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  1. Handbook of Complex Percutaneous Carotid Intervention : Jacqueline Saw :
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Other investigators have independently confirmed in concurrent datasets that complex PCI lesions evidencing thrombus, calcification, bifurcation or ostial location, chronic occlusion , was also associated with increased in-hospital and 1-year mortality rates compared with PCI of simpler lesions. Fortunately, however, such considerations have not impeded the advancement of PCI techniques and technologies that have continued to flourish, fueled by scientific innovation and the clinical need for minimally invasive solutions to the growing burden of advanced coronary heart disease.

Highlighted below are selected procedural and cost considerations in complex PCI subsets with particular focus on bifurcation disease, representing a commonly encountered, technically challenging, and well-studied complex lesion subset. Landscape of Contemporary Percutaneous Coronary Intervention and Challenges Associated with Specific Lesion Sets What began as simple balloon dilation of single, de novo coronary lesions has evolved into myriad variations on the theme of complex coronary intervention, the majority involving the implantation of one or more DES and a significant proportion utilizing adjunctive devices for PCI guidance and optimization.

Broad technical considerations relevant to each of these lesion subtypes are summarized in Table 2, with bifurcation disease also addressed below in greater detail. While it is beyond the scope of this article to discuss each of the aforementioned complex lesion subtypes in detail, suffice it to say that tools and validated strategies currently exist for each scenario listed.

Handbook of Complex Percutaneous Carotid Intervention : Jacqueline Saw :

It is incumbent upon the operator aspiring to tackle complex disease in the catheterization laboratory, to gain intimate familiarity with these data and technical strategies. Multiple bifurcation classification systems have been developed with the common goal of clarifying optimal interventional strategy and predicting complication risk. Even more numerous than bifurcation classification systems are the technical approaches described to date, varying widely in terms of the number of stents mandatorily used, completeness of coverage of the side branch ostium, and procedural complexity.

A consensus classification of families of bifurcation techniques was proposed by the European Bifurcation Club EBC some years ago. Various bifurcation techniques, including those double-stent techniques detailed in Figure 2 along with several others, are categorized under each lettered group and further broken out by the use of one, two, or three stents.

Two-stent techniques that do not insure complete side branch coverage include the variations on the T-stent technique see Figure 2 including classical and reverse T-stenting. More advanced techniques that allow for complete side branch coverage include variations on crush stenting, culotte stenting, and classical or modified simultaneous kissing stent SKS techniques.

Figure 2: Commonly Used Double-stent Bifurcation Techniques Figure 3: Rotational Atherectomy and Culotte Stenting of a Medina 1,0,1 Bifurcation The results of numerous published clinical trials and registries of bifurcation technique have been evaluated in the context of several meta-analyses. However, specific situations exist where one may wish to commit early to a complex bifurcation strategy.


Figure 3 depicts step-wise detail of a culotte stenting procedure in which calcified de novo and restenotic disease in the bifurcation of an LAD and large diagonal branch warranted a complex, multistent approach following debulking with rotational atherectomy. In planning percutaneous therapy for complex bifurcation disease, careful pre-procedure consideration of the coronary anatomy, aforementioned criteria, and various technical strategies, is therefore warranted.

Cost-effectiveness Considerations in Routine and Complex Percutaneous Coronary Intervention When broadly considering the cost impact of treatment strategies in patients with CAD, multiple therapeutic comparisons are of clinical and fiscal relevance. The first set of considerations relates to medical management versus revascularization in the setting of stable CAD. The next relates to mode of revascularization, surgical versus percutaneous, with the additional matter of routine versus selective use of DES in the latter group. In the interest of brevity, we will focus on cost-effectiveness of various revascularization strategies as it relates to patients with complex disease.

While it is beyond the scope of this article to explore economic modeling in detail, it bears mention that variability and complexity of cost modeling methodology, differences in individual costs within the US healthcare system and across countries, and local trends in the practice of IC have all contributed to the lack of uniformity in conclusions regarding the cost-effectiveness of various revascularization strategies. As noted, given the lack of mortality benefit with DES, the economic case to be made in favor of DES usage rests primarily with the ratio of incremental cost of these devices over BMS to enhanced quality of life QoL for patients who enjoy greater freedom from repeat revascularization following DES implant.

Although all included studies were in agreement that restenosis negatively affects QOL, routine use of DES to avoid restenosis was found unlikely to be cost-effective. In another systematic review of DES cost-effectiveness, Ligthart and colleagues similarly found wide variability in the reported cost-effectiveness of DES that the authors concluded was influenced by the quality of the studies analyzed, source of study funding, and the country in which the studies were conducted.

Twelvemonth rates of major adverse cardiac or cerebrovascular events were significantly higher in the PCI group A formal cost-effectiveness analysis conducted by Cohen et al. However, when the trial data were projected over a lifetime survival horizon, CABG posted significant gains in quality-adjusted life expectancy relative to PCI. Percutaneous chronic total occlusion CTO revascularization is another sector of contemporary interventional practice that has recently seen renewed interest and utilization driven by advances in technology as well as the development of hybrid percutaneous treatment algorithms.

As experience grows with use of the hybrid CTO algorithm as well as with current strategies for tackling bifurcation lesions with conventional DES or with dedicated bifurcation stent systems available outside the US, additional cost modeling data addressing these complex PCI subsets will hopefully be forthcoming.

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Conclusions Technically complex PCI procedures, while increasingly performed, remain associated with lower rates of procedural success and higher rates of MACE compared with more straightforward catheter-based interventions. Multivessel and unprotected LMCA disease, fibrocalcific lesions, chronic total occlusions, and bifurcation disease comprise many of the lesion sets requiring additional resource allocation, procedural planning, and sophistication. Bifurcation lesions, in particular, have been the subject of intense systematic study and some degree of controversy.

Cost considerations in PCI are perhaps most relevant to patients with extensive, multivessel disease in whom CABG may also be a viable therapeutic option. Uh-oh, it looks like your Internet Explorer is out of date.

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For a better shopping experience, please upgrade now. Javascript is not enabled in your browser. Enabling JavaScript in your browser will allow you to experience all the features of our site. Learn how to enable JavaScript on your browser. The Handbook of Complex Percutaneous Carotid Intervention supplements hands-on training in interventional cardiology with a specific focus on percutaneous intervention in patients with extracranial carotid artery stenosis.

As both technology and technique continue to improve, the volume of carotid stent procedures performed worldwide has increased dramatically. The authors recognize that interventionalists of the cerebrovasculature must perform stenting of other major cerebral vessels, and thus provide cutting-edge approaches for percutaneous interventions of intracranial stenosis, vertebral artery stenosis, and acute stroke. Part I covers topics such as carotid angioplasty and stenting trials, noninvasive imaging of the carotid artery, and cerebrovascular angiography.

Part II explores innovative techniques, equipment, and potential complications of carotid artery stenting. Detailed approaches to intracranial carotid artery intervention and intracranial and extracranial vertebral artery stenting are also examined. Part III provides a case-based approach to stenting, with particular attention to the kind of high-risk patients with challenging anatomies that often undergo revascularization procedures.

David S. Lee

The Handbook of Complex Percutaneous Carotid Intervention, a comprehensive guide to this exciting and burgeoning field, is an essential reference for interventional cardiologists, vascular surgeons, interventional radiologists, and interventional neurologists. Trainees in this field will particularly benefit from the detailed approach to carotid stenting. Emilio Exaire, David S. Lee, Jay S.

Top Authors

Yadav Section One: Clinical Experience 1. Lee, MD 3.

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Lee, MD and Jay S.