Essential Concepts in Cardiovascular Intervention

American Journal of Neuroradiology

Deepak L. Bhatt, ed. London: Remedica; 175 pages, 51 illustrations. $45.

This brief paperback is presented in a question-and-answer format. There are 11 chapters by multiple authors. Each chapter begins with 10 or so multiple-choice questions. Some of the questions include angiographic images or images from other ancillary studies. The answers to the questions are then discussed in detail in the pages that follow with an extensive list of references.

This book has little to offer diagnostic or interventional neuroradiologists, neurologists, or neurosurgeons. The obvious audience is interventional cardiologists. The chapters include coronary anatomy, vascular biology of atherosclerosis, evaluation of coronary lesions, intervention for acute coronary syndromes, equipment selection, and interventional devices, as well as adjunctive pharmacology. One chapter is entitled “Hemodynamics” and deals exclusively with coronary and cardiovascular physiology. Cerebral hemodynamics, however, are not discussed.

The single noncardiac chapter covers endovascular therapy for peripheral and cerebrovascular disease, and four of the 10 questions relate to the treatment of carotid artery stenosis. The other six discuss other peripheral vascular interventions, such as angioplasty for iliac artery stenosis. The four carotid questions are generally accurate and well-referenced, with two notable exceptions. Two misconceptions are perpetuated here. First, the natural history risk for stroke for patients with asymptomatic carotid stenosis greater than 80% is grossly overestimated. The authors quote a 5% annual rate from a single center study from the 1980s (Chambers and Norris) and ignore more recent data from the randomized carotid endarterectomy trials (Asymptomatic Carotid Atherosclerosis Study [ACAS] and the Asymptomatic Carotid Surgery Trial) that found no relationship between the degree of stenosis and stroke risk. In ACAS, higher degrees of stenosis were paradoxically associated with lower rates of stroke than patients with 60–70% stenosis.

The second misconception is the need for distal embolic protection devices. The authors state that it is “almost unethical” to not use these devices. Although plaque debris is sometimes retrieved from these devices, large case series have not shown any significant reduction in stroke risk with their use. There are complications associated with their use, such as vessel dissection and spasm. Some vascular anatomies preclude their use. It must be noted that the senior author of this chapter developed the distal protection device featured here and may have a substantial financial conflict of interest.

In summary, this book presents a potpourri of information related primarily to endovascular cardiac intervention in a question and answer format. There is very limited information relevant to specialists in neuroimaging and neurovascular intervention.