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Angioplastie primara 45 (56 of 221)

Din punct de vedere tehnic, cea mai relevantă caracteristică de intervenții coronariene percutanate (PCI) pentru
infarctul miocardic acut (AMI) este necesitatea de restabilire rapidă a fluxului epicardial normal într-un cadru unde
o componentă trombotică a leziunii țintă este aproape constanta, și este in mod frecvent componenta dominanta
a leziunii țintă. Rapiditatea procedurii este o componentă relevantă a calității sale și depinde de modelul logistic
folosit pentru programul PCI primar, de abilitatea operatorului și de alegerea corectă a tehnicilor și a materialelor
de realizare a strategiei de intervenție adecvată.

Abordul
Selectarea locului de abord la un pacient cu AMI ar trebui să se bazeze pe ușurința și viteza introducerii unui shaft,
pe plasarea cateterului și pe posibilitatea de a realiza schimbari ulterior, dacă este necesar. Cel mai utilizat mod de
abord este abordul femural. Are mai multe avantaje față de abordul radial și brahial.Cel mai important avantaj este
faptul că zona femurala permite folosirea unor catetere mari, cu posibilitatea folosirii tuturor tipurilor de tehnici și
dispozitive. La pacienții cu boala ocluzivă aorto-iliacă nesemnificativa, plasarea cateterului este ușoara și rapida, în
timp ce pentru pacienții cu boala ocluzivă aorto-iliacă avansata, problemele potențiale legate de stenoza iliacă sau
tortuozitate pot fi rezolvate prompt cu utilizarea unor fire hidrofile și shafts lungi. În schimb, in schimbul abordului
radial sau brahial, rezolvarea acestor probleme nu poate fi ușoara, iar plasarea unui shaft lung ar putea să fie mai
problematică și mai dăunătoare. Aceste avantaje ale abordului femural fata de celelalte moduri de abord sunt mai
evidente la populația în vârstă, unde tortuozitatea și boala vaselor periferice este frecventa. În concluzie, abordul
femural permite o plasare mai usoara si mai prompta a stimulării ventriculare dacă este necesara. Utilizarea a două
accesele arteriale - una pentru procedura PCI și alta pentru contrapulsarea balonului intraaortic - face abordul
femural alegerea preferata pentru comoditatea operatorului. Abordarea radială are un avantaj major asupra
abordării femurale, si anume riscul scăzut de sângerare și complicații vasculare, deși în PCI de urgență pentru AMI,
potențialul său de reamblare imediată nu poate fi considerat un avantaj semnificativ. Abordarea radială poate fi
luată în considerare in cazul pacienților stabili cu un puls radial bun care permite plasarea ușoară a cel putin 7
French (Fr) shaft. Utilizarea provizorie a abordărilor radiale sau brahiale in urma tentativelor esuate de abord
femural necesita sa fie luate in considerare. Dacă boala aorto-iliaca sau tortuozitateaa au împiedicat o abordare
femurală reușită, este probabil că abordul radial sau brahial sa nu fie usor. O mică amplitudinea a impulsului radial
poate sugera necesitatea utilizarii unui shaft 6 Fr, cu limitări ulterioare privind utilizarea dispozitivelor mari
(dispozitive de aterictomie sau trombectomie) sau tratamentul leziunilor de bifurcare. Abordarea brahiala ar trebui
să fie luata în considerare după eșecul abordului radial și femural. Tehnica brahială percutană are riscul major de
comprimare ischemică sau de complicatii neurologice din cauza sângerării.

Catetere
Selectarea cateterului în setarea AMI se bazează pe aceleași criterii ca și cele utilizate pentru PCI. Cateterele mari
(7 sau 8 Fr) sunt de preferat, deoarece acestea oferă o poziție mai stabilă și sustinere mai buna în comparație cu
cateterele de 6 sau 5 Fr.

Moreover, in patients with complex

coronary anatomy, or unknown anatomy of the totally
occluded target vessel, large guiding catheters allow the
use of all types of devices, and are more convenient for
the treatment of bifurcation or trifurcation lesions. In the
Florence experience, most cases could be successfully and
quickly approached with the use of a Voda curve guiding
catheter for the left coronary system, and a Judkins right
curve for the right coronary artery (RCA).
The Voda curve catheter has the advantage of superior
backup compared with the Judkins left curve. In patients
with a normal ascending aorta and origin of the left main
coronary artery – the first-option Voda curve is 3.0 for the
left anterior descending artery (LAD) and 3.0 or 3.5 for
the circumflex artery; a longer Voda curve for the circumflex
artery allows more direct alignment of the guiding
catheter with the vessel, favoring pushability of coronary
devices. For the treatment of middle or distal left main
occlusion, a Voda 3.0 or 3.5 is considered the first-option
curve, while for very proximal left main disease or a true
left main ostial lesion, the first choice should be the multipurpose
curve, or alternatively the Amplatz left curve.
These curves allow placement of the distal tip of the
catheter near the left main ostium, avoiding uncontrolled
intubation of the left main with the risk of subsequent left
main dissection. The Voda and Amplatz left curves are the
first-option guiding catheter curves if the right radial or
brachial approaches are used. As in non-AMI procedures,
left coronary system disease in the large ascending aorta
can be approached with longer Voda, Amplatz, or Judkins
catheter curves, or other types of catheters (such as the
El-Gamal B type, multipurpose catheters, and others).
An anomalous origin of the left main from the right
coronary sinus can be approached with multipurpose or
Amplatz curve catheters.

Coronary wires and

angioplasty balloons
An intermediate-type coronary
wire is effective in most cases in ‘softly’ crossing the target
lesion and in providing sufficient support to coronary stenting.
Techniques for assessment of
the anatomy of a target
vessel persistently occluded
after crossing the wire
In a substantial minority of patients, crossing of the
coronary wire is not followed by re-establishment of
infarct-related artery flow. A persistent TIMI grade 0–1 flow
after crossing the wire prevents angiographic definition of
vessel anatomy and the characteristics of the target lesion.
In these cases, an ultraselective dye injection beyond the
occlusion may be extremely useful for judging the correct
placement of the wire, the need for a second wire if a
major branch is involved in the target lesion, the thrombotic
burden, the length of the lesion, and other significant
lesions within the infarct-related artery.
A more convenient approach to this problem is the use
of Multifunctional Probing (Boston Scientific, Maple Grove,
MN). This device is a dual-lumen catheter. One lumen is
used for transport of the catheter beyond the occlusion
with a monorail system, while the second lumen can be
used for dye injection. The multiple functions that the
device may discharge include ultraselective administration
of drugs, exchange of the coronary wire, and support for
the placement of second wire into a branch with an
unfavorable take-off.
An alternative is an over-the-wire balloon catheter.
However, the use of an over-the-wire catheter has several
disadvantages, such as the need for removal of the
coronary wire for dye injection and ultimately a more timeconsuming
procedure.
Another alternative to ultraselective dye injection is reestablishment
of flow, avoiding embolization. This goal may
be achieved with a thrombectomy device, since in most
cases thrombus is a large component of the occlusion in
AMI.
46 Primary Angioplasty
Other techniques with the potential for major embolization,
such as repeat crossings of a deflated angioplasty
balloon through the occlusion, or angioplasty using undersized
balloons, should be avoided.
Thrombectomy
Despite the very high risk of embolization during conventional
PCI for AMI, the use of thrombectomy or atherectomy
devices was limited for a long time due to the
potential of older devices, such as directional coronary
atherectomy and transluminal extraction atherectomy
devices, to cause a paradoxical increase in the risk of
embolization. The high profile of these devices, as well as
their poor flexibility and trackability, resulted in very
traumatic approach to the target lesion, with the dislodgment
of thrombus and atheromatous debris in the peripheral
coronary network. Recent advances in the conception
and design of this type of device have dramatically
decreased the risk of embolization, and it is easy to predict
a wide utilization of these systems in the setting of AMI.
The AngioJet rheolytic thrombectomy system (Possis
Medical Inc., Minneapolis, MN) consists of a dual-lumen
catheter with an external pump providing pressurized
saline solution via the effluent lumen to the catheter tip.
Multiple saline jets from the distal part of the catheter
travel backwards at 390 mph (630 km/h), and create a
localized negative-pressure zone into which thrombus is
drawn and fragmented by the jets; the small fragments are
then propelled to the evacuation lumen of the catheter.
Emboli protection devices
There are two types of antiembolic systems: nonocclusive
systems based on filters that trap embolic debris and
occlusive systems based on occlusion of the vessel distally
to the target lesion and subsequent retrieval of the embolic
debris after the procedure by aspiration catheters. Both
systems have the potential major disadvantage that emboli
protection may be complete only if the device can be
placed beyond the occlusion in a segment without major
branches. Otherwise, debris from the target lesion may
embolize into the branches. On the other hand, a very
proximal location of the device in tortuous vessels may
provide poor support for a successful stenting procedure.
The prototype of the filter devices is the Angioguard XP
filter wire (Cordis, Johnson & Johnson, Miami Lakes, FL).
This consists of a guidewire with an integrated filter at the
distal end of the device. The available basket sizes range
from 4 to 8 mm, and the device should oversize the vessel
diameter by 0.5–1.0 mm in order to provide correct
apposition to the vessel wall of the filter in the open
position. Otherwise, a poor circumferential wall apposition
between the struts of the basket allows embolization.
The GuardWire (Medtronic, AVE, Santa Rosa, CA) is
the prototype of the occlusive protection systems. The
system consists of a 0.014 inch balloon wire, a microseal
adapter for inflation and deflation of the balloon, and a 5 Fr
aspiration catheter (Export catheter). The balloon wire has
a very low profile (2.1 Fr) allowing good trackability and a
relatively low risk of embolization during wiring of the
target lesion. The efficacy of this device in protection from
embolization was shown in patients with diseased saphenous
vein grafts.
Stents
A major pitfall of conventional coronary angioplasty in the
setting of AMI is the high incidence of early and late
restenosis or reocclusion of the infarct-related artery
(IRA).13–18 Early IRA reocclusion occurs in 10–15% of
patients treated successfully by coronary angioplasty, while
late target vessel failure rate requiring repeat intervention
in the first 6 months remains disappointing high. In the
PAMI-2 trial, the risk of early restenosis or reocclusion of
the IRA was 8% in low-risk patients and 20.2% in high-risk
patients.16 In the PAMI-2 patient cohort, the angiographic
predictors of early target vessel failure were a nonoptimal
angiographic result of the procedure, defined as a residual
stenosis over 30%, or residual dissection after coronary
angioplasty.
The mechanism of early restenosis or reocclusion of the
IRA is occlusive thrombosis, which is favored by an abnormal
flow due to disrupted atherosclerotic plaque associated
with postangioplasty vessel elastic recoil or, more
frequently, vessel dissection.
It is important to point out
that most patients with recurrent ischemia due to target
vessel failure experience only angina or nonfatal reinfarction,
while death as a consequence of recurrent ischemia
accounts for only a minority of deaths (10% in the PAMI
trial cohort),16 since the large majority of deaths after
successful coronary angioplasty are due to refractory
cardiogenic shock despite a patent IRA. As a consequence,
the expected benefit of stenting in terms of reduction of
mortality is limited to patients with a large area at risk or
with severe left ventricular dysfunction. In these patients,
reocclusion of the IRA may result in fatal reinfarction. For
patients ‘not at high risk’, the benefit of stenting may be
restricted to a significant reduction of the incidence of
nonfatal reinfarction and mainly of repeat target vessel
revascularization.
All studies showed a benefit of
primary stenting in terms of decreased incidence of early
and late repeat target vessel revascularization, while, as
expected, no benefit of stenting in terms of decreased
mortality could be demonstrated.
The STENTIM-2 trial was based on a sample of 211
patients with AMI.30 In contrast to previous trials, the
primary endpoint of the study was not clinical but angiographic,
that is, the 6-month angiographic restenosis rate.
The restenosis rate was significantly lower in patients
randomized to stenting compared with patients randomized
to angioplasty (25.3% versus 39.6%; p = 0.04). No
differences could be revealed between stenting and angioplasty
in clinical outcome, including the need for a repeat
procedure (5.0% versus 5.4%). However, the very high
incidence of crossover to stenting of patients randomized
to angioplasty (36.4%) rendered the analysis based on
intention-to-treat unacceptable.
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