In April 2024, WellSpan York Hospital hosted the second annual Women Treating High Risk Indicated Patients (WHiP) conference, bringing together 21 female cardiologists while streaming to more than 75 cardiologists in five countries. This event, spearheaded by Dr. Rhian Davies , Interventional Cardiologist and Director of Complex Coronary Care at WellSpan, focused on advancing skills in complex coronary care and fostering a supportive network among women in this male-dominated field.
Dr. Davies was joined by two of her interventional cardiologist colleagues, Dr. Kate Kearney , Director of the Cardiac Cath Lab at the Heart Institute at University of Washington Medical Center, and Dr. Margaret McEntegart , Director of Complex PCI and CTO programs at Columbia University Irving Medical Center.
The conference, hosted by ASAHI Intecc, featured live case demonstrations of complex chronic total occlusion procedures. In this video, hear Dr. Davies explain different aspects of the procedure just as she did during the live event.
WellSpan York Hospital is recognized as one of the leading hospitals in the nation for chronic total occlusion percutaneous coronary interventions, performing over 250 such procedures each year. This annual conference not only highlights the hospital's commitment to excellence in cardiac care but also its dedication to supporting the professional growth of female cardiologists in a challenging specialty.
This was a day in our well spanned cardiac cath lab where female interventionists from across the country and globally were invited to Wellspan to sit and watch cases and learn from each other with a goal of building a community. This was roughly 20 to 30 female interventionists in person and a little over 100 virtually attended. We started by reviewing some of the cases that had been previously done to particular patients depending on the clinical scenario and those who are having recurrent symptoms or found to have new symptoms showing 100% blockages of territory. With their coronary system and the patients were brought back in during this planned procedure day for the treatment of those blockages. course of the morning into the afternoon we discussed 3 or 4 different cases before tabling those patients just so we all had a clear plan as to what we were going to do very similar to what we would normally do for patients who present for procedures that are high risk or more complex and involved. So prior to a patient coming into the cath lab, we prep the cath lab in its entirety so that we're equipped for any aspects of what that case may entail, meaning we know what kind of imaging catheter we're going to use. We know what guiding catheters we're going to use. We have already sorted out which access we're going to obtain in the patient in order to successfully get the procedure done. Additionally, we'll prep any any equipment that may be more involved, such as mechanical circulatory sport and that sort of thing that may be advantageous for the case depending on what anatomy the patient has and or what sort of um underlying heart function they have. I did put the vitamin for the right. I did. I'm gonna start with the first. He Access is gonna be first obtained uh for the patient so we'll typically either get femoral or radial access uh in more of these complex or CTO cases we tend to get two access sites in this part. In case we opted to get a femoral and a radial, uh, and then once we have access, we usually check some basic hemodynamics, meaning blood pressure and or some filling pressures depending on the clinical scenario so that we know where we're starting at in case the patient is to get sick during the procedure or note some changes so that we have a good baseline as to where they are at the start of the case. And then myself and the assistant at the table in this situation, it is my tech who is injecting and we're doing simultaneous injections or dual angiograms because it's a CTO or 100% blockage. And we do our set up shots by taking an image of the arteries that supply collaterals to the territory in addition to the artery that actually has the 100% blockage in it, and then we sort out which avenues we're going to take to get that blockage opened. So we'll start with a couple setup shots in various angles to make sure that we're getting all that appropriate information up front. And then from there we'll kind of dictate which views we'll use to help correct or fix that blockage. And we have all these views saved. Thank you. All right. Yeah. Yeah. After we have the setup shots completed or those dual angiograms completed, we'll evaluate them and kind of flip through frame by frame is what we would call it, and that is what we are doing here. We're going frame by frame to look at where those collaterals are as best in the projections that we obtained so as to treat them and do it in the. est risk possible. So what we do is we look at where those collaterals are coming from, whether they're coming from septals, they're coming from failed bypass grafts. They're coming off of what we call epicardials, and that's ranking those collaterals from lowest risk to highest risk. So we'll try to start either with failed bypass grafts or graphs that are going down, followed by septals, and lastly take on epicardials to get us backwards if we need to. Versus starting with an an agreed approach or a forwards approach, and as we kind of go through the procedure, that plan can change because sometimes some collaterals look better than other ones until you get in there, and other times collaterals are hidden and then once you get in there they start to show themselves a little bit more and then you're able to use them to your advantage. Do they want to reset it we'll just keep going. OK, I'm here with you. Mhm Mhm Yes. Yeah, let's go back over to the Iore. Once we have the wire across the lesion, whether that's forwards or backwards, we'll determine the next steps. Those next steps typically include ballooning or what we call pre-dilating the blockage. We sometimes start with smaller balloons and then get gradually bigger depending on how large of an area it is or how big that vessel appears. Then we would take an imaging catheter in. Typically for these procedures I'm using what we call intravascular ultrasound or IVIS that gives us the actual plaque morphology, plaque burden, the size of the vessel, as well as if additional modalities are necessary to clean out the blockage that we've now worked through. Those could include calcium modification tools that may include arthrectomy, shock wave, wolverine. Um, or different specialty gear to help kind of lessen the burden of the plaque that's in the vessel that's resulted in the blockage from developing. From there after we've appropriately modified everything, we'll often reimage to make sure that it's truly modified, and then that's when we start. Considering placement of stents and or if there's been stents put in from before, maybe we would use drug coded balloons or other therapy modalities to clean out the area and to make sure we have an appropriate result. The downside of the Xian wire is it's really, really soft and super nice to do this sort of thing. 15 to 3, which is a trap here. What you What parts came up the guy, yeah, it's just like it's sometimes that's the hardest part for me when they have double CTOs as to which one I'm gonna go after first. It's a lot easier to be like dogmatic and be like, I'm gonna do this, this and this and then you end up not helping the patient and you get stuck and not having any vessel open at the end of the case or losing your collaterals because you cause hematomas and and stuff. All right. 16, you want 25 maybe something long and 15 yeah that went very easy. er 16 5. I just. Same Thank you So we just that so far as competitive for you. 12 5. Yeah 14 for 16. 163 We would then go back in with our imaging catheter. That imaging catheter, after we've prepped the vessel, we've re-evaluated that the vessel is to the best of our ability, cleaned out. And then we put a stent in, we would go back in after that stent is in. Uh, to make sure that we have the result that we were aiming to obtain. And if not, what we need to do additional, such as taking larger balloons or we call NC balloons to further dilate that stent. In a typical case, we'll do an average run of Run 2 to 4 times our imaging catheter down the heart artery, um, and sometimes more than that, particularly in folks who have underlying kidney disease so as to prevent them from having a high burden of contrast in their system, which could lead to worsened kidney function, that's the other advantage of using IVIS or intravascular ultrasound. Once the coronaries are to the appropriate level of or what our goal was at the start of the case is when we would take our final angiograms and then we would determine whether or not anything else needs to be done, such as if we found another lesion or a blockage while we were in there or if there's anything else that's kind of going on where we might need to reevaluate heart pressures and that sort of thing. And then ultimately as long as that's all looking reasonable and we're happy with our results and the patient's doing well, that's where we would remove our in coronary equipment, that being the the wires or balloons and guide extensions. And subsequently take the guiding catheters and that gear all out of the body and then determine what we are going to do with our access location. So sometimes we'll send the patient back to recovery with sheets still in place because they have peripheral vascular disease, in which case we try to avoid sometimes putting vascular closure devices in. And they will have what we call manual hemistasis in the post-op area where the sheets were removed there and pressure applied for a duration of time depending on the size of the axis. Alternatively, if the areas that we went into are healthy, we can put a vascular closure plug in or a small suture device in. Those are typically used for the femoral arteries, whereas the radial artery would get a TR band, which is a transradial compression system that applies pressure to the radial artery. And then I'll take that 1:35. I think there's some where I'm assuming your actual vacation is, it looks like there's enough disease it's sort of making it hard to tell, so. Shanna run through back end and then we'll be. So. 4 thank you. Mhm Maybe First out 25 talker. Yeah 06 Yeah, like I'm sure it's just a pill, but it's because it's huge, it's a huge pill. And maybe you wanna This 823. 12 6 And we'll take a 3530. It's like a 3 time. I'm just gonna take a little picture here. I saw Um, airport. A few weeks ago where she was pulling a work for or somebody on um and came out with a J on it and it. Yeah.
