PCI of SVG to OM1 – April 2012

68-year old male with prior CABG x1 + AVR in 2005, presented new onset crescendo angina CCS Class III. A stress MPI revealed large anteroapical and moderate inferolateral ischemia. Cardiac cath on March 20, 2012 revealed 3 vessel CAD, stenosed SVG to OM1, normal LV function and normal aortic bioprothesis. He underwent successful intervention of culprit mid and distal LAD using Xience V DES and Tryton BMS in D2 under Tryton bifurcation Trial. Patient is now planned for PCI of SVG to OM1.

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Q&A

Q Can you briefly decribe the Tryton trial?
A. Tryton trial is comparing a dedicated sidebranch bare metal stent with PTCA only of sidebranch with DES in the main vessel in both the groups.
Q Would there be a role for FFR in this situation?
A. Not in the Tryton trial but certainly in the usual day to PCI; FFR is playing a major role to see if we should go after the sidebranch many of them just look hazy and of borderline stenosis.
Q In the next decade, with the expansion of hybrid labs, do you see the complete demise of use of SVG?
A. Not really as many of complex CAD such as heavily calcified lesions and CTO's still will require CABG.
Q How many hybrid procedures does your institution do?
A. Very little. May be 4-5 per year.
Q What is your algorithm - first PCI, then LIMA-LAD?
A. Best approach is first LIMA to LAD and then PCI just a day before the discharge. Hence CABG can be done while pt is not on plavix.
Q What is your anti-coagulant strategy during hybrid procedures?
A. All cases with Bivalirudin and avoid GP IIb/IIIa inhibitors. Clopidogrel is preferred ADP receptor blocker.
Q Is there problems with insurance reimbursements for the hybrid procedures?
A. So far we have not encountered the insurance barrier for hybrid cases.
Q Do you see a decline for emboli protection devices for SVG management?
A. agree with the statement that despite the Class I recommendation for DPD use in SVG PCIs, they are needed in only <25% of the cases. That exactly is the national trend as per ACC-NCDR data.
Q What are your biggest concerns about the M-Guard device?
A. Biggest concern about M-guard device is that it is not coated with the antiproliferative drug at this time.
Q Of all emerging technologies for SVG treatment, which appears the most promising to you?
A. Still M-guard stent has the best promise as there are not much emerging technology in the field of SVG PCI.

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