
Debulking in Cardiovascular Interventions and Revascularization Strategies
Between a Rock and the Heart
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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.
Key Features
- Review and discussion of the pathophysiology of cardiovascular resistant lesions
- Analysis of the impact on revascularization outcome of cardiovascular lesions/bio-tissues which exhibit resistance to standard revascularization
- Introduction of the concept of debulking for revascularization of cardiovascular diseases: comprehensive description
- Presentation of the clinical scenarios associated with resistant cardiovascular lesions and bio-tissue that require debulking
- Delineation of various state-of-the -art diagnostic imaging modalities for detection and demonstration of the lesions and tissues that require debulking
- Presentation of the expansive array of mechanical revascularization tools available for debulking
- Description of surgical debulking approaches to resistant cardiovascular lesions
- Summary of debulking outcomes
Readership
Basic research scientists, biology college and graduate students. Pathologists, general cardiologists, coronary and peripheral Interventional cardiologists, diagnostic and interventional radiologists, vascular medicine specialists, cardiac surgeons, general and vascular surgeons, hospitalists, internists, residents and advanced training fellows in the fields of cardiology, radiology and surgery as well as medical school students and nurse practitioners. Pathology and clinical medicine including internal medicine, general surgery, cardiology, cardiac surgery, thoracic and vascular surgery, vascular medicine, oncology, pathology, medical school courses, residency and fellowship programs and biology, college and graduate programs of biomedical engineering
Table of Contents
- 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
Product details
- No. of pages: 970
- Language: English
- Copyright: © Academic Press 2022
- Published: January 21, 2022
- Imprint: Academic Press
- eBook ISBN: 9780128214626
- Paperback ISBN: 9780128214510
About the Editor
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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