Complex coronary cases
Multivessel Staged PCI of CTO LAD and LCx OM2 using Orbital Atherectomy and DES with OCT Guidance – June 2017
Views 4321

62 year old male with recent onset CCS Class III angina with a positive SPECT MPI for inferior and anterior ischemia. A Cardiac Cath on May 2, 2017 revealed III Vessel CAD: 80% RCA-RPL1, 100% calcified proximal LAD with distal vessel filling via bridge collaterals, 90% calcified LCx OM2 bifurcation and SYNTAX score of 40.5. After Heart Team discussion, CABG was recommended, but declined. Patient underwent successful PCI of RCA branch RPL1 using Promus Premier DES. Now planned for multivessel staged PCI of CTO LAD and LCx OM2 using orbital atherectomy and DES with OCT guidance.

Moderator: Sameer Mehta, MD

1:32:33

Q&A
Q
In reviewing your conference coronary live cases, which of the live cases did you find most instructive?
A.

I found the most educational and instructive case was severely angulated calcified subtotal circumflex which had a potential of causing coronary perforation. This case was done very cautiously after crossing the lesion with Fielder wire and then exchanged for the Rotawire and used 1.25mm burr very cautiously. All went very well and we highlighted various points in performing Rota in these extremely angulated heavily calcified lesions.


Q
And among Structural Heart Disease?
A.

The case of Valve-in-Valve TAVR using Evolut R was very educational providing tips of accurate Supra annular deployment of the Evolut R Valve leading to minimal residual gradient.


Q
While teaching your students, which CTO score do you emphasize?
A.

J-CTO score is s simple and very useful tool in predicting procedural success as well rough time it will take for CTO lesion to cross. I usually ask the interventional fellows to calculate J-CTO score as part of pre-procedure discussion and analysis.


Q
Is the Ellis Proximal Cap Ambiguity a useful practical tool?
A.

Yes, proximal blunt tip, which is the ambiguous proximal cap certainly is an adverse factor for CTO recanalizaion.


Q
Should today's case have been performed with Rotablator?
A.

Both Rotational as well Orbital atherectomy can be used interchangeably in majority of calcified lesions. Hence yes, Rota could have also been used in today's case.


Q
What made you select Orbital Atherectomy?
A.

We have shown Rotational Atherectomy so many times in our live webcasts, hence, we wanted to teach the steps of performing Orbital Atherectomy (OA) correctly. That was simply the reason to use OA in the current case.


Q
In which aspect is Orbital Atherectomy simpler than Rotational Atherectomy?
A.

Orbital Atherectomy is simple to set up, simple to learn and all device parts & controls are on the table (field).


Q
Besides the degree of calcification (less for Orbital) and relative simplicity of use, can you define some indications where Orbital Atherectomy is more effective than Rotational Atherectomy?
A.

Orbital Atherectomy has the advantage of treating multiple lesions in a vessel by single burr by increasing the speed (80,000 to 120,000). Also, there is no need for temporary pacemaker with OA even during RCA or dominant Circumflex ablations. Our study of 20 cases with OCT have shown that in circumferential calcified lesions, Orbital Atherectomy makes deep cuts which results in better stent expansion compared to Rotablator.


Q
How do you find the specialty guide wires for Orbital Atherectomy in comparison to Rotablator wire?
A.

Viper wire by its virtue of 0.012" size, is better steerable and can be advanced in the vessel in the majority of cases rather than exchanging with the workhorse wire which we usually do with Rota wire (which is 0.009" and is very flimsy). Also in some proximal lesions, Viper wire can also be used to deliver balloons and Stents post ablation, avoiding inserting another 0.014" wire.


Q
Have you had any cases of stubborn no reflow with Orbital Atherectomy?
A.

Yes, we have seen some refractory slow flow even with Orbital Atherectomy but it certainly occurs less than with Rota. Treatment of slow flow remains the same with both devices; avoid hypotension, use vasodilators and in some cases IABP insertion for a few hours.


comments

Join the Discussion

One thought on “Multivessel Staged PCI of CTO LAD and LCx OM2 using Orbital Atherectomy and DES with OCT Guidance – June 2017”

  1. Shivan says:

    Excellent you are doing a great job


Leave a Reply

Your email address will not be published. Required fields are marked *

suggestion
Suggestions
PCI of Complex LAD D1 Bifurcation with Mini-crush Technique
Tags: | |
Views 316

Case and Plan: 84-year-old female presented with new onset CCS Class III angina with positive SPECT MPI for multivessel ischemia. A Cardiac Cath on January 28, 2020 revealed 3 V CAD: 90% proximal RCA, subtotal large proximal LAD/Diagonal bifurcation lesion, 80% small LCx-OM1, SYNTAX Score of 21 and LVEF of 55%. Patient had a successful […]


OCT Guided Complex Intervention of LM and Long Calcified Aneurysmal LAD – January 2020
Tags: | |
Views 493

Case and Plan: 76-year-old female presented with new onset CCS Class III angina with positive SPECT MPI for mild lateral ischemia. A Cardiac Cath on January 6, 2020 revealed 3 V + LM CAD: 70% distal LM, 80% proximal LAD/D1 bifurcation, 80% long calcified aneurysmal mid LAD, 80% LCx-OM1, SYNTAX Score of 35 and LVEF […]


OCT Guided PCI of Calcified LAD Bifurcation using 2-Stent + OA – December 17, 2019
Views 782

Case and Plan: 67-year-old male controlled NIDDM, presented with CCS Class I angina and positive stress echo for multi vessel ischemia. A Cardiac Cath on August 9, 2019 revealed 3 V CAD: calcified 80% mid LAD and D2 bifurcation, 70% distal LAD, CTO mid RCA and CTO proximal LCx, SYNTAX Score of 38 with moderate […]


Imaging Guided Calcified LM PCI with Interactive Discussion about EXCEL Trial Results by Dr. Gregg Stone and Dr. John Puskas – November 2019
Tags: | | |
Views 1409

Case and Plan: 77 year-old male with stable class II angina and exertional dyspnea was noted to have calcified 90-95% left internal carotid artery stenosis on carotid duplex for ongoing neurological symptoms. A Cardiac Cath on November 18, 2019 as the part of pre-op evaluation for carotid endarterectomy revealed calcified severe 2V (RCA and LCx) […]