Podcasts about Angioplasty

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Sirolimus-Eluting Balloon Versus Repeat Drug-Eluting Stenting or Balloon Angioplasty for In-stent Restenosis

This week, join Associate Editor and Editorialist Graeme Hankey as he discusses the article "Bailout Intracranial Angioplasty or Stenting After Thrombectomy for Acute Large Vessel Occlusion: 1-Year Outcomes of ANGEL-REBOOT and the editorial "Unsuccessful Thrombectomy During Acute Ischemic Stroke: Can It Be Rescued by Angioplasty and/or Stenting?" For the episode transcript, visit: https://www.ahajournals.org/do/10.1161/podcast.20251117.229007

Resources:  Rutherford Chapters (10th ed.): 174, 175, 177, 178 Prior Holding Pressure episode on AV access creation: https://www.audiblebleeding.com/vsite-hd-access/ The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access: https://www.jvascsurg.org/article/S0741-5214%2808%2901399-2/fulltext  KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update: https://pubmed.ncbi.nlm.nih.gov/32778223/    Venous Hypertension   Definition A functioning AV circuit delivers high volume arterial flow towards a stenotic venous segment, causing buildup in pressure and venous hypertension. If there are few or no branching veins between the access and stenosis, thrombosis could occur   Etiology The most common etiology is venous stenosis caused by a history of vessel wall trauma by centrally-inserted venous devices such as tunneled and non-tunneled dialysis catheters, central lines, pacemakers, or defibrillator. In a study performed at a large academic medical center1, new hemodynamically significant central venous stenosis was associated with the duration of catheter dependence (26% in patients with CVCs for more than 6 months, versus 11% in patients with CVCs for less than 6 months). PICC lines can directly damage cephalic and basilic veins Venous stenosis can often go undetected until AV access creation occurs   Patient Presentation Symptoms of venous insufficiency will be present– most commonly regional edema, in the area of venous stenosis. If there are patent venous branches between the AV anastomosis and the stenotic area, swelling can occur throughout the arm. Pigmentation, induration, dermatosclerosis, and ulceration may also be observed. An extensive collateral network of veins may be visible throughout anterior chest, shoulder, or flank SVC obstruction can result in swelling of the head, neck and shoulders, as well as a feeling of head and neck fullness, airway compromise, and visual problems Normal palpable thrill can be replaced by a strong pulse Dialysis can be complicated by difficulty with needle access, recirculation syndrome, and arm swelling after dialysis sessions. Workup  Central vein thrombosis can be hard to detect on ultrasound because clavicle and sternum can block transmission Venography is essential to determine the presence and severity of venous stenosis or occlusion.   Prevention The ideal scenario is to avoid central dialysis catheters completely, and this involves evaluating CKD patients and placing AVF or AVG before the need for dialysis arises.  If a patient presents placement of an AVF/AVG, it is important to perform venography if a patient has a history of a central venous catheter or clinical signs of venous hypertension. A history of SVC obstruction from any cause can preclude permanent AV access creation in both upper extremities Treatment Endovascular approaches to venous outflow stenosis can be first-line treatment options, due to their minimal risk. They can also be performed at the same time as a diagnostic venogram. Angioplasty alone or with stenting are the endovascular options. In a study by Bakken et al2 that compared primary high-pressure balloon angioplasty versus stenting, primary patency was equivalent between groups, with 30-day rates of 76% for both groups and 12-month rates of 29% for angioplasty and 21% for stenting. Assisted primary patency was also equivalent with a 30-day patency rate of 81% and 12-month rate of 73% for the angioplasty group,  84% at 30 days, and 46% at 12 months for the stenting group. This study, along with others, shows that the major downside of endovascular interventions, whether angioplasty or stenting, often require repeat intervention and have poor long-term patency. For subclavian vein stenosis, angioplasty alone is appropriate due to its anatomical location that can put a stent at risk for extrinsic compression from the first rib and clavicle. Surgical bypass can be performed Possible bypasses include axillary-axillary, axillary-jugular, axillary-right atrial, and axillary-femoral. In these bypasses, the preferred conduits are autogenous saphenous or femoral veins. In cases where the proximal subclavian vein is obstructed, a jugular vein turndown can be performed. In this procedure the distal jugular vein is transected, sewed end-to-side at the distal subclavian vein, effectively acting as a bypass route for that obstructed segment. The Hemoaccess Reliable Outflow (HeRO) Vascular Access Device can be used as a hybrid approach, combining endovascular and open surgical techniques to bypass a central venous occlusion  and provide a reliable outflow for dialysis.  This device has a PTFE inflow limb that is sewn end-to-side onto the brachial artery. This limb is tunneled subcutaneously and connected to a silicone-coated nitinol outflow catheter that is inserted into a central vein and tracked directly into the right atrium. This effectively bypasses central venous stenoses. In the largest study to date on HeRO access grafts placed in 167 patients,3 HeRO primary and secondary patency was 48.8% and 90.8%, respectively, at 12 months. Interventions to maintain or re-establish patency were required in 71.3% of patients resulting in an intervention rate of 1.5/year. Access-related infections were reported in 4.3% patients. The authors concluded that HeRO device had performed comparably to standard AVGs and had proven superior to tunneled dialysis catheters in terms of patency, intervention, and infection rates. If no treatment options for venous hypertension or outflow obstruction  are available, an alternate AV access site can be created, either in the contralateral arm if the SVC is uninvolved, or through placement of femoral AV access or a peritoneal dialysis catheter.   Bleeding Access Site   Etiology and Risk Factors Bleeding can be caused by high venous pressure after dialysis, pseudoaneurysm rupture, or trauma. Patients with end stage renal disease (ESRD) have a baseline elevated risk of bleeding due to uremia-induced platelet dysfunction and use of systemic anticoagulation within the hemodialysis circuit. Additional risk factors include dialysis through an AV graft, hypertension, longer duration of access use, and compromised integrity of the vascular access due to complications (clotting, infection) or invasive procedures. Dual antiplatelet therapy is also associated with overall bleeding events in ESRD patients. Dialysis patients could be on antiplatelet therapy for management of comorbid cardiovascular risk and/or patency of AV graft Patients with bleeding fistulas often present from their dialysis unit when standard digital pressure at the cannulation site fails to stop the bleeding. This is a very serious condition since most mature fistulas have high blood flow and the patients are at risk for hemorrhagic shock and death.    Initial Management  The first step of management is to obtain hemostasis. Elevate the limb above the level of the heart and apply firm and directed pressure at the site of bleeding using gauze for at least 30-40 minutes Milosevic et al4 reviewed non-operative management of bleeding fistulas and grafts and found that compared to standard dressings, the use of specialized hemostatic dressings decreased bleeding time at arterial and venous cannulation sites. These hemostatic materials included the IRIS compression bandage and cellulose-based, chitosan-based, poly-N-acetyl glucosamine-based, and thrombin-soaked dressings. There has been a “bottlecap method” described where the hollow side of a bottlecap is pressed on top of the puncture site. Maintaining pressure on the cap will cause the cap to fill with blood and clot, which tamponades the bleeding. The provider can also place a shallow figure-of-8 or purse string stitch just below the skin surface to aid in hemostasis. It is important to avoid placing the suture too deep as this can cause inadvertent fistula ligation. During this process, an assistant applies pressure just proximal and distal to the bleeding site to stop blood flow so the sutures can be placed. If these methods fail to achieve hemostasis, apply a tourniquet proximal to the fistula and tighten it until bleeding stops and the radial pulse is lost. This signifies complete occlusion of arterial inflow to the fistula. Tourniquet use should be limited to 3 hours or less, since limb ischemia beyond this timepoint is associated with permanent neuromuscular damage. Regardless of the method used for initial hemostasis, the patient is at risk for repeat hemorrhage, hematoma formation, vessel stenosis, and thrombosis. They should be evaluated by a vascular surgeon as soon as possible.  Definitive Management Definitive management depends on etiology of each case, and there are a variety of interventions that can be pursued (i.e. aneurysmorrhaphy for aneurysmal bleeding) If skin erosion over the conduit is present, it should be assumed that the AV access is infected and emergency intervention should be pursued. A jump graft can be placed through with healthy tissue.  A covered stent could be introduced through a separate percutaneous puncture site Finally, coagulopathy can be addressed by administering cryoprecipitate, DDAVP, erythropoietin, estrogen, tranexamic acid. Aneurysms and Pseudoaneurysms   Definition and Etiology Aneurysms involve all three layers of the vessel wall and they develop due to hemodynamic changes causing remodeling of the vein wall in an AV fistula. This is necessary for vein maturation, but becomes problematic if the post-anastomotic vein continues to dilate and becomes aneurysmal.  Aneurysms can also occur at anastomosis sites due to technical aspects of the surgery. Pseudoaneurysms only involve some layers of the vessel wall caused by repeated puncture for hemodialysis.  Both aneurysms and pseudoaneurysms can enlarge due to venous outflow stenosis causing increased intraluminal pressures. Both true aneurysms and pseudoaneurysms can lead to overlying skin erosion and subsequent hemorrhage, pain, AV access dysfunction, and cannulation difficulties.  Dialysis cannulation should be avoided at the aneurysmal sites to prevent bleeding complications. Diagnosis They can be diagnosed on ultrasound, which also provide information on flow rates, presence inflow/outflow/stenoses, and vessel diameters.  Indications for Treatment Treatment is indicated for aneurysms that are rapidly expanding or ulcerating through the skin surface. These are at high risk for rupture and hemorrhage, which is life-threatening. Treatment is also indicated when the aneurysm occurs at the anastomotic site of the AV fistula, the patient has a cosmetic concern, cannulation becomes difficult, there is concern for infection, or the patient has high-output heart failure that could be exacerbated by high flow through the fistula. Treatment is not indicated in asymptomatic aneurysms, regardless of their size. True  aneurysms and pseudoaneurysms are not prone to spontaneous rupture.   Treatment Options Aneurysmorrhaphy is the most common treatment. It involves the resection of the aneurysmal vein wall to restore a normal diameter and removal of excess skin. Anastomosis is performed along the lateral wall to prevent issues with cannulation along the suture line. Aneurysm resection with interposition grafting is also possible. If multiple aneurysmal segments require treatment, staging their repairs can allow for continuation of dialysis without needing to place a temporary dialysis catheter. AV access ligation is an appropriate alternative to AV access salvage in certain situations but usually requires excision of the aneurysm/pseudoaneurysm due to the potential to develop thrombophlebitis and the cosmetic appearance of the thrombosed segment. If there is concern for an infected pseudoaneurysm or aneurysm, surgery should include removal of all infected material. References   1. Al-Balas A, Almehmi A, Varma R, Al-Balas H, Allon M. De Novo Central Vein Stenosis in Hemodialysis Patients Following Initial Tunneled Central Vein Catheter Placement. Kidney360. 2022;3(1):99-102. doi:10.34067/KID.0005202021 2. Bakken AM, Protack CD, Saad WE, Lee DE, Waldman DL, Davies MG. Long-term outcomes of primary angioplasty and primary stenting of central venous stenosis in hemodialysis patients. J Vasc Surg. 2007;45(4):776-783. doi:10.1016/j.jvs.2006.12.046 3. Gage SM, Katzman HE, Ross JR, et al. Multi-center Experience of 164 Consecutive Hemodialysis Reliable Outflow [HeRO] Graft Implants for Hemodialysis Treatment. Eur J Vasc Endovasc Surg. 2012;44(1):93-99. doi:10.1016/j.ejvs.2012.04.011 4. Milosevic E, Forster A, Moist L, Rehman F, Thomson B. Non-surgical interventions to control bleeding from arteriovenous fistulas and grafts inside and outside the hemodialysis unit: a scoping review. Clin Kidney J. 2024;17(5):sfae089. doi:10.1093/ckj/sfae089

Is the axiom of balloon angioplasty, “the more you gain the more you lose,” still true in the era of DCB with paclitaxel?

Send us a textThis recording features audio versions of Month Year Journal of Vascular and Interventional Radiology (JVIR) abstracts:Optimal Timing of Percutaneous Cholecystostomy across Different Grades of Acute Cholecystitis: A Retrospective Cohort Study ReadGallbladder Cryoablation for Calculous Cholecystitis Initially Treated with Percutaneous Drainage: A Prospective Trial in High-Risk Patients ReadComparative Prognostic Utility of Updated Model for End-Stage Liver Disease Scores for Prediction of Early Mortality after Transjugular Intrahepatic Portosystemic Shunt Creation ReadLong-Term Outcomes of Angioplasty and Stent Placement for Portomesenteric Vein Obstruction following Hepatobiliary and Pancreatic Surgery ReadThe Impact of Chronic Kidney Disease on Amputation and Death Rates in Patients with Peripheral Artery Disease in the United States ReadPercutaneous Microwave Ablation of Small (

In this episode, Dr. Valentin Fuster presents groundbreaking international research on balloon pulmonary angioplasty (BPA) as a crucial alternative for treating chronic thromboembolic pulmonary hypertension patients ineligible for surgery. Drawing from nearly 500 patients across 18 centers, the discussion highlights BPA's promising outcomes and challenges, underscoring the importance of expert, high-volume centers for optimal safety and effectiveness.

Send us a text"We had no tools. We just had to improvise. In a way, like you said, that was what made us think, 'How can I do this?' Because you had no tools, you had to think of ways to use what you had available to do procedures that otherwise you wouldn't have been able to do back then." —Wilfrido R. Castaneda-Zuniga, MD, FSIR, on innovation in early interventional radiologyIn this episode, part of the ongoing celebration of the Society of Interventional Radiology (SIR) 50th anniversary, hosts Keith Horton, MD, FSIR, and Hector Ferral, MD, FSIR, speak with interventional radiology pioneer Wilfrido R. Castaneda-Zuniga, MD, FSIR, reflecting on lessons learned working with Kurt Amplatz, MD, FSIR, and others, stories of how their most seminal work came into being, the importance of peer mentorship, and more.  Related resources:View the society's 50th Anniversary celebration page"Mechanics of angioplasty: an experimental approach" by Wilfrido R. Castaneda-Zuniga, MD, FSIR, et al.SIR thanks BD for its generous support of the Kinked Wire.Contact us with your ideas and questions, or read more about about interventional radiology in IR Quarterly magazine or SIR's Patient Center.(c) Society of Interventional Radiology.Support the show

Dr Ashwin Mehta's Journey from Learner to Leader in Retrograde Angioplasty by TheRightDoctors

DAD Catheter: An Angioplasty Apparatus for Facilitating Accurate Placement of a Lumen Stent for Dilating Ostial Stenosis

In this episode of Audible Bleeding, Jamila, Anh, and Naveed discuss the LifeBTK Trial with Principal Investigator Dr. Brian DeRubertis, where we discuss the new Abbott Esprit everolimus-eluting resorbable scaffold for the below-knee popliteal space. Guest: Dr. DeRubertis, is the Principal Investigator of the LIFE-BTK trial. He is the Chief of the Division of Vascular & Endovascular Surgery at New York-Presbyterian and Weill Cornell Medicine in New York City. Audible Bleeding Team Dr. Jamila Hedhliis a general surgery resident at the University of Illinois. Anh Dang, (@QuynhAnh_Dang), is a fourth year medical student at the University of Pennsylvania.  Dr. Naveed A. Rahman, (@naveedrahmanmd), is a Vascular Surgery Fellow at the University of Maryland.    References: Drug-Eluting Resorbable Scaffold versus Angioplasty for Infrapopliteal Artery Disease (LIFE-BTK). Advances in Endovascular Treatment of CLTI: Insights From the LIFE-BTK Trial. Diversity, Equity, and Inclusion in the LIFE-BTK Trial Evaluating the Esprit™ BTK Drug-Eluting Resorbable Scaffold for the Treatment of Infrapopliteal Lesions in Patients with Chronic Limb-Threatening Ischemia, VIVA 2024. Sirolimus-eluting stents vs. bare-metal stents for treatment of focal lesions in infrapopliteal arteries: a double-blind, multi-centre, randomized clinical trial (YUKON). Randomized comparison of everolimus-eluting versus bare-metal stents in patients with critical limb ischemia and infrapopliteal arterial occlusive disease (DESTINY).  A prospective randomized multicenter comparison of balloon angioplasty and infrapopliteal stenting with the sirolimus-eluting stent in patients with ischemic peripheral arterial disease (ACHILLES). Sex Differences in Outcomes Following Endovascular Treatment for Symptomatic Peripheral Artery Disease: An Analysis From the K- VIS ELLA Registry. Drug-Coated vs Uncoated Percutaneous Transluminal Angioplasty in Infrapopliteal Arteries: Six-Month Results of the Lutonix BTK Trial.  Paclitaxel-Coated Balloon in Infrapopliteal Arteries: 12-Month Results From the BIOLUX P-II Randomized Trial (BIOTRONIK'S-First in Man study of the Passeo-18 LUX drug releasing PTA Balloon Catheter vs. the uncoated Passeo-18 PTA balloon catheter in subjects requiring revascularization of infrapopliteal arteries).  The IN.PACT DEEP Clinical Drug-Coated Balloon Trial: 5-Year Outcomes.     Follow us @audiblebleeding Learn more about us at  https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

N Engl J Med 2003;349:733-742Background: In patients with ST elevation myocardial infarction, treatment with balloon angioplasty improved outcomes compared to fibrinolysis, as seen in the Primary Angioplasty in Myocardial Infarction Study Group trial. Other trials showed similar findings. However, these trials were relatively small in size and mainly conducted at hospitals with high experience in angioplasty.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.At the time this trial was conducted, limited number of hospitals offered angioplasty. Transporting patients with ST-elevation myocardial infarction to these centers posed a significant challenge, and sometimes resulting in delays in treatment.The DANAMI-2 investigators sought to conduct a community-wide trial comparing on-site fibrinolysis vs transferring the patients for primary angioplasty.Patients: Eligible patients had ST-segment elevation myocardial infarction with symptoms lasting for at least 30 minutes but less than 12 hours. The EKG criteria were cumulative ST-segment elevation of at least 4 mm in at least two contiguous leads.Exclusion criteria were many and included contraindication to fibrinolysis, left bundle branch block, acute myocardial infarction and fibrinolytic treatment within the previous 30 days, pulseless femoral arteries, renal failure defined as creatinine > 2.83 mg/dL, life expectancy less than 12 months due to non-cardiac disease, and more. Patients were also excluded if they were high risk for transportation because of cardiogenic shock, persistent life-threatening arrhythmias, or a need for mechanical ventilation.Baseline characteristics: The trial randomized 1,572 patients – 790 randomized to angioplasty and 782 to fibrinolysis. A total of 1129 patients were randomized at referral hospitals, and 443 patients were randomized at invasive-treatment centers.The average age of patients was 63 years and 73% were men. Approximately 20% had hypertension, 7% had diabetes, 11% had prior myocardial infarction, and 58% were current smokers.Among patients who underwent angiography and data were available, 53% had single vessel disease, 25% had two vessel disease and 14% had three vessel disease. Approximately 3% had left main involvement.Procedures: Patients were randomly assigned in a 1:1 ratio to undergo fibrinolysis or angioplasty. Patients were recruited from 24 referral hospitals without angioplasty facilities and 5 invasive-treatment hospitals with angioplasty facilities. For patients recruited from referral hospitals, transfer to angioplasty center had to be completed within 3 hours. A physician accompanied the patient. The participating hospitals served 62% of the Danish populationPatients assigned to fibrinolysis received 300 mg of aspirin orally, beta-blocker intravenously, tissue plasminogen activator (alteplase, given as a 15-mg bolus and an infusion of 0.75 mg/kg over 30 minutes, followed by an infusion of 0.5 mg/kg for 60 minutes), and an intravenous bolus of unfractionated heparin (5000 U), followed by a 48-hour infusion of unfractionated heparin.Patients assigned to angioplasty received 300 mg of aspirin intravenously, beta-blocker intravenously, and 10,000 U of unfractionated heparin bolus, with additional heparin during the angioplasty procedure to achieve an activated clotting time of 350 to 450 seconds.Angioplasty was only performed for target-vessel related infarct.Endpoints: The primary end point was a composite of death from any cause, clinical reinfarction or disabling stroke, at 30 days. Procedure-related reinfarction was not counted in the primary end point.The trial was designed with two parallel sub-studies: One involving patients randomized at referral hospitals and the other involving patients randomized at invasive-treatment centers.Analysis was performed based on the intention-to-treat principle. Sample size calculations assumed that the combined primary endpoint would occur within 30 days in 16% of patients assigned to fibrinolysis, 10% of those assigned to angioplasty at referral hospitals, and 9% of those assigned to angioplasty at invasive-treatment centers. Based on these assumptions, 1100 patients were needed to be enrolled at referral hospitals and 800 patients at invasive-treatment centers.Results: Among the 4,278 patients screened for inclusion, 1,572 (36.7%) were randomized. The study was stopped early after the third interim analysis demonstrated superiority of angioplasty in the referral-hospital sub-study. The median time from the onset of symptoms to randomization was 135 minutes. The median distance patients were transported from a referral hospital to an invasive-treatment center was 50 km. The time from randomization at the referral hospital to arrival in the catheterization laboratory was under 2 hours in 96% of the patients. There were no deaths during transportation.Among the patients randomized to fibrinolysis, 99% received the assigned treatment. Among the patients randomized to angioplasty, 98% underwent angiography. Angioplasty was attempted in 89.4% of the patients, and among them, stents were implanted in 90.4%.Angioplasty reduced the primary composite endpoint among all patients (8.0% vs 13.7%; p

N Engl J Med 1993;328:673-679Background: Previous trials established that thrombolysis improves mortality in patients with acute myocardial infarction, as seen in the GISSI-1 and ISIS-2 trials. However, thrombolysis has limitations, including an increased risk of bleeding and the inability to achieve arterial patency in approximately 20% of the cases. As a result, there was a growing interest in the use of percutaneous transluminal coronary angioplasty (PTCA).Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.The Primary Angioplasty in Myocardial Infarction Study Group sought to test the hypothesis that PTCA compared to thrombolysis, improves outcomes and reduces bleeding in patients with acute myocardial infarction.Patients: Eligible patients presented within 12 hours of ischemic chest pain and had ST elevation of at least 1 mm in two or more contiguous electrocardiographic leads. Patients were excluded if they had dementia, LBBB, cardiogenic shock or elevated bleeding risk.Baseline characteristics: The study enrolled 395 patients – 195 assigned to the PTCA arm and 200 assigned to the thrombolysis arm. The average age of patients was 60 years with 73% being men. Approximately 14% had prior myocardial infarction, 43% had hypertension, 12% had diabetes and 2% had congestive heart failure. The average ejection fraction 52%.The infarct was anterior in 34% of the patients, inferior in 59% and lateral in 8%.Procedures: All patients were given 325 mg of aspirin plus 10,000-unit bolus of intravenous heparin. After that, patients were randomly assigned to thrombolytic therapy or PTCA. The thrombolytic agent used was tissue plasminogen activator (t-PA) at a dose of 100 mg (or 1.25 mg/kg of body weight for patients weighing less than 65 kg) over three hours. Patients randomly assigned to PTCA underwent immediate diagnostic catheterization.Angiographic criteria for exclusion from PTCA included left main stenosis of more than 70%, infarct-related vessel was patent, three-vessel disease, morphologic features of the lesion known to indicate high risk, small infarct-related vessels or stenosis 70 years or admission heart rate > 100 bpm. PTCA reduced in-hospital mortality in the “not low risk” group (2.0% vs 10.4%; p= 0.01) but not in the low risk group (3.1% vs 2.2%; p= 0.69).Conclusion: In patients with ST-elevation myocardial infarction, PTCA compared to t-PA reduced death and reinfarction at the hospital and at 6 months with a number needed to treat of approximately 14 and 12, respectively.This was one of the trials that established the foundation for the use of PTCA in patients with acute myocardial infarction. While the treatment effect was large, there are important considerations to keep in mind. First, the sample size was small. In comparison, GISSI-1 had almost 12,000 patients and ISIS-2 had over 17,000. The results of small trials are not always replicated in larger pragmatic trials. Second, the use of aspirin + heparin + t-PA likely increased bleeding in the t-PA arm as heparin plus thrombolysis compared to thrombolysis without heparin increased bleeding without improving outcomes, as seen in the GISSI-2 and ISIS-3 trials. Third, two thirds of the patients had inferior or lateral infarcts and these subgroups did not benefit from thrombolysis in the GISSI-1 trial. Finally, standalone angioplasty is infrequently performed nowadays and patients often receive a stent which has improved vessel patency.In the current era, patients with ST-elevation myocardial infarction receive early revascularization with stent placement, which improved outcomes in these patients. We discussed the limitations above to help readers and learners appraise clinical trials, as these limitations were important at the time of this trial's publication.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

In this episode, Dr. Valentin Fuster discusses the findings of a major randomized trial examining the use of drug-coated balloons (DCB) in treating side branch stenosis during coronary bifurcation procedures. The study suggests that DCBs offer better one-year outcomes compared to non-coated balloons, showing a significant reduction in myocardial infarction rates, but highlights ongoing challenges in managing bifurcation lesions, especially considering the high cost and potential risks.

DCB-BIF: Comparison of Noncompliant Balloon with Drug-Coated Balloon Angioplasty for Side Branch Stenosis After Provisional Stenting for Patients with True Coronary Bifurcation Lesions

ECLIPSE: A Large-Scale, Randomized Trial of Orbital Atherectomy vs. Conventional Balloon Angioplasty in Severely Calcified Coronary Arteries Prior to DES Implantation

Author Shao-Liang Chen, MD, FACC, and JACC Associate Editor Celina M. Yong, MD, FACC, discuss patients with simple and true coronary bifurcation lesions undergoing provisional stenting. Main vessel stenting with a DCB for the compromised side branch resulted in a lower 1-year rate of the composite outcome compared with an NCB intervention for the side branch. The high rates of periprocedural myocardial infarction, which occurred early and did not lead to revascularization, are of unclear clinical significance.

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The Lancet Volume 391, Issue 10115, 6–12 January 2018, Pages 31-40Background:  For decades, cardiologists commonly used percutaneous coronary intervention (PCI) for the relief of angina. It made sense because PCI resulted in near complete resolution of blood flow through a stenosed vessel. The problem facing evidence-based clinicians was that no previous trial had compared PCI to a placebo (sham) procedure. Instead, previous trials had compared PCI (a procedure) to tablets. In the absence of blinding, a procedure will exert a larger placebo effect than tablets.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.The Objective Randomized Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina (ORBITA) trial was designed to assess the effect of PCI versus placebo on exercise time in patients with stable ischemic symptoms.ORBITA met ethical criteria because previous trials, primarily the COURAGE trial, had found that PCI in addition to medical therapy did not reduce hard outcomes, such as myocardial infarction or death due to cardiovascular causes, compared to medicine alone. In other words, PCI in patients with stable coronary artery disease was not a disease-modifying therapy; it was used to relieve symptoms.Patients:  Patients had to have single-vessel coronary artery disease (≥ 70% stenosis) that was appropriate for PCI and angina or equivalent symptoms. The authors published in the appendix pictures of every patient enrolled in the trial. Exclusion criteria included acute coronary syndrome, previous bypass surgery, left main stenosis, chronic total occlusions, severe valvular disease or left ventricular dysfunction, moderate or severe pulmonary hypertension, or life-expectancy less than 2 years.  Baseline Characteristics: The mean age of patients was 65 years. More than 79% were male. Almost 90% had normal left ventricular function. Canadian Cardiovascular Society class included about 60% with class 2 symptoms and nearly 40% with class 3 symptoms. Angina had been present for a mean of 9 months. Trial Procedures: ORBITA had two phases. First was a 6-week medical optimization phase wherein patients were optimally treated with medical therapy. They had a questionnaires, dobutamine stress echo, and a cardiopulmonary exercise test.  They then had the blinded procedure with either PCI or placebo.All PCI was done with drug-eluting stents. The procedure included measures to insure blinding, such as headphones during the procedure, sedation and a measure of hemodynamics such as fractional flow reserve. The second phase was a 6-week period of blanking in which patients underwent follow-up assessment. Testing procedures were similar to the pre-procedure protocol.At all times, the staff were blinded to the procedural data. This included procedural details as well as post-procedural assessment. The recovery staff were well rehearsed in their role of maintenance of blinding. Patients and subsequent medical caregivers were also blinded to treatment allocation. The study physicians present during the procedure had no further contact with the patient during the study.By the time of randomization, in the PCI group, 103 (98%) of 105 patients were taking aspirin, 103 (98%) were taking a second antiplatelet, and 99 (94%) were taking a statin, compared to 93 (98%), 94 (99%), and 91 (96%) of 95 patients, respectively, in the placebo group. At the same timepoint, in the whole study population, 156 (78%) of 200 patients were taking β blockers and 182 (91%) were taking calcium channel antagonists.The mean number of antianginal medications in the PCI group was 0·90 (SD 0·8) at enrollment, 2·8 (1·2) at pre-randomization, and 2·9 (1·1) at follow-up, compared to the placebo group in which the mean number of medications was 1·0 (0·9; p=0·357), 3·1 (0·9; p=0·097), and 2·9 (1·1; p=0·891), respectively.Endpoints: The primary endpoint of ORBITA was the difference between PCI and placebo groups in the change in treadmill exercise time. The power calculation relied on previous trials wherein PCI had resulted in a 48-55 second increase in exercise time over medicine. ORBITA authors designed the trial to detect a 30 second increase in exercise time.They estimated that a sample size of 100 patients per group had more than 80% power to detect a between-group difference in the increment of exercise duration of 30 seconds, at the 5% significance level, using the two-sample t test of the difference between groups. This calculation assumed a between-patient standard deviation of change in exercise time of 75 s. Since there had been no previous placebo-controlled trials of PCI, the authors initially allowed for a one-third dropout rate in the 6-week period of medical optimization between enrollment and randomization and therefore planned to enroll 300 patients. But the dropout rate was much lower, so only 230 patients had to be enrolled. The primary endpoint was continuous, and it was calculated as a difference between groups. They also measured secondary endpoints, including measures of angina severity and quality of life.Results: A total of 368 patients were screened for eligibility, and 200 were randomly assigned. Most were excluded from randomization because they declined to participate. There were 105 allocated to PCI (all but one had PCI) and 95 to placebo (4 patients had PCI due to a procedural complication).Across all patients, the mean area stenosis by quantitative coronary angiography was 84·4% (SD 10·2), mean FFR was 0·69 (0·16), and mean iFR was 0·76 (0·22). 57 (29%) patients had FFR greater than 0·80 and 64 (32%) had iFR greater than 0·89.The median length of stent implanted was 24 mm (IQR 18–33). After PCI, the mean FFR improved to 0·90 (SD 0·06; p

For full review of the trials, please visit https://cardiologytrials.substack.com/ Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

N Engl J Med 2007;356:1503-1516Background: By the turn of the 21st century more than 1 million coronary stent procedures were performed each year in the United States and approximately 85% were undertaken electively in patients with stable coronary artery disease. This pattern evolved without a single clinical trial demonstrating a concrete improvement in hard endpoints with percutaneous coronary intervention (PCI) compared to optimal medical therapy (OMT) alone. We have already reviewed several of these trials including ACME, RITA-2 and the Atorvastatin vs Angioplasty trial. Each trial was relatively small and none showed a significant benefit for revascularization compared to medical therapy on death or MI.Previous trials involving PCI compared to standard care or OMT included less than 3,000 patients altogether, did not broadly use intracoronary stents (instead using balloon angioplasty only) and they did not employ what would be considered a contemporary standard of medical management. Thus many questions involving the efficacy and safety of PCI versus OMT alone for managing stable CAD remained unanswered.The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial was designed to test the hypothesis that up front PCI plus OMT would significantly reduce the risk of death and nonfatal MI compared to OMT alone in patients with stable CAD.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.Patients: Eligible patients had stable CAD defined as either 1) a coronary stenosis of >/= 70% in one or more proximal epicardial coronary arteries and objective evidence of myocardial ischemia (based on the resting ECG or with exercise or pharmacologic vasodilator stress testing) or 2) a coronary stenosis of >/= 80% and classic angina without provocative testing. Patients were excluded if they had persistent Canadian Cardiovascular Society (CCS) class IV angina, a markedly positive stress test defined by substantial ST-segment depression or hypotensive response during stage 1 of the Bruce protocol), refractory heart failure or cardiogenic shock, an EF /=50% (4%).Patients in the trial were adherent with medical interventions and motivated to improve diet and lifestyle. For all patients, BP and cholesterol were improved and activity levels increased over the course of the study. For example, in the OMT group, baseline SBP and LDL were 130 mm Hg and 102 mg/dl at baseline and declined to 122 mm Hg and 72 mg/dl at 5 years, respectively. Similar reductions were seen in the PCI group. Fifty five percent of patients performed moderate physical activity at baseline and this increased to 77% at 5 years. Dietary adherence improved across the board and smoking decreased. Patients were followed for a median time of 4.6 years and 9% were lost to follow up with no significant difference between group. Overall, PCI + OMT did not reduce the primary endpoint of death or nonfatal MI compared to OMT alone (19.0% with PCI vs 18.5% with medical therapy; HR 1.05; 95% CI 0.87-1.27). Periprocedural MI was numerically more frequent in the PCI group whereas spontaneous MI was nearly identical between groups (statistics not provided). There were no statistically significant differences noted in any of the endpoints reported with the exception of revascularization during the follow up period, which occurred less frequently in the PCI group (20% vs 30%; p

A new trial assessed whether balloon angioplasty plus aggressive medical management was superior to aggressive medical management alone for patients with symptomatic intracranial atherosclerotic stenosis. Author Zhongrong Miao, MD, PhD, from Beijing Tiantan Hospital, discusses the BASIS randomized clinical trial with JAMA Deputy Editor Christopher C. Muth, MD. Related Content: Balloon Angioplasty vs Medical Management for Intracranial Artery Stenosis Is Balloon Angioplasty the Future for Intracranial Stenosis? Read Transcript

Commentary by Dr. Zhi-Cheng Jing

Commentary by Dr. Dong Oh Kang

Commentary by Dr. Emile Daoud

Comparison of Intravascular Ultrasound-Guided versus Angiography-Guided Angioplasty on the Outcomes of Drug-Coated Balloon Treatments in Femoropopliteal Artery Disease

Drug-Coated Balloons vs Drug-Eluting Stents or Plain Old Balloon Angioplasty for In-Stent Restenosis: A Nationwide Segment-Level Analysis from SCAAR of 7987 Patients

Bypass surgery and angioplasty are two of the most widely-used treatments for coronary artery disease, and they have a long track record in medicine. Bypass surgery was first done in 1960, while the first coronary angioplasty was done in 1977. What are the differences between these procedures, and how do doctors determine which procedure is more suitable for individual patients? We discuss these with Dr Jayakhanthan Kolanthaivelu, Consultant Cardiologist, Cardiac Vascular Sentral KL.

Fresh off an abrupt diagnosis that throws his life into disarray, Bill Fitzpatrick is admitted to the hospital to receive a stent. Fitzpatrick guides the audience into a frantic hospital scene that ultimately results in a discharge home, though more health obstacles remain in his way outside the four walls of the hospital. His family provides an intimate look at the fear and uncertainty that accompanies a heart disease diagnosis and how perilous the road to recovery looks.Dr. Rohit Vuppuluri, a cardiologist based in Chicago, details the clinical process behind a coronary angioplasty and how stents are used to treat blocked arteries.Dr. Suzanne Steinbaum, a preventative cardiologist, spokesperson for Go Red for Women initiative through the American Heart Association and founder of Adesso, a heart prevention and wellness program for women, talks about what the recovery timeline looks like for patients who receive treatment for heart disease.MM+M, in conjunction with Cardiology Advisor, presents Me and My Heart, a special four-part podcast series delving into Fitzpatrick's turbulent patient journey, the persistence of heart disease and issues surrounding access to care in America. Check us out at: mmm-online.com Follow us: YouTube: @MMM-onlineTikTok: @MMMnewsInstagram: @MMMnewsonlineTwitter/X: @MMMnewsLinkedIn: MM+M To read more of the most timely, balanced and original reporting in medical marketing, subscribe here.

CME credits: 4.75 Valid until: 30-11-2024 Claim your CME credit at https://reachmd.com/programs/cme/balloon-pulmonary-angioplasty-issues-and-perspectives/16508/ The Midwest Regional Pulmonary Hypertension Summit occurred on October 14, 2023, in Chicago, IL. The event highlighted the management of PH with other coexisting comorbidities. Leading experts discussed the appropriate risk stratification, management of PH, updates on ERS/ERC guidelines, and optimal patient care practice.

Primary Outcomes of a Pivotal Multicenter Randomized Trial Comparing the AGENT Paclitaxel-Coated Balloon with Conventional Balloon Angioplasty for In-Stent Restenosis

In this week's episode from SCAI 2023, Dr. Aimee Armstrong of Nationwide Children's Hospital joins Dr. Pass in a live session from the annual scientific sessions of SCAI. Professor of Pediatrics at UC Davis, Dr. Frank Ing, reviews his experience with recanalization of central veins in a large pediatric cohort. Who is a candidate for this intervention? When are stents preferred vs. angioplasty alone? Should all patients having central lines removed be evaluated to prevent venous occlusion? What sort of radiation dose is associated with this intervention? Dr. Ing shares his deep knowledge in a live "Pediheart" session from Phoenix, Arizona on 5/19/23 at SCAI 2023. https://doi.org/10.1016/j.jscai.2022.100547

Commentary by Dr. Candice Silversides

What role do genetics, diet, exercise and cholesterol play in preventing and treating diseases of the heart? Learn about advances in the prevention and treatment of heart disease, coronary artery disease and heart attacks, abnormal rhythms such as atrial fibrillation, cardiac arrest, the failing heart, and diseases of the heart valves. In this program, Dr. Krishan Soni discusses interventions such as angioplasties and stents to treat heart attacks. Series: "Mini Medical School for the Public" [Health and Medicine] [Show ID: 38484]

What role do genetics, diet, exercise and cholesterol play in preventing and treating diseases of the heart? Learn about advances in the prevention and treatment of heart disease, coronary artery disease and heart attacks, abnormal rhythms such as atrial fibrillation, cardiac arrest, the failing heart, and diseases of the heart valves. In this program, Dr. Krishan Soni discusses interventions such as angioplasties and stents to treat heart attacks. Series: "Mini Medical School for the Public" [Health and Medicine] [Show ID: 38484]

What role do genetics, diet, exercise and cholesterol play in preventing and treating diseases of the heart? Learn about advances in the prevention and treatment of heart disease, coronary artery disease and heart attacks, abnormal rhythms such as atrial fibrillation, cardiac arrest, the failing heart, and diseases of the heart valves. In this program, Dr. Krishan Soni discusses interventions such as angioplasties and stents to treat heart attacks. Series: "Mini Medical School for the Public" [Health and Medicine] [Show ID: 38484]

What role do genetics, diet, exercise and cholesterol play in preventing and treating diseases of the heart? Learn about advances in the prevention and treatment of heart disease, coronary artery disease and heart attacks, abnormal rhythms such as atrial fibrillation, cardiac arrest, the failing heart, and diseases of the heart valves. In this program, Dr. Krishan Soni discusses interventions such as angioplasties and stents to treat heart attacks. Series: "Mini Medical School for the Public" [Health and Medicine] [Show ID: 38484]

What role do genetics, diet, exercise and cholesterol play in preventing and treating diseases of the heart? Learn about advances in the prevention and treatment of heart disease, coronary artery disease and heart attacks, abnormal rhythms such as atrial fibrillation, cardiac arrest, the failing heart, and diseases of the heart valves. In this program, Dr. Krishan Soni discusses interventions such as angioplasties and stents to treat heart attacks. Series: "Mini Medical School for the Public" [Health and Medicine] [Show ID: 38484]

Commentary by Dr Duk-Woo Park

Commentary by Dr. Valentin Fuster

A client reports that she has a femoral artery stent, placed in 2017. Her doctor and nurse think massage is fine. All systems go, right? Maybe, maybe not. It turns out this topic is a lot more controversial than we knew, and a lot depends on what kind of stent she got.   Sponsors:   Books of Discovery: www.booksofdiscovery.com      Host Bio:          Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist's Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Werner is also a long-time Massage & Bodywork columnist, most notably of the Pathology Perspectives column. Werner is also ABMP's partner on Pocket Pathology, a web-based app and quick reference program that puts key information for nearly 200 common pathologies at your fingertips. Werner's books are available at www.booksofdiscovery.com. And more information about her is available at www.ruthwerner.com.                                   Recent Articles by Ruth:          “Unpacking the Long Haul,” Massage & Bodywork magazine, January/February 2022, page 35, www.massageandbodyworkdigital.com/i/1439667-january-february-2022/36. “Chemotherapy-Induced Peripheral Neuropathy and Massage Therapy,” Massage & Bodywork magazine, September/October 2021, page 33, http://www.massageandbodyworkdigital.com/i/1402696-september-october-2021/34.           “Pharmacology Basics for Massage Therapists,” Massage & Bodywork magazine, July/August 2021, page 32, www.massageandbodyworkdigital.com/i/1384577-july-august-2021/34.       Resources:    Pocket Pathology: https://www.abmp.com/abmp-pocket-pathology-app   Adlakha, S. et al. (2010) ‘Stent fracture in the coronary and peripheral arteries', Journal of Interventional Cardiology, 23(4), pp. 411–419. doi:10.1111/j.1540-8183.2010.00567.x.   Al-Nouri, O. et al. (2012) ‘Failed superficial femoral artery intervention for advanced infrainguinal occlusive disease has a significant negative impact on limb salvage', Journal of Vascular Surgery, 56(1), pp. 106–111. doi:10.1016/j.jvs.2011.10.108.   Angioplasty and stent placement - peripheral arteries - discharge : MedlinePlus Medical Encyclopedia (no date). Available at: https://medlineplus.gov/ency/patientinstructions/000234.htm (Accessed: 5 April 2022).   Angioplasty and stent placement - peripheral arteries: MedlinePlus Medical Encyclopedia (no date). Available at: https://medlineplus.gov/ency/article/007393.htm (Accessed: 5 April 2022).   Cerino, V., July 15, U. public relations |, and 2015 (2015) Researchers study failed stents for peripheral artery disease, University of Nebraska Medical Center. Available at: https://www.unmc.edu/news.cfm?match=17216 (Accessed: 5 April 2022).   How Do Stents in Legs Help Unblock Arteries to Treat PAD? (no date). Available at: https://www.webmd.com/heart-disease/what-to-know-stents-legs-peripheral-artery-disease (Accessed: 5 April 2022).   Kerr, H.D. (1997) ‘Ureteral stent displacement associated with deep massage', WMJ: official publication of the State Medical Society of Wisconsin, 96(12), pp. 57–58.   Martin, R. et al. (2021) ‘Common Femoral Artery Stenting: Computed Tomography Angiography Based Long-Term Patency', Journal of Vascular Surgery, 74(2), p. 676. doi:10.1016/j.jvs.2021.05.003.   Peripheral Vascular Stent Insertion: Background, Indications, Contraindications (no date). Available at: https://emedicine.medscape.com/article/1839716-overview (Accessed: 5 April 2022). Schillinger, M. and Minar, E. (2009) ‘Past, present and future of femoropopliteal stenting', Journal of Endovascular Therapy: An Official Journal of the International Society of Endovascular Specialists, 16 Suppl 1, pp. I147-152. doi:10.1583/1545-1550-16.16.I-147.

Fixing coronary blockade without opening the chest is an attractive option to patients and their families… No surprise, Percutaneous coronary intervention PCI growing steadily since 1980s. 4 million PCIs are performed annually round the globe. A market size of 10 billion dollars!! What's the best practice in PCI? Access, Assessment, gadgets, adjunctive medications. Let's see what does the ACC/AHA guidelines recommend….

Coronary revascularization; the bread and butter of modern cardiology practice and it got new guidelines! Jointly issued by the American Heart Association, American College of cardiology and the sky, and also reviewed by American Association for Thoracic Surgery, the guideline document was published simultaneously in JACC and in circulation less than a month ago. Noteworthy that these are first guidelines on the topic in 10 years. Several practice-changing trials were published in the same period.  This long-waited document comes to replace or retire five guidelines partially or totally, not only 2011 PCI and CABG guidelines, but also will replace sections in STEMI guidelines, ACS guidelines and stable IHD guidelines. So this is a document not to miss!

Interventional Cardiologist Behnam Tehrani and Interventional Radiologist Reha Butros from Inova Health System tell us about their team approach to endovascular treatment of chronic thromboembolic pulmonary hypertension (CTEPH) with Balloon Pulmonary Angioplasty (BPA). --- CHECK OUT OUR SPONSOR RADPAD® Radiation Protection https://www.radpad.com/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/TCTEY3 --- SHOW NOTES In this episode, interventional radiologist Dr. Reha Butros, interventional cardiologist Dr. Behnam Tehrani, and our host Dr. Michael Barraza discuss chronic thromboembolic pulmonary hypertension (CTEPH) and medical, endovascular, and surgical treatment options for CTEPH. CTEPH affects patients of all different ages and medical histories. While it has been associated with prior pulmonary embolism, it can also arise in patients due to blood clotting disorders and infected pacemakers. Both Dr. Butros and Dr. Tehrani stress the importance of collaborating with pulmonary hypertension experts to identify CTEPH patients before right sided heart failure occurs. CTEPH is diagnosed with dual energy CT, which shows perfusion, and right heart catheterization, which measures blood pressure. The three treatment options discussed are medical management, balloon pulmonary angioplasty (BPA), and pulmonary thromboendarterectomy (PTE). Medical management is discussed as an initial treatment for CTEPH, while PTE can be appropriate for good surgical candidates. Finally, Dr. Butros and Dr. Tehrani present BPA as an appropriate treatment for patients of all ages. BPA over multiple sessions and increasing balloon size has been shown to be effective at promoting pulmonary artery remodeling and dilation. The doctors share their own experiences with learning BPA technique, noting that it has a learning curve, but it is ultimately rewarding when patients' quality of life is improved.

Angiogram and Angioplasty at the Vascular Center... --- Support this podcast: https://podcasters.spotify.com/pod/show/dialysisdiaries/support

Stent, Angioplasty, Atherectomy, CABG and Peripheral Bypass Grafts

Interview with Dr. Ruchit Shah, Cardiologist, IndiaLeaders from companies worldwide have expressed to me their confusion and concern around Covid 19- To help us clear many of our doubts and misconceptions and be on track for growth and good health we have with us today on this episode of The Payal Nanjiani  Leadership  Podcast - Dr Ruchit Shah who will talk to us about - Unmasking Covid- the facts you and your team must knowDr. Ruchit is a well-known Cardiologist Attached to Breach Candy, Jaslok, Saifee hospital. He is Trained in LA, the USA, and S. Korea. Dr. Shah specializes in Specialises in Angioplasty, Pacemaker, and Valve procedures. He has presented papers at national and international conferences. His motto is to give the best possible treatment to his patient.  Dr. Shah talks about:What are some of the most common myths about COVID-19✅How can we establish effective safety protocols at work?✅What steps can people take to build their immunity and stay healthy during the COVID-19 pandemic?✅What are some mental health concerns leaders must take care of during this time?……………………and much more.Live on any of your favorite podcast channels, on ALEXA and www.payalnanjiani.com

This week, we finish off our history of cardiac surgery. We invent two new procedures to deal with blockages in coronary arteries: one goes through the blockages, and the other goes around. Then, some brilliant folks invent pacemakers, and then implantable defibrillators. Check out our website!E-mail me!Say hi on Facebook!Transcripts and Sources here!