CARAT Tutorials: Percutaneous Coronary Intervention

Stenting Variations

We will use a complex LAD bifurcation stent procedure to illustrate the CARAT stent documentation process, specifically a Culotte procedure:

First, the ‘Edit Menu’ is opened by right-clicking on a free part of the drawing area.

‘Stent’ is then selected, and the ‘Stent Edit Mode’ is shown to be active in the lower left corner of the screen. Click and hold the left mouse button and trace the first stent, proximal to distal, from the proximal LAD into the proximal diagonal. The stent being edited or described is shown in pink; stents that are inactive and not being modified are shown in blue.


Figure 1.

The next step is to right-click on the stent and select ‘Interventional Detail’ (see Figure 1).  On the top of the Interventional Detail drop-down the point of origin and termination of the stenting procedure is automatically specified. In the middle of the drop-down menu ‘Devices’ is then selected. You are now ready to document the sequence of events during the Culotte procedure.

Predilatation of the proximal LAD and proximal diagonal lesions is performed and documented by selecting ‘Balloon’ under ‘Device Type’; select the balloon used from the drop-down menu and enter diameter, length, and pressure detail.

Next, ‘Add’ is selected, the ‘Device Type’ is changed to ‘Stent’, and ‘Device Model’ and parameters are entered as shown (Figure 2).


Figure 2.

The final step (with respect to this stent) was to post-dilate. This is documented by selecting ‘Add’, then ‘Balloon’ under ‘Device Type’ and finally the balloon size and inflation particulars (Figure 3). When done, select “OK”.


Figure 3.

The second stent is then drawn from a point close to the heel of the previous stent, but now extending past the second LAD lesion (Figure 4). Again notice that the origin and termination points of this second stent are automatically recorded.


Figure 4.

The ‘Interventional Detail’ option is selected after right-clicking on the new stent. The first step is to document the pre-dilatation by selecting ‘Balloon’ under Device Type and entering the balloon deployment particulars (Figure 4).

Next, ‘Add’ is selected and ‘Stent’ is chosen as the ‘Device Type’. Once again, the ‘Device Model’ and deployment details are entered, as in Figure 5.


Figure 5.

Finally, the post-dilatation balloon is documented by selecting ‘Add’, then selecting ‘Balloon’, then finally selecting the Device ‘Model’ and deployment particulars (see Figure 6).


Figure 6.

At this point, we also want to document that this was indeed a bifurcation procedure and we wish to specify the strategy used. (See Figure 7) ‘Culotte’ is selected in the ‘Bifurcation’ Strategy section, and we will also specify that a Kissing Balloon procedure was used.

Figure 7.

Balloon Angioplasty (POBA) Documentation

Interventional procedures that do not use a stent are entered in a different way. Specifically, this is accomplished while in the ‘Lesion Edit Mode’, rather than the ‘Stent Edit Mode’. In this example an 80% circumflex lesion is the POBA target (Figure 8 and 9).


Figure 8.

The lesion intervened upon is right-clicked and the ‘Intervention Detail’ option is selected as shown in Figure 8 for this mid-circumflex 80% lesion.


Figure 9.

The ‘Devices’ menu tab is selected, allowing entry of the procedure detail in a manner similar to that described for stenting (Figure 9).

After the POBA procedure, the lesion intervened upon is designated by the letter “B” at the site of the lesion, and the device and pre and post lesion detail is filed on the final report’s ‘Balloon Summary’ table (Figure 10).

All of the information entered is now carefully tabulated in the ‘Stent and Balloon Tables’ in the upper left portion of the report, while other important information on the technique used is automatically recorded in the ‘Comments’ section below.


Figure 10.

Key Points

• Stents should be drawn from proximal to distal while in the ‘Stent Edit Mode’.

• Sequential procedural detail is presented in table on the report. Our deliberate attempt is to present all anatomic and procedural detail on a single page.

• If a patient returns for another procedure in the future, only stent information is carried forward from the intervention description.


 

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