// thresholds · doses · targets · trials · classification systems · ic fellowship
Educational resource for trainees & fellows only — not for clinical use. Reference official publications and discuss with your supervisor.
| 1 French | 0.333 mm |
| OD formula | Fr ÷ 3 = OD (mm) |
| 4 Fr OD | 1.33 mm |
| 5 Fr OD | 1.67 mm - diagnostic radial |
| 6 Fr OD | 2.00 mm - standard PCI |
| 7 Fr OD | 2.33 mm - complex / rota |
| 8 Fr OD | 2.67 mm - large bore |
| 6Fr Slender OD | = 5Fr standard (0.12 mm wall) |
| 7Fr Slender OD | = 6Fr standard |
| SAR target (radial) | <1.0 (low RAO risk) |
| Radial artery avg female | 2.2-2.4 mm |
| Radial artery avg male | 2.6-2.8 mm |
| 5 Fr inner lumen | 0.056" (1.42 mm) - diagnostic only |
| 6 Fr inner lumen | 0.070" (1.78 mm) - standard PCI |
| 7 Fr inner lumen | 0.081" (2.06 mm) - two wires / rota |
| 8 Fr inner lumen | 0.091" (2.31 mm) - large bore |
| Guide length standard | 100 cm |
| Sheath standard length | 11 cm |
| Long radial sheath | 25 cm |
| Balloon shaft (RX) | 140-145 cm |
| Balloon shaft (OTW) | 150 cm |
| Min guide for rota ≥1.75 mm | 7 Fr |
| Standard diagnostic size | 4–6 Fr (5 Fr most common for radial) |
| Standard length | 100 cm |
| Tip shape | Determines coronary engagement — not sized to vessel diameter |
| Injection technique | Hand injection ONLY — NEVER power inject through a coronary diagnostic catheter |
| LCA injection volume | 6–8 mL hand injection |
| RCA injection volume | 4–6 mL hand injection |
| Flushing | Continuous heparinised saline via manifold — de-air all connections before every use |
| Waveform check | Confirm non-damped non-ventricularised before EVERY injection — every time without exception |
| Shape | Pre-formed double curve; primary curve engages LM ostium; secondary curve rests against opposite aortic wall |
| Sizes | JL3.5 / JL4 / JL4.5 / JL5 (cm between primary and secondary curve tips) |
| JL4 | Standard for most patients from femoral; normal aortic root |
| JL3.5 | Small aortic root, small frame patients, paediatric |
| JL4.5 / JL5 | Dilated aorta, horizontal heart, large patients |
| From radial | Tends to prolapse into aorta — advance into LSCA first then pull back to engage; Tiger or Ikari often preferred |
| Shape | Large U-shaped secondary curve sitting in aortic root; primary curve engages LM from below |
| Sizes | AL0.75 / AL1 / AL2 |
| Use | Anomalous LCA origin, horizontal or dilated aorta, when JL fails to engage |
| Critical disengagement rule | ADVANCE to disengage (prolapse out of ostium) — do NOT pull back; pulling drives tip deeper into LM |
| Tiger (Terumo) | Single catheter engages both coronaries without exchange; most common radial diagnostic catheter in Europe/Asia |
| Ikari Left | Specifically designed for right radial to LCA; accounts for radial artery takeoff angle |
| Advantage | Reduces catheter exchanges; efficient bilateral coronary angiography from right radial |
| Shape | Single primary curve; sits in right sinus of Valsalva; tip points anteriorly toward RCA ostium |
| Sizes | JR3.5 / JR4 (standard) / JR5 |
| From femoral | Advance to aortic valve level; withdraw with clockwise rotation; tip drops into RCA ostium |
| Limitation | Low backup — inadequate for complex RCA PCI; escalate guide early |
| Sizes | AR1 / AR2 |
| Use | Shepherd's crook RCA, anomalous RCA, high takeoff, when JR4 fails |
| Caution | Can deeply intubate RCA; dissection risk if non-coaxial — gentle technique required |
| Shape | Straight with end-hole and multiple side holes |
| Uses | RCA in difficult anatomy; right heart cath; LV gram; SVG cannulation; temporary pacing wire positioning |
| Sizes | JL3.5 / JL4 / JL4.5 / JL5 |
| JL4 6 Fr from femoral | Standard for most elective LCA PCI |
| From radial | JL3.5 often better; less backup than EBU from radial — escalate to EBU early |
| Sizes | EBU 3.5 / 3.75 / 4.0; XB 3.5 / 4.0 |
| Mechanism | Secondary curve contacts opposite aortic wall — much greater coaxial backup than JL |
| EBU 3.5 | Most common from right radial — first-choice guide for most LCA PCI from radial |
| EBU 3.75 / 4.0 | Larger aortic root or from femoral access |
| Disengagement | Pull back with counterclockwise rotation — do NOT push forward (drives tip into LM) |
| Sizes | AL0.75 / AL1 / AL2 |
| Use | Maximum backup LCA PCI; LM PCI; anomalous left coronary |
| Disengagement rule | ADVANCE to prolapse out — never pull back hard (drives deeper into LM — dissection risk) |
| Preferred for LM PCI | AL1 or AL2 in 7–8 Fr |
| IMA catheter | LIMA / RIMA engagement and graft PCI; approach LIMA from left radial (shorter path) or femoral |
| Left bypass (LCB) | SVG to LAD or LCx; ostium faces anteriorly and leftward |
| Right bypass (RCB) | SVG to RCA; ostium faces anteriorly and superiorly; JR4 gives poor coaxial alignment |
| Standard use | First-choice from femoral and radial for routine RCA PCI |
| Limitation from radial | Low backup — inadequate for complex / calcified / distal RCA; escalate to AL0.75 early |
| Backup | Best backup for RCA from radial — significantly superior to JR4 |
| AL0.75 | Standard-sized RCA or anterior takeoff — most common escalation from JR4 |
| AL1 | Larger RCA, more horizontal or superior takeoff |
| Rule | Disengage by advancing (same rule as for LCA use) |
| Hockey Stick (HS) | Gentle single curve; horizontal or anterior RCA takeoff; SVG to RCA; moderate backup |
| AR1 / AR2 | More backup than JR4; shepherd's crook RCA, high takeoff; risk of deep intubation |
| Right bypass (RCB) | Specifically shaped for SVG to RCA — JR4 gives poor coaxial alignment for SVG to RCA |
| Purpose | Selective LIMA / RIMA engagement for angiography or graft PCI |
| Approach | Femoral or left radial (shorter path to LIMA) |
| Technique | Advance into LSCA; pull back slowly with slight rotation to find LIMA ostium |
| Caution | LIMA spasm common — give IC GTN 200 mcg prophylactically before IMA PCI; do not engage deeply |
| Tip | Circular coil with multiple side holes — prevents LV perforation during power injection |
| LV gram | 30–36 mL at 12–15 mL/s |
| Aortogram | 40–60 mL at 20–25 mL/s |
| LV entry | Advance to aortic root; straighten tip across valve with clockwise rotation; confirm LV position by pressure waveform before injecting |
| Bernstein / Headhunter | Specialty angled catheters for anomalous coronaries, difficult ostia, bypass graft cannulation when standard shapes fail |
| Multipurpose (MP) | Straight end-hole + side holes; RCA difficult anatomy; right heart cath; ventriculography; temp pacing |
| LCA PCI standard from radial | EBU 3.5 (first choice) or JL3.5 |
| LCA PCI standard from femoral | JL4 or EBU 3.5 |
| LCA PCI extra backup needed | EBU 3.5 → AL1 |
| LM PCI | EBU 3.5 or AL1 (7–8 Fr preferred) |
| RCA PCI standard from femoral | JR4 |
| RCA PCI standard from radial | JR4 then escalate to AL0.75 early in any complexity |
| RCA PCI complex or distal | AL0.75 or AL1 |
| Shepherd's crook RCA | AL0.75 or Hockey Stick |
| RCA PCI maximum backup (femoral) | AL1 8 Fr |
| SVG to LAD or LCx | JL4 or LCB (left bypass) |
| SVG to RCA | RCB (right bypass) or AR1 |
| LIMA or RIMA PCI | IMA catheter |
| Anomalous LCA from right sinus | JR4 or AL from right coronary cusp |
| Anomalous RCA from left sinus | JL or AL from left cusp |
| Bifurcation PCI LCA (two wires needed) | EBU 3.5 or AL1 in 7 Fr |
| Rotablation ≥1.75 mm burr | 7 Fr minimum — EBU or AL |
| Right radial to LCA | JL tends to prolapse — advance into LSCA first then withdraw; Tiger or Ikari preferred for diagnostics; EBU preferred over JL for guide |
| Right radial to RCA | JR4 works well — shorter path; good engagement; standard first choice |
| Right radial backup LCA | EBU 3.5 significantly superior to JL4 — use as default guide for LCA PCI from right radial |
| Right radial backup RCA | AL0.75 or AL1 significantly superior to JR4 — standard escalation for any complex RCA case from radial |
| Left radial | More direct path to LCA; JL4 works well without prolapse; preferred for LIMA access |
| Femoral advantages | Larger sheaths easier (7–8 Fr); better torque transmission; preferred for max backup cases and large-bore structural |
| Torque from radial | Slightly reduced due to subclavian and axillary curves — guide selection more critical to compensate |
| Universal diameter | 0.014 inches (0.36 mm) - ALL coronary wires |
| Standard length | 180 cm |
| Exchange length | 300 cm |
| Hydrophilic wires | Slippery coating - easier navigation, less tactile feel, higher perforation risk |
| Non-hydrophilic | Better tactile feedback, safer feel, preferred in CTO for control |
| Tip shaping | Manual - 1-2 mm 45 deg routine; 90 deg / J for complex |
| Wire | Company | Tip Load | Hydrophilic? | Key Use / Notes |
|---|---|---|---|---|
| Workhorse - Routine PCI | ||||
| BMW Universal | Abbott | 0.7 g | Partial distal 30 cm | Reference workhorse. Moderate torque, atraumatic floppy tip. |
| BMW Heavy | Abbott | 0.9 g | Non-hydrophilic (tip) | Stiffer shaft than BMW Universal. Same floppy tip. Extra support in tortuous vessels. Good for calcified workhorse cases. |
| Runthrough NS | Terumo | 0.6 g | Non-hydrophilic | Excellent 1:1 torque. Very popular Europe/Asia. Atraumatic. |
| Sion | Asahi | 0.5 g | Polymer jacket (semi) | Excellent torque. Best for bifurcations / SB access. Retrograde CTO. |
| Sion Blue | Asahi | 0.5 g | Hydrophilic distal | Slippier than Sion. Tortuous vessels. Routine PCI. |
| Support / Extra Backup | ||||
| Iron Man | Abbott | Stiff shaft | Hydrophilic distal | Maximum support. Calcified / tortuous. Stiff proximal shaft. |
| Grand Slam | Abbott | Stiff shaft | Hydrophilic distal | Similar to Iron Man. Device delivery in difficult anatomy. |
| Wiggle Wire | Abbott | Stiff | Hydrophilic | Wavy distal segment - maintains guide position in RCA. Prevents prolapse. |
| Platinum Plus | Boston Scientific | Stiff shaft | Hydrophilic distal | Support wire. Excellent radiopacity from platinum tip. |
| Hydrophilic Specialty - Tortuous / Subtotal / CTO Antegrade | ||||
| Whisper MS/LS | Abbott | 0.8 g | Full hydrophilic | Very slippery. Subtle channels. Subintimal tracking. |
| Pilot 50 | Abbott | 1.5 g | Full hydrophilic | CTO antegrade first escalation. Beyond workhorse. |
| Pilot 150 | Abbott | 2.7 g | Full hydrophilic | More penetrating than Pilot 50. Mid-cap CTO antegrade. |
| Pilot 200 | Abbott | 4.0 g | Full hydrophilic | High-load hydrophilic. Hard cap antegrade. Subintimal tracking. |
| Fielder XT | Asahi | 0.8 g | Polymer jacket | CTO antegrade - intraplaque channel navigation. Low tip load. |
| Fielder FC | Asahi | 0.8 g | Polymer jacket | Similar to XT. Slightly more flexible. Channel navigation. |
| CTO Penetration - Escalating Tip Load | ||||
| Gaia 1st | Asahi | 1.7 g | Polymer jacket | Tapered 0.010" tip. Excellent 1:1 torque. BEST directional control. First CTO penetration wire. |
| Gaia 2nd | Asahi | 3.5 g | Polymer jacket | Tapered 0.010". More penetrating. Moderate-hard caps. |
| Gaia 3rd | Asahi | 4.5 g | Polymer jacket | High-load tapered tip. Hard fibrous caps. Still good torque. |
| Confianza Pro 9 | Asahi | 9 g | Polymer jacket | Tapered 0.009" tip. Maximum penetration. Hard calcified caps. Less torque than Gaia. |
| Confianza Pro 12 | Asahi | 12 g | Polymer jacket | Highest Asahi tip load. Very hard caps only. Use with microcatheter support always. |
| Miracle Bros 3 | Asahi | 3 g | Non-hydrophilic | Classic escalation series. Less refined than Gaia for modern CTO work. |
| Miracle Bros 6 | Asahi | 6 g | Non-hydrophilic | Mid-load. Harder caps. |
| Miracle Bros 12 | Asahi | 12 g | Non-hydrophilic | Very hard caps. High perforation risk. |
| Hornet 10 | Boston Scientific | 10 g | Non-hydrophilic | High stiffness. Hard proximal caps. Alternative to Confianza. |
| Hornet 14 | Boston Scientific | 14 g | Non-hydrophilic | Highest tip load available. Very hard calcified caps only. |
| Retrograde CTO - Collateral Navigation | ||||
| Sion (retrograde) | Asahi | 0.5 g | Polymer jacket | Atraumatic. Standard retrograde wire through septal collaterals. |
| Sion Black | Asahi | 0.5 g | Polymer jacket | Slightly stiffer. Better through tortuous collaterals. |
| Fielder XT-R | Asahi | 0.5 g | Polymer jacket | Ultra-low load. Most atraumatic retrograde. Epicardial collaterals. |
| Suoh 03 | Asahi | 0.3 g | Polymer jacket | Lowest tip load available. Delicate epicardial collateral navigation. |
| Specialty / Dedicated Wires | ||||
| Rotawire Floppy | Boston Scientific | - | Non-hydrophilic | Dedicated Rotablator. Floppy distal tip. Standard rotablation cases. |
| Rotawire Extra Support | Boston Scientific | - | Non-hydrophilic | Stiffer for tortuous vessels during rotablation. |
| ViperWire Advance | CSI / Abbott | - | Non-hydrophilic | Dedicated orbital atherectomy (CSI Diamondback) wire. |
| FFR significant | ≤0.80 → treat |
| FFR safe to defer | >0.80 |
| iFR significant | ≤0.89 → treat |
| RFR significant | ≤0.89 |
| iFR gray zone | 0.86-0.93 → adjudicate with FFR |
| Post-PCI FFR target | ≥0.90 |
| Post-PCI iFR target | ≥0.95 |
| QFR (wire-free) | Angiography-derived FFR - FAVOUR III positive |
| Guideline class | Class 1A ESC 2024 / ACC 2025 |
| IV infusion dose | 140 mcg/kg/min |
| IV route | Antecubital vein (NOT hand - slow transit) |
| IV steady state onset | ~60-90 seconds |
| IV duration (pullback) | Continuous during entire FFR pullback (≥2 min) |
| IC bolus - LCA | 60-150 mcg (most use 100-150 mcg) |
| IC bolus - RCA | 60-100 mcg (smaller territory) |
| IC onset | ~5-10 seconds |
| IC duration | ~30-60 seconds - spot measurement only |
| IC vs IV accuracy | IC adequate for spot FFR. IV preferred for pullback. |
| Side effects | Chest tightness, flushing, dyspnoea, AV block (esp RCA) |
| Contraindications | 2nd/3rd degree AV block (no pacer), severe asthma |
| Reversal | Spontaneous - half-life <10 seconds |
| CFR abnormal | <2.0 (some use <2.5) |
| IMR elevated CMD | >25 |
| IMR severe MVO (post-STEMI) | >40 |
| HMR elevated | >2.5 |
| RRR abnormal | <3.5 |
| IMR formula | Pd x Tmn (at hyperaemia) |
| CFR formula | Tmn rest / Tmn hyperaemia |
| Yong correction (FFR <0.80) | IMR x (1 - FFR sq) / (1 - FFR) |
| ACh epi spasm criterion | >90% reduction + symptoms + ECG changes |
| ACh micro spasm criterion | Sx + ECG + slow flow, NO visible epi spasm |
| ACh doses LCA | 2 mcg → 20 mcg → 100 mcg IC (each 20s) |
| ACh RCA max | 50 mcg (AV block risk) |
| Reversal | IC GTN 200 mcg |
| TIMI 0 | No flow past occlusion |
| TIMI 1 | Penetrates but no distal fill |
| TIMI 2 | Fills slowly, clears slowly |
| TIMI 3 | Normal flow and clearance |
| TFC frame rate (standard) | 30 fps (Gibson 1996) |
| Adjust for 25 fps labs | Multiply by 25/30 |
| Normal TFC - LAD | <36 frames |
| Corrected TFC - LAD | TFC / 1.7 (target <21) |
| Normal TFC - LCx | <22 frames |
| Normal TFC - RCA | <20 frames |
| MBG 3 (normal blush) | Contrast enters and clears normally |
| MBG 0 (no blush) | No myocardial opacification - severe MVO |
| IVUS frequency | 20-40 MHz ultrasound |
| IVUS axial resolution | 100-200 um |
| IVUS penetration | 5-8 mm (full arterial wall) |
| IVUS flush needed? | NO - works through blood |
| IVUS ostial LM? | YES - preferred modality |
| OCT wavelength | ~1300 nm near-infrared light |
| OCT axial resolution | 10-15 um (10x better than IVUS) |
| OCT penetration | 1-2 mm (superficial only) |
| OCT flush needed? | YES - contrast flush required |
| OCT ostial LM? | AVOID - cannot adequately flush |
| Guideline class (both) | Class 1A ESC 2024 / ACC 2025 |
| IVUS MLA - LM significant | <6.0 mm sq |
| IVUS MLA - non-LM significant | <4.0 mm sq |
| OCT MLA - LM significant | <4.5 mm sq |
| OCT MLA - non-LM significant | <2.5 mm sq |
| Post-stent MSA - LM target | ≥7-8 mm sq |
| Post-stent MSA - non-LM (IVUS) | ≥5.5 mm sq |
| Post-stent MSA - non-LM (OCT) | ≥4.5 mm sq |
| LM crossover - proximal LM | ≥11.4 mm sq (5yr MACE-free) |
| LM crossover - distal LM | ≥8.4 mm sq |
| LM crossover - LAD ostium | ≥8.1 mm sq |
| Calcium arc (>180 deg) | Consider modification |
| Calcium arc (>270 deg) | Modification very likely needed |
| Calcium length (>5 mm) | Consider modification |
| Calcium thickness (>0.5 mm OCT) | Modification likely needed |
| Superficial calcium (<180 um) | Rotablation preferred (surface modification) |
| Deep calcium | IVL preferred (penetrates deeper layers) |
| Nodular calcium (OCT) | Protruding nodule: IVL preferred, AVOID rota |
| NC balloon waist >18 atm | Escalate regardless of calcium arc |
| <90 deg (mild) | NC balloon 18-20 atm |
| 90-180 deg (moderate) | Scoring balloon (AngioSculpt) |
| 180-270 deg (severe) | Rotablator or IVL |
| >270 deg or nodular | IVL preferred; rota if unavailable |
| Tortuous + calcified | IVL only - rota cannot navigate |
| Normal ACT | 70-120 seconds |
| Target ACT - PCI | 250-350 seconds |
| Target ACT - PCI + GP IIb/IIIa | 200-250 seconds |
| UFH PCI dose | 70-100 units/kg IV |
| UFH with GP IIb/IIIa | 50-70 units/kg IV |
| UFH diagnostic only | 2,000-5,000 units IV |
| Protamine reversal | 1 mg per 100 units UFH given |
| Bivalirudin bolus | 0.75 mg/kg IV |
| Bivalirudin infusion (PCI) | 1.75 mg/kg/hr |
| Bivalirudin post-PCI (MATRIX) | 0.25 mg/kg/hr x 4 hours |
| Bivalirudin half-life | ~25 minutes |
| Enoxaparin de novo PCI | 0.5-0.75 mg/kg IV |
| Fondaparinux + PCI | Add UFH 85 units/kg bolus |
| IV bolus | 0.25 mg/kg IV |
| IV infusion | 0.125 mcg/kg/min x 12 h (max 10 mcg/min) |
| IC bolus (preferred) | 0.25 mg/kg IC - same dose, local delivery |
| Offset | 48-72 h (receptor-bound - longest acting) |
| IV bolus | 180 mcg/kg x 2 boluses (10 min apart) |
| IV infusion | 2 mcg/kg/min x 18-24 h |
| IC bolus | 180 mcg/kg IC single bolus |
| Renal adjustment | Reduce infusion to 1 mcg/kg/min if CrCl <50 |
| IV bolus | 25 mcg/kg IV over 3 min |
| IV infusion | 0.15 mcg/kg/min x 18-24 h |
| IC bolus | 25 mcg/kg IC |
| Reduce UFH when using | Cut to 50-70 units/kg (additive anticoagulation) |
| IC vs IV delivery | IC preferred for no-reflow - concentrated local dose |
| Routine STEMI use | NOT recommended (BRAVE-3, HORIZONS-AMI) |
| Selective use | Large thrombus, bail-out no-reflow, stent thrombosis |
| Aspirin load | 300-325 mg (chewed - faster absorption) |
| Aspirin maintenance | 75-100 mg daily indefinitely |
| Clopidogrel load (PCI) | 600 mg oral |
| Clopidogrel maintenance | 75 mg OD |
| Clopidogrel onset | 2-6 hours (variable - CYP2C19 dependent) |
| Clopidogrel offset | 5-7 days |
| Ticagrelor load | 180 mg oral |
| Ticagrelor maintenance | 90 mg BD |
| Ticagrelor onset | ~30 min (fastest oral P2Y12) |
| Ticagrelor offset | 3-5 days (reversible binding) |
| Prasugrel load | 60 mg oral |
| Prasugrel maintenance | 10 mg OD (5 mg if >75yr or <60 kg) |
| Prasugrel onset | 30-60 min |
| Prasugrel offset | 5-7 days |
| Cangrelor bolus (IV only) | 30 mcg/kg IV bolus |
| Cangrelor infusion | 4 mcg/kg/min during PCI |
| Cangrelor onset | 2 minutes (fastest) |
| Cangrelor offset | 60 minutes after stopping |
| Prasugrel - prior stroke/TIA | ABSOLUTE contraindication |
| DAPT ACS minimum | 12 months |
| DAPT elective PCI standard | 6 months |
| Strut thickness | 81 um (CoCr ML8 platform) |
| Drug / polymer | Everolimus / fluoropolymer durable coating |
| Deployment behaviour | Elongates minimally at markers |
| Diameters available | 2.25 / 2.5 / 2.75 / 3.0 / 3.25 / 3.5 / 4.0 / 4.5 / 5.0 / 5.25 mm |
| Lengths available | 8 / 12 / 15 / 18 / 23 / 28 / 33 / 38 / 48 mm |
| Nominal pressure | 8 atm |
| RBP (≤3.5 mm) | 18 atm |
| RBP (>3.5 mm) | 16 atm |
| Longitudinal strength | 3 connectors - good stability |
| Strut thickness | 74 um SV / 79 um LV (ultra-thin PtCr) |
| Drug / polymer | Everolimus / biodegradable PLGA (~4 months) |
| Deployment behaviour | Deploys AT markers - minimal foreshortening |
| Diameters available | 2.25 / 2.5 / 2.75 / 3.0 / 3.25 / 3.5 / 4.0 mm (XD up to 5.0 mm) |
| Lengths available | 8 / 12 / 16 / 20 / 24 / 28 / 32 / 38 / 44 / 48 mm |
| Nominal pressure | 8 atm |
| RBP (≤3.5 mm) | 18 atm |
| RBP (>3.5 mm) | 16 atm |
| Longitudinal strength | Best in class (Peak PCI trial) |
| Strut thickness | 81 um (CoCr + platinum core wire) |
| Drug / polymer | Zotarolimus / BioLinx durable polymer |
| Deployment behaviour | Foreshortens ~1-2 mm - account for this |
| Diameters available | 2.0 / 2.25 / 2.5 / 2.75 / 3.0 / 3.5 / 4.0 / 4.5 / 5.0 mm |
| Onyx XL diameters | 4.5 / 5.0 / 5.5 / 6.0 mm (large vessel) |
| Lengths available | 8 / 12 / 15 / 18 / 22 / 26 / 30 / 34 / 38 mm |
| Nominal pressure | 9 atm |
| RBP (≤3.5 mm) | 18 atm |
| RBP (>3.5 mm) | 16 atm |
| RBP (Onyx XL 5.0 mm) | 14 atm |
| Radiopacity | BEST in class - Pt core wire |
| Strut thickness | 60 um (≤3.0 mm) / 80 um (>3.0 mm) - thinnest available |
| Drug / polymer | Sirolimus / biodegradable PLLA polymer |
| Deployment behaviour | Foreshortens ~2-3 mm - account for this |
| Diameters available | 2.25 / 2.5 / 2.75 / 3.0 / 3.5 / 4.0 mm |
| Lengths available | 9 / 13 / 18 / 22 / 26 / 30 / 35 / 40 mm |
| Nominal pressure | 8 atm |
| RBP (≤3.5 mm) | 18 atm |
| RBP (>3.5 mm) | 16 atm |
| Key trials | BIOFLOW V - superior to XIENCE in ACS; BIOSTEMI - superior in STEMI |
| Strut thickness | 80 um (CoCr) |
| Drug / polymer | Sirolimus / biodegradable abluminal polymer |
| Diameters available | 2.5 / 2.75 / 3.0 / 3.5 / 4.0 mm |
| Lengths available | 8 / 13 / 18 / 23 / 28 / 33 / 38 mm |
| Nominal pressure | 8 atm |
| RBP | 16-18 atm depending on size |
| Feature | Good flexibility for tortuous vessels. Helical support structure. |
| BMS restenosis rate | 15-30% |
| 1st gen DES struts | >130 um (SS platform, durable polymer) |
| 2nd gen DES struts | 80-90 um (CoCr / PtCr) |
| Ultrathin DES struts | <70 um |
| Modern DES ISR rate | ~4% |
| Synergy deploys | AT markers (minimal change) |
| XIENCE deploys | Elongates minimally |
| Resolute Onyx deploys | Foreshortens ~1-2 mm |
| Orsiro deploys | Foreshortens ~2-3 mm |
| Delivery shaft (RX) | 140-145 cm |
| True bifurcation (two-stent consider) | Medina (1,1,1) / (1,0,1) / (0,1,1) — SB ostial disease present |
| Non-true bifurcation (provisional default) | Medina (1,1,0) / (1,0,0) / (0,1,0) — SB ostium usually unaffected |
| Default approach | Provisional stenting — one-stent unless compelling indication for two-stent |
| Key evidence | NORDIC I/II: no MACE benefit to routine two-stent for non-LM bifurcations. Provisional established as default. |
| OCTOBER 2023 | OCT-guided bifurcation PCI: MACE RR 0.63 vs angio — image all bifurcations |
| SB size + disease | SB diameter ≥2.5 mm with >5 mm ostial disease (not just plaque shift) |
| Large territory | First diagonal, large OM, PDA — SB loss would cause significant ischaemia |
| Anatomy | Bifurcation angle <70°, likely SB occlusion risk, long SB ostial lesion |
| LM bifurcation | LM + LAD/LCx — two-stent strongly preferred; DK Crush gold standard (DKCRUSH-V) |
| T Stenting | Angle exactly 90°; rare ideal anatomy; largely historical — TAP preferred |
| TAP | Angle <70–90°; modification of T; most common rescue/elective technique; 1–2 mm protrusion into MV |
| Culotte | Similar MV/SB calibres; wide angle; acceptable for non-LM large SB (DKCRUSH-III: DK superior to Culotte) |
| DK Crush | LM bifurcation (DKCRUSH-V); complex true bifurcation; large SB ≥2.5 mm — highest evidence base |
| 1 — Wire both vessels | Workhorse wire in MV and SB; confirm wire positions fluoroscopically in two views |
| 2 — Predilate | MV ± SB as needed; NC balloon for calcified lesions; avoid routine SB predilation (risk of dissection) |
| 3 — Stent MV | Deploy MV stent covering bifurcation; SB wire jailed inside stent struts |
| 4 — POT | Large NC balloon in proximal MV sized to proximal MV diameter; appose proximal stent + open distal strut cells for rewiring |
| 5 — Assess SB | TIMI flow, residual ostial stenosis, ECG change, haemodynamic status |
| 6a — SB acceptable | Remove SB wire. Final angiogram. Done — no further intervention needed. |
| 6b — SB compromised | Rewire SB through distal stent cell (Sion Blue or Fielder FC; not proximal cell — causes carina shift) |
| 7 — KBI | NC in MV (sized to distal MV) + NC in SB (sized to SB); inflate SB first then both simultaneously to same pressure |
| 8 — Final rePOT | NC in proximal MV only — restores proximal circularity; never inflate MV alone after KBI without this step |
| Never | Rewire SB through proximal cell / inflate MV-only post-KBI without rePOT / skip POT / assume SB acceptable without imaging if vessel ≥2.5 mm |
| 1 — Wire both vessels | Workhorse wire in MV and SB; predilate as needed |
| 2 — Position SB stent | Flush at SB ostium — zero protrusion into MV; any protrusion risks MV lumen obstruction |
| 3 — Deploy SB stent | Remove SB wire and delivery catheter |
| 4 — Stent MV | MV stent deployed covering bifurcation; jails SB stent ostium |
| 5 — Rewire SB | Through MV stent struts (Sion Blue or Fielder FC) |
| 6 — KBI + rePOT | Simultaneous NC MV + NC SB kissing balloon; final rePOT in proximal MV |
| Key limitation | Flush positioning only achievable at exactly 90°; ostial gap common at other angles — TAP preferred in most real-world cases |
| 1 — Wire both vessels | Workhorse wire in MV and SB |
| 2 — Stent MV first | Deploy MV stent; SB wire jailed |
| 3 — POT | Large NC in proximal MV — opens distal cells for SB rewiring |
| 4 — Rewire SB | Through distal MV stent cell (Sion Blue or Fielder FC) |
| 5 — Predilate SB | NC balloon through MV stent struts at SB ostium |
| 6 — Position SB stent | Advance SB stent to protrude 1–2 mm into MV — ensures full ostial SB coverage regardless of angle |
| 7 — Position MV balloon | Advance NC balloon alongside protruding SB stent in MV (not inflated yet) |
| 8 — Deploy SB stent | Deploy SB stent; remove SB delivery catheter |
| 9 — KBI + rePOT | Simultaneous NC MV + NC SB kissing balloon; final rePOT proximal MV |
| Key advantage over T | 1–2 mm protrusion guarantees complete SB ostial coverage at any bifurcation angle — preferred over T stenting in practice |
| 1 — Wire both; predilate | Workhorse wire in MV and SB; NC balloon predilation of both recommended |
| 2 — Stent SB first | SB stent protruding 2–3 mm into MV; covers bifurcation from SB side |
| 3 — Deploy SB stent | Remove SB delivery system |
| 4 — POT of SB stent | Large NC in proximal MV portion of SB stent — appose + open cells for MV rewiring |
| 5 — Rewire MV through SB stent | Rewire MV through SB stent struts; remove original MV wire after confirmed |
| 6 — Open MV cells | NC balloon through SB stent struts into MV — expand struts for stent passage |
| 7 — Stent MV through SB stent | Advance MV stent through SB stent into distal MV; deploy covering full bifurcation |
| 8 — Rewire SB through MV stent | Rewire SB through new MV stent struts (distal cell) |
| 9 — KBI + final rePOT | Simultaneous NC MV + NC SB kissing; final rePOT proximal MV |
| Double stent layer at carina | Both stents cover the bifurcation — more metal at carina; excellent ostial SB coverage; avoid in dissimilar vessel sizes or acute angles |
| 1 — Wire both; predilate SB | Workhorse wires in MV and SB; NC balloon predilation of SB strongly recommended |
| 2 — Position SB stent | SB stent protruding 3–4 mm into MV; position MV balloon alongside (not inflated) |
| 3 — Deploy SB stent | Remove SB delivery catheter; keep MV wire and balloon in position |
| 4 — CRUSH | Inflate MV balloon — crushes protruding SB stent struts against MV wall; remove MV balloon |
| 5 — Rewire SB (1st time) | Rewire SB through crushed stent struts (Sion Blue / Fielder FC); advance NC SB balloon through crushed struts |
| 6 — 1st KBI (DK step 1) | Simultaneous NC MV + NC SB — fully expands crushed SB ostium before MV stent deployed; this is the key DK step |
| 7 — Deploy MV stent | Remove SB balloon (keep SB wire); deploy MV stent over crushed + kissed SB stent ostium |
| 8 — Rewire SB (2nd time) | Rewire SB through new MV stent struts (through distal cell; not proximal) |
| 9 — 2nd KBI + final rePOT (DK step 2) | Simultaneous NC MV + NC SB kissing; final rePOT large NC proximal MV |
| DK vs standard crush | Intermediate KBI (step 6) expands crushed struts fully before MV stent — prevents strut under-coverage at SB ostium; ↓ TLR and ↓ thrombosis |
| DKCRUSH-V (NEJM 2019) | DK Crush vs provisional for LM bifurcation: 30-day MACE 5.0% vs 10.7% (p=0.02). Gold standard for LM. |
| DKCRUSH-III (2013) | DK Crush vs Culotte for non-LM bifurcations: TLF 6.2% vs 10.3%. DK superior to Culotte. |
| Never | Skip the intermediate KBI / rewire through proximal cell / attempt DK without IVUS guidance / leave without final rePOT |
| POT | NC balloon sized to proximal MV diameter; deployed at bifurcation; appose proximal stent + open distal cells for SB rewiring |
| KBI | Simultaneous NC in MV (distal MV diameter) + NC in SB (SB diameter); inflate SB first, then both simultaneously to same pressure |
| rePOT | NC in proximal MV only after KBI — restores proximal MV circularity distorted by kissing inflation |
| Balloon type for POT/rePOT | NC only — never SC for POT; prevents proximal over-expansion of non-diseased vessel |
| Standard sequence | POT → rewire SB → KBI → rePOT applies to ALL two-stent techniques |
| Critical rule | Never inflate MV-only balloon after KBI without rePOT — causes carina shift and acute SB compromise |
| SC balloon nominal | 6-10 atm |
| NC balloon range | 18-26 atm |
| Post-dilation target (NC) | 18-20 atm |
| Pre-dilation sizing | 0.5 mm undersize vs reference vessel |
| Post-dilation NC sizing | 1:1 or +0.25 mm to stent size |
| POT balloon type | NC ONLY - sized to proximal MV |
| KBI balloon type | SC ONLY - one per vessel, simultaneous deflation |
| DCB contact time | 30-60 seconds minimum |
| Balloon diameters | 1.0-5.0 mm (NC up to 6.0 mm) |
| Balloon lengths | 8 / 10 / 12 / 15 / 20 / 25 / 30 / 38 / 40 mm |
| Indeflator standard volume | 20 mL |
| Inflation mix | 50:50 contrast:saline (faster deflation) |
| Mechanism | Diamond-coated burr - differential cutting superficial calcium only |
| Operating speed | 140,000-180,000 RPM |
| Max run duration | 15-20 seconds per run |
| RPM deceleration warning | >5,000 RPM drop = too aggressive, stop |
| Max burr:artery ratio | 0.6 (never exceed) |
| Burr sizes available | 1.25 / 1.5 / 1.75 / 2.0 / 2.15 / 2.25 / 2.38 / 2.5 mm |
| Min guide - 1.25-1.5 mm | 6 Fr |
| Min guide - 1.75 mm | 6 Fr (tight) / 7 Fr recommended |
| Min guide - ≥2.0 mm | 7 Fr minimum |
| Wire required | Dedicated Rotawire ONLY (floppy or extra support) |
| Rotaflow cocktail | Heparin + verapamil 2.5-5 mg + GTN 100 mcg in saline |
| Particle size | <10 um (cleared by RES - no microembolisation) |
| Treats | Superficial calcium only |
| Mechanism | Eccentric orbiting diamond crown - rotates AND orbits - superficial + deep calcium |
| Operating speed | 80,000-120,000 RPM |
| Crown sizes available | 1.25 mm micro crown / 1.25 mm classic crown |
| Vessel range (one crown) | 2.5-4.0 mm (orbital motion adapts) |
| Min guide | 6 Fr compatible (all sizes) |
| Wire required | Dedicated ViperWire Advance ONLY |
| Speed settings | Low (80k RPM) / High (120k RPM) - use low first |
| vs Rotablator key diff | Treats deeper calcium; one crown multiple vessel sizes; no deceleration issue |
| Mechanism | Balloon-based sonic pressure waves - cracks deep + circumferential + nodular calcium |
| Initial inflation pressure | 4 atm (to deliver pulses) |
| Pulses per inflation | 10 pulses per 10-second cycle |
| Max pulses per lesion | 80 pulses (8 cycles) |
| After pulsing | Inflate to high pressure for full expansion |
| Catheter diameters | 2.5 / 3.0 / 3.5 / 4.0 mm |
| Catheter lengths | 12 mm and 22 mm |
| Min guide | 6 Fr (all sizes) |
| Wire required | Standard 0.014" workhorse wire |
| Key advantage | Treats nodular, deep, circumferential Ca; tortuous vessels; workhorse wire |
| Key trial | DISRUPT CAD III - 92.4% procedural success, 7.6% MACE at 30 days |
| 1 — Guide selection | 7 Fr (AL or EBU for LCA; AL1 for RCA); 8 Fr for ≥2.0 mm burr; ensure coaxial engagement without damping |
| 2 — Rotaflow cocktail | Heparin + verapamil 2.5–5 mg + GTN 100 mcg in saline; infuse continuously via dedicated manifold sideport throughout ablation |
| 3 — Wire exchange | Cross lesion with workhorse wire first; exchange to Rotawire Floppy (tortuous = Extra Support) via microcatheter; confirm distal position |
| 4 — ACT check | ACT ≥300 s before ablation; re-check if procedure prolonged |
| 5 — Temporary pacing | RCA / dominant vessel lesions and bradycardia-prone patients — prophylactic TPW before starting ablation |
| 6 — Confirm RPM | 140,000–180,000 RPM; verify stable on console before advancing burr to lesion |
| 7 — Pecking motion | Advance burr 1–2 mm at a time; never force; allow burr to decelerate fully between passes; each run ≤15–20 seconds |
| 8 — Monitor RPM continuously | Drop >5,000 RPM = advancing too aggressively; pull back immediately; let decelerate; re-advance more slowly |
| 9 — Burr escalation | Upsize burr if inadequate calcium modification; max burr:artery ratio 0.6; typically 2–3 passes per burr size |
| 10 — Wire exchange back | Exchange Rotawire to workhorse wire via microcatheter before balloon or stent |
| 11 — Post-rota balloon | SC balloon first at low pressure (lesion compliance now changed); then NC balloon pre-dilation; confirm adequate preparation before stenting |
| 12 — IVUS/OCT mandatory | Confirm calcium modification and adequate lumen; guide stent sizing and post-dilation endpoints |
| Never | Advance burr without rotaflow running / Ignore >5,000 RPM deceleration / Burr:artery ratio >0.6 / Use non-dedicated (non-Rotawire) wire / Skip post-rota imaging |
| Normal LVEDP | ≤12 mmHg |
| Mildly elevated LVEDP | 13-18 mmHg |
| Moderately elevated LVEDP | 19-25 mmHg |
| Severely elevated LVEDP | >25 mmHg - reduce LV gram volume + rate |
| Normal aortic systolic | 100-140 mmHg |
| Normal pulse pressure | ~40 mmHg |
| Severe AR pulse pressure | >80 mmHg (wide = hallmark) |
| Severe AS mean gradient | >40 mmHg |
| AVA severe AS | <1.0 cm sq |
| AVA very severe AS | <0.6 cm sq |
| Severe MS mean gradient | >10 mmHg |
| MVA severe MS | <1.0 cm sq |
| Normal PCWP | <12 mmHg |
| PCWP V-wave significant MR | >40 mmHg |
| PCWP V-wave severe MR | >80 mmHg |
| Normal LV - volume | 30-36 mL |
| Normal LV - rate | 12-15 mL/s |
| LVEDP >25 - volume | Reduce to 20-25 mL |
| LVEDP >25 - rate | Reduce to 10-12 mL/s |
| Poor EF (<30%) | 20-25 mL at 10 mL/s or omit entirely |
| Severe MR (3+/4+) | May increase to 35-40 mL (rapid escape via MR) |
| Severe AS + high LVEDP | 20 mL at 10 mL/s or omit - use echo data |
| Renal impairment | 15-20 mL diluted (50:50) or omit |
| Aortogram volume | 40-60 mL |
| Aortogram rate | 20-25 mL/s |
| PSI limit (LV gram) | 600-900 PSI |
| Max safe contrast formula | 3-4 x eGFR (mL) |
| Low-risk contrast:Cr ratio | <3.7 |
| Type I | Extraluminal crater only. No extravasation beyond adventitia. LOW risk. Observe + serial echo. |
| Type II | Pericardial/myocardial blush - no jet extravasation. LOW-MOD risk. Prolonged balloon + heparin reversal. |
| Type III | Frank jet ≥1 mm. HIGH risk. Tamponade ~50%. Balloon tamponade + covered stent + pericardiocentesis. |
| Type III cavity spill | Free flow into chamber or pericardium. CRITICAL. Surgical emergency. Autotransfusion. |
| Type III incidence | ~0.1-0.2% of all PCI |
| Covered stent options | Graftmaster (Abbott) 2.8-4.8 mm / PK Papyrus (Biotronik) 2.5-5.0 mm |
| Type A | Minor radiolucency, no flow limitation. Observe. |
| Type B | Parallel tracts / double lumen, no flow limitation. Consider stent if large. |
| Type C | Extraluminal cap - dye retained. Usually stent - propagation risk. |
| Type D | Spiral dissection. Urgent stenting - cover entire dissection. |
| Type E | Persistent reduced flow (TIMI <3). Urgent stenting. |
| Type F | Total occlusion (TIMI 0). Emergency - MCS standby. |
| Aortocoronary dissection | STOP injecting. CT aorta urgently. Cardiac surgery immediately. |
| Stenting direction | Distal to proximal - seal from below, work upward |
| Format | (pMV, dMV, SB) - 1=disease present, 0=none |
| True bifurcation examples | (1,1,1) / (1,0,1) / (0,1,1) |
| Non-true bifurcation | (1,1,0) / (1,0,0) - SB rarely compromised |
| Ostial LAD disease | (0,1,0) - main vessel only, no LM, no SB |
| Threshold for SB treatment | >75% SB stenosis after MV stenting + POT + TIMI <3 |
| Grade 0 | No thrombus |
| Grade 1 | Possible thrombus - hazy blush only |
| Grade 2 | Small (<0.5x vessel diameter) |
| Grade 3 | Medium (0.5-2x vessel diameter) |
| Grade 4 | Large (>2x vessel diameter) |
| Grade 5 | Total occlusion from thrombus |
| Aspiration threshold | Consider Grade 4-5 in STEMI or stent thrombosis |
| Acute ST | 0-24 hours |
| Subacute ST | 1-30 days |
| Late ST | 30 days - 1 year |
| Very late ST | >1 year |
| Definite ST | Angiographic/pathological confirmation + clinical event |
| Probable ST | Unexplained death <30 days or MI in stented territory |
| Possible ST | Unexplained death >30 days |
| Acute ST mortality | 20-45% |
| #1 cause acute ST | Stent underexpansion (MSA below target) |
| Type I - focal | <10 mm in-stent. DCB first choice (Class 1). |
| Type II - diffuse intra-stent | >10 mm within stent margins. DES re-stenting preferred. |
| Type III - proliferative | >10 mm beyond stent edges. DES or consider CABG. |
| Type IV - total occlusion | TIMI 0. Treat as CTO. CABG if PCI fails. |
| Stage A - At risk | Not yet in shock. High-risk features (large MI, prior HF). |
| Stage B - Beginning | Mild hypotension/tachycardia. Compensated. Normal lactate. |
| Stage C - Classic | Hypoperfusion, elevated lactate. Needs active intervention. |
| Stage D - Deteriorating | Failing despite initial support. Escalating vasopressors. |
| Stage E - Extremis | Cardiac arrest / near-arrest. CPR or full mechanical support. |
| Grade 1+ | Faint incomplete LV opacification - clears each beat |
| Grade 2+ | Full but faint LV opacification - clears slowly |
| Grade 3+ | LV density equals aortic density |
| Grade 4+ | LV denser than aorta - opacifies on first beat |
| Grade 1+ | Small LA opacification - clears each beat |
| Grade 2+ | Moderate LA - less dense than LV |
| Grade 3+ | LA as dense as LV - persists |
| Grade 4+ | LA denser than LV - pulmonary veins opacify |
| SYNTAX low | 0-22 → PCI acceptable |
| SYNTAX intermediate | 23-32 → Heart Team decision |
| SYNTAX high | >32 → CABG preferred |
| STS low surgical risk | <4% |
| STS intermediate | 4-8% |
| STS high surgical risk | >8% → favour PCI / TAVI |
| GRACE high risk | >140 → invasive <2 hours |
| GRACE intermediate | 108-140 → invasive <24 hours |
| GRACE low risk | <108 → invasive <72 hours |
| TIMI high risk | 5-7 points |
| TIMI intermediate | 3-4 points |
| TIMI low risk | 0-2 points |
| HEART score high risk | ≥7 → early invasive |
| HEART score intermediate | 4-6 |
| HEART score low risk | ≤3 → safe discharge |
| HAS-BLED high bleed | ≥3 |
| DAPT score - prolong | ≥2 (ischaemic benefit > bleed risk) |
| DAPT score - standard | <2 (no net benefit from prolonging) |
| ARC-HBR major criteria | OAC use, eGFR <30, Hb <11, prior ICH, active malignancy, cirrhosis |
| PRECISE-DAPT high bleed | ≥25 → consider short DAPT 3-6 months |
| IABP - access sheath | 7-8 Fr femoral (standard) |
| IABP balloon sizes | 25 / 34 / 40 / 50 cc (by patient height) |
| IABP size <162 cm | 34 cc |
| IABP size 162-182 cm | 40 cc (most common) |
| IABP size >182 cm | 50 cc |
| IABP size paediatric | 25 cc |
| IABP augmentation support | 0.5 L/min - reduces afterload, augments diastolic pressure |
| IABP trigger modes | ECG (R-wave), pressure, pacemaker, internal |
| IABP timing (1:1) | Inflate at dicrotic notch; deflate just before systole |
| IABP-SHOCK II (2012) | No mortality benefit in cardiogenic shock |
| Impella 2.5 | 2.5 L/min - 13 Fr femoral |
| Impella CP | 3.5-4.0 L/min - 14 Fr femoral |
| Impella 5.0 | 5.0 L/min - surgical cutdown |
| Impella 5.5 | 5.5 L/min - surgical cutdown |
| Impella RP | Right-sided support - RV failure |
| DanGer Shock 2024 | Impella CP: 180-day mortality 45.8% vs 58.5% - FIRST MCS mortality benefit |
| Impella contraindications | Severe AR, LV thrombus, mechanical AVR |
| VA-ECMO | Full cardiopulmonary bypass equivalent |
| ECMO-CS (2023) | VA-ECMO - no mortality benefit vs standard care |
| ECPELLA | ECMO + Impella = LV venting to prevent distension |
| IABP sheath | 7-8 Fr femoral |
| Impella CP sheath | 14 Fr femoral |
| Impella 5.0 / 5.5 | Surgical cutdown - 21 Fr |
| VA-ECMO arterial | 15-21 Fr femoral arterial |
| VA-ECMO venous | 21-25 Fr femoral venous |
| TAVI transfemoral | 14-16 Fr (most modern systems) |
| TAVI Edwards SAPIEN 3 | 14 Fr (small/regular) / 16 Fr (large) |
| TAVI Evolut (Medtronic) | 14 Fr EnVeo sheath (all sizes) |
| BAV (standard) | 8-12 Fr femoral arterial |
| BAV (large balloon) | 12-14 Fr femoral arterial |
| Pericardiocentesis drain | 6-8 Fr pigtail catheter |
| Rotablator guide min | 7 Fr (≥1.75 mm burr) |
| Atherectomy / IVL | 6 Fr (OA and IVL - all sizes) |
| Indication | Bridge to TAVI / SAVR in severe AS; palliation; haemodynamic stabilisation pre-procedure |
| Access route | Retrograde femoral arterial (most common) |
| Sheath size | 8-14 Fr depending on balloon size used |
| Wire required | 0.035" stiff wire (Amplatz Extra Stiff or Lunderquist) |
| Wire position | Deep in LV apex (prevents wire prolapse during inflation) |
| Balloon sizes available | 18 / 20 / 22 / 23 / 25 mm diameter |
| Starting balloon size | Usually 2-4 mm smaller than annulus (undersizing intentional) |
| Balloon length | 40-60 mm (standard BAV balloons) |
| Key balloon brands | NUCLEUS (NuMed) / Z-MED II (NuMed) / TRUE Dilation (Bard) |
| Inflation medium | 1:4 contrast:saline mix (fast inflation / deflation) |
| Inflation technique | Rapid inflation / deflation during RV pacing at 180-220 bpm |
| Pacing rate (standstill) | 180-220 bpm (reduces cardiac output to minimise balloon ejection) |
| Pacing wire position | RV apex via femoral or jugular venous access |
| Inflation time | 3-5 seconds (shorter = less haemodynamic compromise) |
| Number of inflations | Typically 2-4 inflations, escalating size if needed |
| Expected result | Reduce mean gradient by ~50% (e.g. 60 mmHg → ~30 mmHg); improve AVA by 0.2-0.4 cm sq |
| Restenosis rate | ~50% at 6 months - NOT a definitive treatment |
| Major complications | Severe AR (3-4%), stroke (~2%), vascular access (~5-10%), haemodynamic collapse |
| Contraindications | Severe AR (≥3+), LV thrombus, bicuspid valve (relative) |
| Indication | Severe mitral stenosis (MVA <1.0 cm sq) - suitable anatomy (Wilkins score ≤8) |
| Access route | Transseptal puncture (femoral venous) |
| Sheath size (venous) | 8-14 Fr femoral venous (Inoue: 12 Fr; double balloon: 2x 9 Fr) |
| Technique | Inoue balloon (most common) or double-balloon technique |
| Inoue balloon sizes | 24 / 26 / 28 / 30 mm (size = patient height / 10 + 10) |
| Inoue sizing formula | Height (cm) / 10 + 10 = starting size (mm) |
| Wire used | 0.025" Inoue coiled wire (specific to system) |
| Transseptal needle | Brockenbrough needle through Mullins sheath - Fossa ovalis |
| Target MVA post-procedure | >1.5 cm sq or doubling of baseline MVA |
| Endpoint - stop if | MR increases by ≥1 grade OR MVA >1.5 cm sq achieved |
| Wilkins score ≤8 | Good morphology - good outcome likely |
| Wilkins score >10 | Unfavourable - consider surgical commissurotomy |
| Restenosis | ~30-40% at 5-7 years (better than BAV - more durable) |
| Confirm wire position | Verify in true lumen — not subintimal before anything else |
| Try smaller balloon | 1.0–1.25 mm compliant balloon; lowest crossing profile available |
| Ensure fully deflated | Check indeflator shows negative pressure before pushing |
| Technique | Slow steady forward pressure with slight rotation — do not stab repeatedly |
| Try shorter balloon | 8 mm vs 15 mm; less friction, less bulk to push through lesion |
| Deep seat guide | Advance 1–2 cm into proximal vessel for more coaxial support — dissection risk with AL catheters |
| Upsize guide — LCA | JL4 → EBU 3.5 → AL1 |
| Upsize guide — RCA | JR4 → AL0.75 → AL1 |
| GuideLiner / Guidezilla | Monorail extension catheter inside guide catheter; extends guide 20–25 cm into vessel; balloons and stents pass through it; advance carefully — tip edge can dissect |
| Key distinction | Microcatheter = over wire inside vessel (wire support and exchange only — devices cannot pass through it). GuideLiner = inside guide catheter (balloons and stents pass through it) |
| Support wire exchange | Exchange workhorse for Iron Man or Grand Slam via OTW balloon or microcatheter |
| Exchange-length wire | 300 cm — maintains position during device exchanges |
| Microcatheter | Finecross or Caravel advanced close to lesion — wire support at lesion site; enables wire exchange without losing position |
| Soft or fibrous lesion | Tornus catheter — screw-motion microcatheter drills through resistant lesions by rotation |
| Calcified lesion | Rotablator — burr:artery ≤0.6; dedicated Rotawire required; 7 Fr guide for ≥1.75 mm burr |
| Nodular or circumferential Ca | IVL (Shockwave) — workhorse wire; 6 Fr compatible; treats nodular, deep, circumferential calcium |
| Arc >270° or nodular | IVL preferred over rotablation |
| ELCA | Excimer laser — fibrous or in-stent resistant lesion; crosses and ablates simultaneously |
| Child-in-mother + anchor | GuideLiner deep into vessel plus anchor balloon in side branch simultaneously — maximum support configuration |
| OTW balloon | Better pushability than monorail — full-length shaft transmits force more efficiently |
| Femoral + 8 Fr AL | Maximum backup — last resort if all radial escalations fail |
| Stage the procedure | If all above fails, stop — do not perforate trying; review CT coronary, plan rota or IVL at next sitting |
| Force balloon repeatedly | Without escalating — causes proximal dissection |
| Leave without crossing | Underexpanded stent = #1 cause of ISR and stent thrombosis |
| High-load CTO wire without microcatheter | Naked Confianza Pro = perforation risk |
| Reshape wire tip | More angulated (45–90°) to direct away from diagonal or side branch |
| Change angiographic view | RAO cranial for mid-LAD to separate from diagonal |
| Torque before advancing | Small clockwise or anticlockwise adjustments while gently pushing — do not force |
| Second workhorse wire | Intentionally place into diagonal to occupy its ostium — acts as doorstop; primary wire preferentially tracks into LAD |
| Brief balloon inflation | Inflate small balloon in diagonal at 1–2 atm briefly to physically close ostium while advancing main wire |
| Sion Blue / Runthrough | Better torque than BMW for subtle channel navigation |
| Fielder FC | 0.8 g, polymer jacket — designed for intraplaque channel navigation in subtotal occlusion |
| Pilot 50 | 1.5 g, full hydrophilic — first escalation with penetrating capability |
| Pilot 150 | 2.7 g, higher load hydrophilic — mid-cap CTO antegrade |
| Gaia 1st | 1.7 g, tapered 0.010", non-hydrophilic, excellent 1:1 torque, best directional control — first CTO penetration wire |
| Gaia 2nd | 3.5 g, same tapered tip — moderate to hard caps |
| Confianza Pro 9 / 12 | 9–12 g, tapered 0.009", maximum penetration, hard calcified caps — ALWAYS use with microcatheter |
| Advance microcatheter | Finecross or Caravel as close to lesion as possible over workhorse wire |
| Wire exchange in catheter | Remove workhorse; reshape penetrating wire tip inside microcatheter — support at lesion gives much better directional control |
| Staining test | Inject contrast through microcatheter if unsure of position — staining = subintimal; stop and reassess |
| ADR — Stingray system | Flat OTW balloon advances subintimally to distal cap; side exit ports allow Stingray wire to puncture back into true lumen — gold standard controlled re-entry |
| STAR technique | Less controlled, more side branch loss — avoid unless necessary |
| Retrograde approach | Via septal collaterals (Sion, Sion Black) or epicardial (Fielder XT-R, Suoh 03); requires dual arterial access |
| Stiff wire without microcatheter | Naked Confianza Pro — how vessels perforate |
| Assume subintimal is acceptable | Always inject contrast through microcatheter if uncertain of position |
| Give up before jailing competitor | Simple second wire often solves the problem — try it first |
| Underexpanded stent | #1 cause of stent thrombosis and ISR — must be fixed before leaving the lab; cannot accept suboptimal result |
| Guide coaxiality | Confirm JR4 / JL4 well seated; deep seat gently 1–2 cm for more coaxial support |
| Balloon fully deflated | Indeflator at negative pressure confirmed before pushing |
| Technique | Slow steady push with slight rotation |
| Second workhorse wire | Place alongside primary wire — stiffens system, reduces compliance, helps guide stay seated; try NC balloon again |
| Iron Man or Grand Slam | Via OTW balloon or microcatheter — stiff shaft straightens tortuosity, reduces system compliance |
| Insert through guide | Advance tip into proximal to mid vessel — 20–25 cm extra support; balloon pushed from within coronary not from ostium |
| Caution | Advance carefully — tip edge can dissect; never force past resistance |
| RCA from radial | Switch JR4 to AL0.75 or AL1 — significantly better backup |
| LCA from radial | Switch JL4 to EBU 3.5 or AL1 |
| Upsize to 7 Fr | Wider lumen, more stable platform |
| Second wire into side branch | PDA, posterolateral, or diagonal |
| Anchor balloon | 1.5–2.0 mm compliant at 2–4 atm in side branch — anchors guide firmly, prevents backing out |
| Advance NC while anchored | Deflate and remove anchor balloon once NC balloon past the problem area |
| OTW NC balloon | Better pushability — full-length shaft vs monorail segment |
| Femoral 8 Fr AL1 | Far more backup than any radial configuration — uncomfortable but underexpanded stent is serious |
| Leave without post-dilating | Underexpansion = primary cause of stent thrombosis |
| Force balloon repeatedly | Without escalating — proximal dissection risk |
| Damped waveform | Blunted low-amplitude trace — catheter tip against vessel wall or in small vessel — pull back immediately, do NOT inject |
| Ventricularised waveform | LV-shaped arterial trace — guide has passed beyond ostium into vessel — emergency, pull back immediately |
| Critical rule | NEVER inject contrast through a damped or ventricularised catheter — dissection risk |
| Pull guide to aortic root | Confirm waveform normalises completely before any injection |
| Re-engage carefully | Clockwise rotation; confirm coaxial position with gentle test injection ONLY when waveform completely normal |
| If dissection suspected | Do not inject forcefully again; wire distal vessel carefully; IVUS to define extent before stenting; stent distal to proximal |
| Aortocoronary dissection | Stop ALL injections; pull guide back; emergency CT aorta; cardiac surgery immediately; do NOT stent into aorta |
| Inject with damped waveform | This is how ostial dissections start |
| Ignore ventricularisation | Deep guide in coronary causes dissection and no-reflow |
| Pull AL catheter back forcefully | Disengage AL by ADVANCING (prolapse out) — pulling back drives it deeper |
| Wire position | Confirm still across lesion and not prolapsed |
| Dissection flap | Flow limitation from mechanical obstruction requires stenting — NOT vasodilators |
| Thrombus | Check for visible filling defect; check guide catheter not obstructing ostium |
| Pharmacological treatment | ONLY after mechanical causes excluded — giving vasodilators first risks treating the wrong cause |
| Adenosine | 30–60 mcg IC bolus — repeat as needed; very short half-life; safe |
| Verapamil | 100–200 mcg IC — CCB; excellent for microvascular spasm |
| Nicardipine | 100–200 mcg IC — dihydropyridine CCB; potent |
| Nitroprusside | 50–200 mcg IC — most potent vasodilator; use cautiously (hypotension risk) |
| Delivery route | IC via infusion catheter or microcatheter wedged distally — maximum local effect |
| IC GP IIb/IIIa | If thrombus-mediated: abciximab 0.25 mg/kg or eptifibatide 180 mcg/kg IC — platelet-rich thrombus resistant to vasodilators alone |
| Haemodynamic support | If BP falling: norepinephrine; consider Impella if severe LVEF impairment |
| SVG PCI mandatory | Distal embolic protection device (FilterWire EZ or SpideRX) — Class I before any SVG PCI; prevents distal embolisation |
| Nitrates for RV infarct no-reflow | RV is preload-dependent — nitrates cause haemodynamic collapse |
| Vasodilators before excluding mechanical | Treat the correct cause first |
| Ignore no-reflow | Can cause large MI, haemodynamic compromise, and death if untreated |
| Wire ladder | BMW / Runthrough → Fielder FC (0.8g) → Pilot 50 (1.5g) → Pilot 150 (2.7g) → Gaia 1st (1.7g) → Gaia 2nd (3.5g) → Gaia 3rd (4.5g) → Confianza Pro 9 (9g) → Confianza Pro 12 (12g) |
| Microcatheter rule | Always use from Pilot 50 onwards — never advance stiff wire without microcatheter support |
| Stingray balloon system | Flat OTW balloon advances subintimally to distal cap; side exit ports allow Stingray wire to puncture back into true lumen — gold standard controlled re-entry |
| Access required | Dual arterial access — femoral + radial or bilateral femoral |
| Septal collateral wires | Sion or Sion Black (0.5g, atraumatic) |
| Epicardial collateral wires | Fielder XT-R (0.5g) or Suoh 03 (0.3g, lowest tip load available) |
| Crossing techniques | Retrograde true lumen; CART; reverse CART (most common — antegrade balloon opens subintimal space for retrograde wire) |
| Dual injection mandatory | Bilateral coronary injections to define distal cap and collateral anatomy |
| Proximal cap ambiguity | IVUS of donor vessel to define true proximal cap location |
| J-CTO score | 0 = easy → 4+ = very difficult; predicts procedural complexity and time |
| CTO PCI success rates | 85–95% at experienced centres — requires dedicated training and proctorship |
| Recognition | TIMI ≤1 in SB after MV stent; ECG change; haemodynamic instability if large territory at risk |
| Act if SB ≥2.5 mm | Significant territory (diagonal, OM, PDA) — intervene; <2.0 mm minor territory — usually conservative |
| First step | Confirm MV wire still in good position; keep any jailed SB wire in place; do not remove wires |
| 1 — Rewire SB | Through distal MV stent cell (not proximal cell — causes carina shift); Sion Blue or Fielder FC |
| 2 — Balloon SB | 1.5–2.0 mm SC balloon at low pressure through stent struts to restore flow; upsize to NC matching SB if residual significant |
| 3 — Assess result | TIMI 3 + residual <75% + small territory = conservative acceptable; IVUS/OCT if available |
| TAP preferred | Advance SB stent 1–2 mm into MV; position MV NC alongside; deploy; KBI + rePOT |
| Not Culotte/DK at rescue | Culotte and DK require planned two-stent setup — TAP is the appropriate unplanned rescue two-stent option |
| IVUS/OCT post-intervention | Confirm stent apposition, no edge dissection, MV result not compromised |
| Never | Assume SB loss acceptable without assessment if ≥2.5 mm / Use hydrophilic wire as first rewire wire / Rewire through proximal stent cell / Deploy SB stent without confirming MV wire position |
| THE WIRE | NEVER REMOVE THE WIRE from the vessel — it is your lifeline back in and may be tamponading the hole. Applies to all perforation types without exception. |
| Inflate balloon at site | 4–6 atm — same balloon being used; tamponades hole while you organise definitive treatment |
| Call for help | Senior operator, extra nursing, alert cardiac surgery immediately |
| Bedside echo NOW | Most important immediate assessment — pericardial effusion drives every decision |
| Stop heparin + GP IIb/IIIa | Stop infusion; no reversal agent for GP IIb/IIIa but stop further dosing |
| Appearance | Extraluminal crater only; no extravasation beyond adventitia |
| Management | Conservative — serial echo at 30 min, 1 h, 4 h; reverse anticoagulation if effusion appears |
| Appearance | Pericardial or myocardial blush — no jet extravasation |
| Prolonged balloon inflation | 5–10 min at perforation site; reverse heparin: protamine 1 mg per 100 units UFH |
| Outcome | Most resolve with prolonged balloon alone — serial echo to confirm |
| Appearance | Frank jet extravasation ≥1 mm |
| Reverse ALL anticoagulation | Protamine for UFH; stop bivalirudin (t½ 25 min); platelet transfusion if GP IIb/IIIa running |
| Pericardiocentesis | Subxiphoid approach; 18G spinal needle toward left shoulder at 45°; echo-guided; confirm with agitated saline; insert 6–8 Fr pigtail drain; autotransfuse drained blood |
| Covered stent — ≥2.5 mm vessel | Graftmaster (Abbott) 2.8–4.8 mm / PK Papyrus (Biotronik) 2.5–5.0 mm (lower crossing profile) |
| Embolisation — <2.5 mm vessel | Autologous clot (2–3 mL blood, clot 5 min, inject); fat pledgets; coil (most precise); thrombin; Gelfoam — via microcatheter |
| Do NOT remove wire | May be tamponading the exit hole — wire removal can open the hole |
| Effusion not accumulating | Inflate balloon proximally to reduce flow; watch echo; may withdraw wire slowly while monitoring |
| Effusion growing | Wedge microcatheter at exit point; suction can seal small wire perforations; embolise if suction fails |
| Withhold heparin | 4–6 hours minimum after confirmed sealing on echo |
| DAPT | Do NOT stop — stent thrombosis risk too high; antiplatelet agents do not cause pericardial haemorrhage like anticoagulants |
| Failure to seal | Ongoing haemorrhage despite covered stent + pericardiocentesis; effusion collecting faster than can be drained |
| Alert early | Do not wait until patient is in extremis — early surgical notification saves lives |
| Remove the wire | Repeated for emphasis — the single most critical rule in perforation management |
| Delay echo | Pericardial effusion assessment drives every decision |
| Give thrombolytics / stop DAPT | Absolute contraindications — one causes haemorrhage, the other causes stent thrombosis |
| NEVER REMOVE THE WIRE | First rule — always; wire is your access to the distal vessel |
| Haemodynamics | Assess immediately — LM dissection can decompensate in seconds |
| Call simultaneously | Senior operator + anaesthetics + cardiac surgery — all at once |
| Pre-emptive MCS | Consider Impella CP before stenting if haemodynamics borderline — stabilise first, then fix |
| Wire LCx FIRST | Before any LM stenting — if LM stented with LCx unwired, LCx may be jailed with no access back |
| IVUS pullback | From distal LAD to LM if time permits (60–90 sec) — defines extent; identifies LM ostial involvement; guides stent landing zones; LM typically 4.0–5.0 mm |
| DISTAL TO PROXIMAL always | Seal the dissection from below and work upward — NEVER start at proximal end (pushes dissection further distally) |
| 1 — Distal LAD | Stent distal LAD extent if significant |
| 2 — LAD to LM junction | Stent LAD to LM junction |
| 3 — Into LM | Stent into LM if needed to cover proximal extent |
| 4 — POT | NC balloon sized to proximal LM after LM stent |
| 5 — Assess LCx | TIMI 3, no ostial compromise → leave; ostial compromise → balloon via rewired strut; TIMI <3 → stent (TAP or DK-Crush) |
| 6 — KBI if LCx treated | SC balloons, simultaneous deflation |
| 7 — Final POT | Final proximal optimisation |
| LM body dissection | Stent back 2–3 mm proximal to dissection entry; IVUS confirms landing zone |
| LM ostial dissection | Stent extends 1–2 mm into aorta; flare proximal edge with NC balloon; technically demanding — senior operator |
| Aortocoronary dissection | STOP all injections; pull guide back gently; emergency CT aorta; cardiac surgery immediately; NEVER stent into aorta |
| IVUS confirmation | LM MSA ≥7–8 mm²; no edge dissection; adequate apposition |
| Angiography | TIMI 3 in LAD and LCx; no residual dissection in multiple views |
| Remove the wire | First rule — always |
| Start stenting from proximal end | Pushes dissection further distally |
| Stent LM without LCx wire | May jail LCx with no way back in |
| Stent into aortic root | If aortocoronary dissection — cardiac surgery emergency |
| Leave without IVUS confirmation | LM result must be verified before leaving lab |
| Presentation | Crushing chest pain + ST elevation in stented territory within 24 h — treat as STEMI; activate cath lab immediately |
| Mortality | 20–45% |
| Aspirin 300 mg | If not already given |
| Reload P2Y12 | Even if on DAPT — inadequate loading may be the cause; if on clopidogrel switch to ticagrelor 180 mg or prasugrel 60 mg (no prior stroke/TIA) |
| Heparin 5000 units IV | Bolus now |
| Underexpansion | Most common — MSA below target at original procedure |
| Malapposition | Struts not in contact with vessel wall |
| Uncovered dissection | Edge dissection missed at original procedure |
| DAPT failure | Non-compliance, poor absorption, CYP2C19 poor metaboliser (~30% clopidogrel patients) |
| Macroplaque prolapse | Thrombus extruding through stent struts |
| Heparin | 70–100 units/kg IV; ACT 250–350 seconds |
| First wire | Workhorse wire first — thrombotic occlusion usually crosses easily (soft thrombus) |
| Avoid hydrophilic wire first | May pass subintimal through thrombus without realising |
| Small to moderate | Direct balloon angioplasty 1:1; restore flow; assess; stent only if needed |
| Large (TIMI grade 4–5) | Aspiration thrombectomy — Export AP or Fetch 2; 60 mL syringe continuous suction; advance to proximal edge; slowly withdraw while aspirating |
| Massive | Aspiration plus IC GP IIb/IIIa before ballooning |
| Rationale | Platelet-rich thrombus resistant to lysis alone |
| Abciximab | 0.25 mg/kg IC bolus then IV infusion 12 h |
| Eptifibatide | 180 mcg/kg IC bolus — faster offset if bleeding concern |
| Delivery | IC preferred — concentrated local dose at thrombus site |
| Underexpansion | High pressure NC balloon 20–26 atm |
| Malapposition | High pressure post-dilation |
| Edge dissection | Additional stent to cover |
| Stent fracture | Re-stent the segment |
| Normal appearance | DAPT failure is the cause — maximise antiplatelet therapy |
| Switch from clopidogrel | Upgrade to ticagrelor 90 mg BD or prasugrel 10 mg OD |
| Platelet function testing | VerifyNow — confirms inadequate P2Y12 inhibition |
| CYP2C19 genotyping | Identifies poor metabolisers who cannot activate clopidogrel |
| Leave without finding the cause | Treat both the thrombosis AND the underlying mechanical problem |
| Stop DAPT perioperatively | Highest stent thrombosis risk is first 30 days |
| Hydrophilic wire first through thrombus | Use workhorse wire first — hydrophilic may pass subintimally |
| Manual compression | Firm sustained pressure above inguinal ligament; call for help; large-bore IV ×2; stop anticoagulation |
| Heparin reversal | Protamine 1 mg per 100 units UFH given |
| Bloods | FBC, coagulation, crossmatch 4–6 units packed red cells |
| Mechanism | Puncture above inguinal ligament — vessel cannot be compressed against femoral head; retroperitoneal space accommodates litres before external signs appear |
| Clinical features | Hypotension disproportionate to visible blood loss; back or flank pain; hip flexion (psoas irritation); ipsilateral femoral nerve palsy (anterior thigh numbness + weakness) |
| Imaging if stable | Urgent CT abdomen/pelvis with contrast — defines location, extent, active extravasation |
| Management if stable | CT angiography then IR embolisation or covered stent |
| Management if unstable | Emergency vascular surgery — do not delay for further imaging |
| Contained haematoma | Sustained manual or mechanical compression (FemoStop/C-clamp) ×20–30 min; serial haematocrit |
| Expanding haematoma | Re-sheath vessel; inflate balloon in femoral artery at puncture site; covered stent if fails; surgical exploration last resort |
| Pseudoaneurysm | Ultrasound-guided thrombin injection (first line); manual compression under US; surgical repair if >3 cm, expanding, or infected |
| AV fistula (small) | Observe — may close spontaneously over weeks |
| AV fistula (large) | Endovascular covered stent or surgical repair — high-output cardiac failure if large |
| Puncture over femoral head | Fluoroscopy to confirm position relative to femoral head |
| Ultrasound-guided access | Standard of care (ACC/AHA) — confirms anterior wall puncture, avoids high sticks |
| Micropuncture technique | 21G needle first; confirm position before upsizing to standard sheath |
| Puncture above inguinal ligament | Without recognising retroperitoneal haematoma risk |
| Assume hypotension is vasovagal | After femoral PCI — always exclude RPH first |
| Delay CT if RPH suspected | Early diagnosis = IR embolisation; late = emergency surgery |
| Call for help | Senior operator, nursing, anaesthetics |
| Stop procedure | Leave wire in place; pull balloon or device back into guide catheter |
| Monitor assessment | ECG rhythm, ST changes, BP, SpO2; check pressure waveform (damped or ventricularised?) |
| Defibrillator | Pads on and charged — ready to use immediately |
| VF or pulseless VT | Defibrillate 200 J biphasic immediately; CPR; adrenaline 1 mg IV every 3–5 min; amiodarone 300 mg after 3rd shock |
| Complete heart block (RCA PCI) | Atropine 0.5–1 mg IV; transvenous pacing — always have pacing available before dominant RCA PCI |
| Sustained VT with pulse | Amiodarone 150 mg IV over 10 min; synchronised cardioversion 100–200 J if haemodynamically compromised |
| Contrast outside vessel | Perforation — balloon tamponade immediately; manage per perforation protocol |
| No flow in treated vessel | Acute vessel closure / stent thrombosis — rewire + IC GP IIb/IIIa |
| Dissection flap | Urgent stenting |
| Air in coronary | 100% O2; forceful IC contrast injection to disperse; aspiration catheter if large bolus; usually resolves in minutes; atropine / pacing if RCA air causes bradycardia |
| Pericardial effusion + RV collapse | Tamponade — pericardiocentesis NOW |
| New RWMA | Acute vessel closure |
| RV dilatation + D-sign | RV failure or massive PE |
| Hyperdynamic small LV | Hypovolaemia |
| Global hypokinesis | Cardiogenic shock |
| Norepinephrine | 0.1–0.3 mcg/kg/min — first-line vasopressor (SOAP II) |
| Dobutamine | 5–20 mcg/kg/min — inotrope for low CO with preserved BP |
| Atropine | 0.5–1 mg IV if bradycardia component |
| IABP | Rapid insertion 7–8 Fr femoral; reduces afterload, augments diastolic; buys time |
| Impella CP | DanGer Shock 2024 mortality benefit; 14 Fr femoral; 3.5–4.0 L/min; pre-position for very high-risk cases |
| VA-ECMO | Full cardiopulmonary support; cardiac arrest or refractory shock; alert perfusion team EARLY — do not wait until arrest |
| RV infarct (inferior STEMI) | IV fluids aggressively — preload-dependent; AVOID nitrates, diuretics, morphine; restore AV synchrony; Impella RP for refractory RV failure |
| Air embolism | 100% O2; forceful IC contrast to disperse; aspiration catheter if large; usually resolves in minutes |
| Tamponade | Pericardiocentesis subxiphoid; 6–8 Fr pigtail drain; autotransfuse collected blood; do NOT give IV fluids as primary treatment |
| LVEF <25% / LM / last vessel | Pre-position Impella CP; anaesthetic standby |
| Dominant RCA PCI | Temporary pacing wire pre-inserted |
| Every complex case | Large-bore IV confirmed; blood crossmatched if high-risk; defibrillator pads on before starting |
| Annual occupational limit | 20 mSv/year (5-year average) |
| Single year maximum | 50 mSv |
| Eye lens annual limit | 20 mSv/year (cataracts recognised) |
| Extremities limit | 500 mSv/year |
| Pregnant - foetal limit | 1 mSv (remainder of pregnancy) |
| Air kerma - skin erythema | 2 Gy (2,000 mGy) - alert patient |
| Air kerma - desquamation | 5 Gy - dermatology follow-up |
| Air kerma - severe skin injury | 10 Gy |
| Air kerma - necrosis risk | 15 Gy |
| Inverse square law | 2x distance = 1/4 dose |
| Low-dose fluoro frame rate | 7.5 fps (50% dose vs 15 fps) |
| Cine vs fluoro dose | Cine = 10-15x more dose per second |
| LOCM osmolality | 500-900 mOsm/kg |
| IOCM osmolality | ~290 mOsm/kg (iso-osmolar - least nephrotoxic) |
| Standard iodine conc. | 320-370 mg I/mL |
| CA-AKI definition | Cr rise ≥0.3 mg/dL within 48-72 h |
| Max safe contrast formula | 3-4 x eGFR (mL) |
| Low-risk contrast:Cr ratio | <3.7 |
| Hydration first line | 0.9% NaCl 1 mL/kg/hr pre + post procedure |
| NAC (PRESERVE 2018) | No benefit vs placebo - not routinely recommended |
| Allergy premedication | Prednisolone 50 mg at 13 h / 7 h / 1 h before |
| Anaphylaxis treatment | Adrenaline 0.5 mg IM (1:1000 solution) |
| DEFER (2001) | Safe to defer PCI if FFR >0.75-0.80 - 5yr MACE equivalent to treated group. Established FFR deferral safety. |
| FAME (2009) | FFR-guided PCI: MACE 13.2% vs 18.3% angio-guided. Less stents, less contrast, less cost. |
| FAME 2 (2012) | FFR-guided PCI superior to medical therapy alone (FFR ≤0.80) - less urgent revascularisation (1.6% vs 11.1%). |
| DEFINE-FLAIR (2017) | iFR noninferior to FFR at 1yr (MACE 6.8% vs 7.0%). Fewer side effects. No adenosine needed. |
| iFR-SWEDEHEART (2017) | iFR noninferior to FFR (6.7% vs 6.1%). Faster, better tolerated, equivalent outcomes. |
| FLAVOUR (2022) | FFR-guided PCI noninferior to IVUS-guided for intermediate stenosis - MACE 10.8% vs 12.3%. |
| IVUS-XPL (2015, Lancet) | IVUS-guided PCI (long LAD/LCx): TLF 2.9% vs 5.8% angio at 1yr. Larger stent area. Direct evidence for LAD ostial PCI. |
| ULTIMATE (2018, JACC) | IVUS-guided: TVF 2.9% vs 5.4% at 1yr. Benefit driven entirely by preventing stent underexpansion. |
| RENOVATE-COMPLEX (2023) | IVUS-guided complex PCI: TVF 7.7% vs 12.3% angio at 1yr. Class 1A basis for complex PCI imaging. |
| ILUMIEN IV (2023, NEJM) | OCT-guided PCI: TVF 7.4% vs 8.9% angio at 2yr (p=0.035). First RCT showing OCT clinical benefit. |
| OCTOBER (2023, NEJM) | OCT-guided bifurcation PCI: MACE RR 0.63 vs angio. OCT superior specifically for bifurcations. |
| OCTIVUS (2023) | OCT noninferior to IVUS for complex PCI - MACE 5.2% vs 4.9%. OCT is a valid alternative. |
| RIVAL (2011, Lancet) | Radial vs femoral: major vascular complications 1.4% vs 3.7%. Trend to mortality benefit in STEMI subgroup. |
| MATRIX (2015, NEJM) | Radial in ACS: NACE 15.2% vs 17.4% femoral. Bleeding reduction AND mortality benefit. |
| RIFLE-STEACS (2012) | Radial in STEMI: 30-day MACE 13.6% vs 21.0% femoral. Radial now standard for STEMI. |
| COMPLETE (2019, NEJM) | Staged complete revascularisation vs culprit-only in STEMI: CV death/MI 7.8% vs 10.5% at 3yr. |
| CULPRIT-SHOCK (2017, NEJM) | Culprit-only PCI in CS + MVD: 30d death/RRT 45.9% vs 55.4% immediate multivessel. Less is more acutely. |
| BIOVASC (2022) | Immediate complete revascularisation noninferior to staged complete at 1yr MACE. |
| COMFORTABLE AMI (2012) | DES vs BMS in STEMI: TLF 4.3% vs 8.7% at 1yr. DES now standard in STEMI. |
| EXAMINATION (2012) | DES vs BMS in STEMI: patient-oriented composite endpoint 11.9% vs 14.2%. DES superior. |
| IABP-SHOCK II (2012, NEJM) | IABP in CS: 30-day mortality 39.7% vs 41.3% control. NO mortality benefit. Practice-changing negative trial. |
| DanGer Shock (2024, NEJM) | Impella CP in STEMI-CS: 180-day mortality 45.8% vs 58.5%. FIRST MCS device to show mortality benefit. RCT. |
| ECMO-CS (2023, NEJM) | VA-ECMO in CS: no mortality benefit vs standard care at 30 days. More limb ischaemia in ECMO group. |
| SOAP II (2010, NEJM) | Norepinephrine vs dopamine in shock: fewer arrhythmias, trend to lower mortality with norepinephrine. First line vasopressor. |
| NORDIC (2006) | Provisional = two-stent for non-LM bifurcations. No MACE difference at 6 months. Provisional first established. |
| BBC ONE (2010) | Provisional superior: MACE 8.0% vs 15.2% two-stent. Less contrast, faster. BBC ONE established provisional standard. |
| EBC TWO (2016) | Culotte noninferior to provisional for non-LM at 1yr. Two-stent acceptable when needed. |
| DKCRUSH-III (2013) | DK-Crush superior to Culotte for non-LM true bifurcations: TLF 6.2% vs 10.3%. |
| DKCRUSH-V (2019, NEJM) | DK-Crush superior to provisional for LM bifurcation: 30-day MACE 5.0% vs 10.7% (p=0.02). Gold standard for LM. |
| EXCEL (2016, NEJM) | LM PCI noninferior to CABG at 3yr. Controversy at 5yr (mortality 13.0% vs 9.9% CABG). Endpoint dispute. |
| NOBLE (2016, Lancet) | LM: CABG superior to PCI at 5yr - MACE 29% vs 19%. CABG preferred for complex LM disease. |
| CURE (2001, NEJM) | Clopidogrel + aspirin vs aspirin alone in NSTEMI: CV death/MI/stroke 9.3% vs 11.4%. Established DAPT. |
| PLATO (2009, NEJM) | Ticagrelor vs clopidogrel: CV death/MI/stroke 9.8% vs 11.7%. ALL-CAUSE mortality reduced. Ticagrelor now standard for ACS. |
| TRITON-TIMI 38 (2007, NEJM) | Prasugrel vs clopidogrel: less MI/ST (9.9% vs 12.1%) but more major bleeding. Contraindicated prior stroke/TIA. |
| CHAMPION PHOENIX (2013, NEJM) | Cangrelor: 26% RRR in periprocedural MI and stent thrombosis vs clopidogrel. |
| AUGUSTUS (2019, NEJM) | AF + ACS/PCI: dropping aspirin from triple therapy = less bleeding, same ischaemic events. Dual therapy standard. |
| TWILIGHT (2019, NEJM) | Ticagrelor monotherapy after 3 months DAPT: less bleeding, noninferior ischaemic outcomes. De-escalation evidence. |
| DISRUPT CAD III (2021, JACC) | IVL (Shockwave): procedural success 92.4%, MACE 7.6% at 30 days. Safe and effective for severe calcium. |
| ORBITAL II (2014) | Orbital atherectomy: procedural success 97.7%, in-hospital MACE 2.2%. |
| BIOFLOW V (2017) | Orsiro (ultrathin sirolimus) superior to XIENCE in ACS subgroup: TLF 6.2% vs 10.9%. |
| BIOSTEMI (2019) | Orsiro superior to BES in STEMI: TLF 4.7% vs 9.4% at 1yr. Best STEMI stent evidence. |
| ABSORB III (2015) | Bioresorbable scaffold (BRS Absorb): higher TLF + scaffold thrombosis vs DES. Absorb withdrawn from market. |
| BMC 2025 - Lee et al. | Crossover stenting: 2yr MACE 2.6% vs floating wire 13.5% vs precise ostial 15.8% (p<0.05, n=116). |
| OPTIMAL (ACC 2026) | IVUS vs angio for LM PCI: no significant MACE difference at 2.9yr. Angio reasonable when IVUS unavailable. |
| D2B target - primary PCI | <90 min from first medical contact |
| D2B - transfer from non-PCI centre | <120 min total ischaemic time |
| Fibrinolysis threshold | >120 min anticipated delay → lyse then transfer (pharmacoinvasive) |
| Hold ticagrelor before CABG | 5 days |
| Hold prasugrel before CABG | 7 days |
| Hold clopidogrel before CABG | 5 days |