April 2014 CCC Live Case

66-year-old male with prior CABG and prior PCI of SVG to Ramus Intermedius presented with crescendo CCS Class II angina despite maximal medical therapy. Stress MPI revealed moderate-size severe anterior ischemia. A cardiac cath on Feb 7, 2014 revealed three vessel CAD with patent SVG to Ramus & OM, 80-90% calcified lesion of tortuous LIMA to LAD distal anastomosis and LVLF 65%. Patient is now planned for PCI of LIMA to LAD distal anastomosis.
Moderator: Sameer Mehta, MD



Q What has been the most remarkable achievement of the affiliation of ccclivecases.org with ACC?
A. Widespread global reach.
Q There is an editorial in Euro Intervention, "Twenty additional minutes gives 20 years of life" stating the value of an additional RIMA. Do your surgeons practice this?
A. Yes there is mindset of CT surgeons now to use RIMA more often especially in younger and non-diabetic pts.
Q How many CABG procedures are being done at your hospital each year?
A. In 2013, 420 Isolated CABG and 244 CABG+Valves were done at Sinai. CABG volume has shown 6-8% growth for last 2 years. This is largely because of our practice of recommending CABG in MV diabetics and high SYNTAX score pts.
Q Are you doing hybrid procedures?
A. At Sinai very few hybrid CABG procedures are done; 5-8 per year. This number is likely to increase with joining of Dr John Puskas at Sinai, who is a great hybrid surgeon and will be leading the recently proposed NIH sponsored Hybrid CABG trial in high SYNTAX score pts, comparing MV PCI with IMA+ PCI.
Q In addition to the LIMA guiding catheter for interventions involving LIMA, for varying anatomy, which other guiders do you recommend?
A. Second catheter for LIMA cannulation will be NOTO or 3dRC once it originate from the vertical position of left subclavian. Rarely FR may also be used.
Q Different lengths?
A. Yes usually 90cm guide catheters are preferred due to LIMA tortuosity.
Q What precautions should be employed when advancing a Rotablator through a LIMA?
A. Rotablator should be advanced via LIMA on Dynaglide motion. Also use Nitro or verapamil liberally to avoid any spasm.
Q Any tips for Cutting Balloon, Angioscupt for this application?
A. We usually try to avoid using Cutting Balloon or AngioSculpt thru LIMA but can safely be used once indicated like in ISR or undilatable lesions.
Q Any experience using Orbital Atherectomy through a LIMA?
A. None yet. Planning to use it in next calcified LAD lesion via LIMA.
Q Ever had a dissection of the LIMA? Can those be managed conservatively?
A. Rarely we have created iatrogenic LIMA dissection at the origin or in the body. Those dissections usually require additional stenting and do well subsequently.


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