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A Physician Perspective on Optimizing PCI

Posted by Giora Weisz, MD
January 10, 2014
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As an interventional cardiologist, my primary concern is patient care. Throughout my career, I have had the opportunity to review, and even help develop, technologies and tools that have dramatically advanced our ability to improve patient outcomes. I have seen us progress from what now seem like rudimentary tools to practice the art of interventional cardiology to today’s advanced techniques supported by evidence based medicine.

Each advancement has provided improved results which can be measured in terms of patient mortality if they present at the ER with a heart attack, or in terms of revascularization rates, measuring if a patient needs a second procedure to again open their initial blockage. Thankfully, we have seen improvement in these metrics, which has enabled us to try and push our field further to help patients with even more complex disease. The question that we face today is how can we optimize our procedures?

A consideration of optimization of a procedure such as PCI (coronary angioplasty) must take all the available tools into consideration. To start, we need to see the target lesion. In the cath lab, we use fluoroscopy (x-ray) to see the relevant anatomy, and we are always trying to reduce the amount of x-ray dose without sacrificing the image quality. As you would expect, positioning the viewing monitor closer, or using a significantly larger monitor, helps us to better see the lesion we want to treat.

We then want to better understand the lesion. Technologies such as Intravascular Ultrasound (IVUS), and Fractional Flow Reserve (FFR) are becoming standard in the modern cath lab as they each provide unique information about the patient’s disease. Not only do we need to understand the make-up of the disease, but technologies such as IVUS and FFR can help us define the specific area on the vessel that we want to treat, which leads to the next decision, which stent, if any, to use to during the interventional procedure.

Stent and balloon technology has advanced over time and the interventional devices are available in a range of sizes and physical properties to precisely fit the region in need of treatment for each patient. As interventionalists, we know that we only want cover the diseased area of the vessel with a stent, and it may be just as critical to cover the whole diseased anatomy as it is not to not have a stent inserted and covering healthy tissue. Under or over stenting can be considered a “Geographic Miss”, and there is published data demonstrating the negative impacts that geographical miss have on rates of revascularization.

A technology such as robotic assisted angioplasty, with the robotic precision it offers can support and improve each of these facets of the PCI procedure. Capability such as 1mm device movements and sub-millimeter measurement capability offer us tools that we have never had access to in the past. When considering optimizing PCI, the interventionalist considers all the technologies that we have available, and in particular considers robotic-assistance a key component to truly optimized procedures.

  
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