PCI of Complex LCx ISR CTO’s using Rotational Atherectomy

Case and Plan:
59-year old ESRD male with chronic CAD and s/p prior PCI’s, presented with typical CCS Class III angina, new decrease in EF and no stress test done. A Cardiac Cath on September 23, 2021 revealed 2 V CAD: multiple 90-95% calcified lesions in RCA, subtotal LCx-OM1 ISR, CTO LCx-LPL1 ISR with LVEF 50% and SYNTAX Score of 21. Patient underwent successful RotaDES PCI of RCA using two Promus Elite stents. Patient is now planned for IVUS guided staged PCI of complex LCx-OM1 & LPL1 CTO ISR using rotational atherectomy.

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Q Which CTO score do you use?
A. We report J-CTO score in our cath reports, as it is simple and has good predictive value of CTO lesion success.
Q Why?
A. Simple m, easy to calculate and predictable. We tell the pt/family of CTO success of 50-60% only if J-CTO score is 4 or 5.
Q Which of the CTO management algorithm do you prefer?
A. We do not use any of the published CTO algorithms as they commonly incorporate ante grade wire entry (AWE) and retrograde wiring & dissection (RWD); both of these techniques we rarely use in our practice.
Q You do not like any dissection creating techniques?
A. We donot promote purposeful dissection (ante grade or retrograde) as it has shown to cause higher subsequent restenosis and higher cardiac enzyme release. Short length in-advertant subintimal dissections are common in long CTOsy but is the part of the procedure.
Q Are you using OCT more to image CTO's?
A. We rarely use OCT in CTO cases; perhaps in few cases in the end to rule out any edge dissections.
Q Do you feel if there was better ablation for this lesion prior to the stenting during his previous procedure, stent apposition would hav been better?
A. That is correct that this pt did not have optimal lesion preparation at the time of initial PCI leading to suboptimal stent expansion. That gave us difficult time during current PCI; but in the end minimal stent area was ok.
Q A larger burr could have been used?
A. Yes larger burr also would have helped better stent expansion.
Q Is orbital atherectomy on its way out with IVL?
A. I believe that with ubiquitous use of IVLin the future, we will need only one atherectomy device. That in my opinion will be Rotational atherectomy and not orbital atherectomy due to better effectiveness and safety.
Q For financial reasons, better to use IVL as outpatient PCI?
A. Yes there are APC outpt codes for IVL but at present it pays only $1500. Hence still a loosing proposition financially.
Q What % of your cases are IVL now?
A. We are just developing our algorithm for IVL use and it's use is limited for obvious financial reasons. At present we use 20% RA, 3% OA and 1% ELCA during our PCIs; IVL is added adjunct in about 2-3% of these cases.


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