intravascular ultrasound (IVUS) 3. Transesophageal echocardiogram (TEE) 4. Optical coherence tomography (OCT) 70

71 Lesion morphology assessment can be done with (all true EXCEPT): 1. Angiography 2. Intravascular ultrasound (IVUS) 3. Transesophageal echocardiogram (TEE) 4. Optical coherence tomography (OCT) 71

72 Match the following lesion characteristics with appropriate lesion type: 1. One characteristic: Tubular, 10-20mm, ostial location, bifurcation 2. Diffuse, >20mm, occlusion > 3m, excessive tortuosity, angulation >90 3. Concentric, <10mm, smooth contour, not ostial, no major side branch 4. More than one characteristic: Tubular, 10-20mm, ostial location, bifurcation a. A b. B1 c. B2 d. C 72

73 Match the following lesion characteristics with appropriate lesion type: 1. One characteristic: Tubular, 10-20mm, ostial location, bifurcation b. 2. Diffuse, >20mm, occlusion > 3m, excessive tortuosity, angulation >90 c. 3. Concentric, <10mm, smooth contour, not ostial, no major side branch a. 4. More than one characteristic: Tubular, 10-20mm, ostial location, bifurcation c. a. A b. B1 c. B2 d. C 73

74 Thrombus formation is characteristic for: 1. CTO patient 2. STEMI patient 3. In-stent restenosis 4. Coronary vasospasm 74

75 Thrombus formation is characteristic for: 1. CTO patient 2. STEMI patient 3. In-stent restenosis 4. Coronary vasospasm 75

76 Which are Chronic Total Occlusion challenges and concerns (all true EXCEPT): 1. Lesion access 2. Female gender 3. Lesion complexity 4. Distal disease 76

77 Which are Chronic Total Occlusion challenges and concerns (all true EXCEPT): 1. Lesion access 2. Female gender 3. Lesion complexity 4. Distal disease 77

78 Dog-boning and Watermelon seeding are characteristic for: 1. In-stent occlusion 2. Calcified lesion 3. In-stent restenosis 4. Tortuous coronary artery 78

79 Dog-boning and Watermelon seeding are characteristic for: 1. In-stent occlusion 2. Calcified lesion 3. In-stent restenosis 4. Tortuous coronary artery 79

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81 Cases Review 81

82 CASE 1 P. A. Age : 76 years Gender : male Risk factors : - hypertension - hiperlipidemia - smoker - Diabetes mellitus tip 2 82

83 Location, approach, type of stent p RCA d RCA r PDA 1 st Diag Approach Balloon pre dilatation Stent to r PDA intermediate intermediate 100%+thrombus intermediate trans radial 1,5/15mmx15atm BMS 2,25/20mmx17atm 83

84 Left coronary artery (RAO 25, CAUD 25) 84

85 RCA (LAO 45) 85

86 RCA (LAO 18, CRAN 18) 86

87 R PDA 100%+thrombus (CRAN 30) 87

88 Balloon catheter pre dilatation 1,5/15x15atm 88

89 Result 89

90 BMS 2,25/20mm x 17atm 90

91 Final result 91

92 CASE 2 A. A. Age : 61 years Gender : male Risk factors : -hypertension -hiperlipidemia -prior IM -prior PCI/stenting -CABG indicated 92

93 Location, approach p RCA LM p LCx Approach plaque 90%+TIMI flow=3 plaque trans radial 93

94 Case 1 CT scan 94

95 RCA (LAO 45) 95

96 Left coronary artery (RAO 30, CAUD 25) 96

97 Left coronary artery (CRAN 45) 97

98 Left coronary artery (CAUD 30) 98

99 Left coronary artery (RAO 20, CRAN 20) 99

100 Left coronary artery (LAO 40, CRAN 20) 100

101 CASE 3 S. B. Age : 68 years Gender : male Risk factors : - hypertension - hiperlipidemia - positive family history - CABG indicated 101

102 Location, approach p RCA m RCA LM p LAD m LAD Approach 99%+TIMI flow=3 95%+TIMI flow=3 80%+TIMI flow=3 95%+TIMI flow=3 100%+collateral trans radial 102

103 RCA (LAO 45) 103

104 RCA (LAO 18, CRAN 18) 104

105 Left coronary artery (RAO 25, CAUD 25) 105

106 Left coronary artery (RAO 10, CRAN 45) 106

107 Left coronary artery (RAO 10, CRAN 45) 107

108 CASE 4 D. P. Age : 60 years Gender : female Risk factors : - hypertension - prior IM 108

109 Location, approach, type of stent p LAD p LCx d LCx 1 st OM Approach Stent to p LCx plaque 85%+TIMI flow=3 95%+TIMI flow=3 95%+TIMI flow=3 trans radial BMS 3.5/15mmx12atm 109

110 Left coronary artery (CAUD 30) 110

111 Left coronary artery (RAO 20, CRAN 20) 111

112 LCx (RAO 25, CAUD 25) 112

113 LCx (LAO 45, CAUD 20) 113

114 BMS 3.5/15mm x 12 atm 114

115 Final Result 115

116 CASE 5 S. F. Age : 49 years Gender : male Risk factors : - hypertension - hyperlipidemia - smoker 116

117 Location, approach, type of stent p RCA m LAD 1 st Diag Approach Thromboaspiration Stent to p RCA 100%+thrombus plaque plaque trans radial 6Fr catheter BMS 3.5/20mm x13 atm 117

118 p RCA 100% + thrombus 118

119 Left coronary artery 119

120 Thromboaspiration catheter 6Fr 120

121 Result 121

122 BMS 3.5/20mm x 13atm 122

123 Final result 123

124 Final result 124