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CME Released: 8/24/2010
Valid for credit through: 8/24/2011, 11:59 PM EST
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Contemporary management of coronary artery disease relies increasingly on percutaneous techniques combined with medical therapy. Although percutaneous coronary intervention (PCI) can be performed successfully in most lesions, several difficult lesion subsets continue to present unique technical challenges. These complex lesions may be classified according to anatomic criteria, including extensive calcification, thrombus, and chronic occlusions, or by location, such as bifurcations, saphenous vein grafts and unprotected left main. PCI of these lesions often requires novel devices, such as drug-eluting stents, hydrophilic guidewires, distal protection balloons or filters, thrombectomy catheters, rotational atherectomy, and cutting balloons. An integrated approach that combines these devices with specialized techniques and adjunctive pharmacologic agents has greatly improved PCI success rates for these complex lesions.
The catheter-based treatment of coronary artery disease (CAD) has advanced substantially over the past 40 years and is currently a safe, reliable and effective therapeutic option for the millions of patients with Cad worldwide. Combined with medical therapy, percutaneous coronary intervention (PCI) reduces anginal symptoms and improves ischemia.[1,2] In select patients, particularly those with acute ST-segment elevation myocardial infarction (STEMI), primary PCI also prolongs survival.[3] The applicability of PCI to patients with CAD continues to expand, with recent data suggesting clinical equipoise between PCI and CABG surgery in complex coronary anatomy, including ostial or mid-shaft left main CAD.[4] These benefits notwithstanding, certain lesion subsets present unique challenges to the interventional cardiologist and are still associated with high rates of restenosis, technical difficulty, and procedural complications.[5] Successful PCI of these complex lesions requires advanced techniques, approaches, or adjunctive devices, and is usually performed by experienced operators at high-volume centers. In this Review, we outline the difficulties and contemporary interventional techniques utilized for six types of complex lesion ( Table 1 ).