FFR Guided Staged PCI of LAD-D1 Bifurcation and LCx-LPL Lesions – Aug 2015

62 year-old male presented to outside hospital with new onset rest angina and non-STEMI (TnI 2.5). A Cardiac Cath on July 24, 2015 revealed 3V CAD: thrombotic subtotal occlusion of mid RCA, 90% LAD-D1 bifurcation lesion (Medina 0,1,1), 80% LCx-LPL branch with mild LV dysfunction and SYNTAX Score of 16. Patient underwent successful intervention of culprit vessel mid RCA (Thrombectomy and Promus Premier DES) with excellent results. Patient is now planned for FFR guided staged PCI of LAD-D1 bifurcation and LCx-LPL lesions as the plan of complete revascularization strategy in this young patient.

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Q&A

Q Do you have an absolute cut off of the diameter of the side branch when deciding whether to wire it or not?
A. As a general rule, any side branch of >1.5mm size requires attention in bifurcation stenting and should be wired to prevent occlusion during main vessel stenting.
Q Is there also a cut off of the per cent stenosis when you will definitely treat the side branch?
A. There is no absolute cutoff for sidebranch stenosis requiring treatment. For many difficult diffusely diseased side branches, our goal is just to keep it open (KIO) by leaving the wire and not to treat it at all. Anytime there is slow flow in the sidebranch, we intend to treat. If there is a question whether to treat a 60-90% lesion of the sidebranch post stenting, FFR of sidebranch will guide us in the decision making.
Q Which guide wire do you recommend to use for crossing a side branch that was not protected but got occluded during the PCI of the native vessel?
A. I found Whisper ES is the best wire in that scenario but others such as Fielder or Choice PT can also be used to recanalize the occluded sidebranch post stenting. Usually, support by a small balloon is also helpful in this situation.
Q For side branch size <2.5 and when deciding to stent it, V stenting will your preference?
A. For moderate to large sidebranches (> 2.5mm), various good interventional techniques are available for 2 stent approach. V stenting is ideal when main vessel has no or has a short lesion (Medina 0,1,1) or for distal LM lesions.
Q Will you accept TIMI flow grade 2 for the side branch at the end of a bifurcation case or always grade 3 flow?
A. Our interventional goal should be the TIMI 3 flow in side branch but some cases even TIMI grade 2 flow is also accepted as long as there is no chest pain or residual lesion is <50% and no dissection. In that case decreased flow is likely from slow flow and will get better by vasodilators and GPI bolus.
Q Any bifurcation stent that you like?
A. There is no good approved bifurcation at present in the market and hence we need to rely on 1 or 2 good two stent approach and master them.
Q Will BVS have any beneficial role for bifurcation lesions and for managing side branches?
A. BVS has shown to cause more sidebranch occlusion due to thicker stent struts. Hence also side branch wiring will also be difficult post stenting. There are brief reports of 2 BVS use for bifurcation lesions but I will not advise their use for this purpose yet. Better scenario will be to use BVS in main vessel and metal DES for sidebranch.
Q Do you still use Gp2b/3a treatment for managing side branch occlusions?
A. Yes I commonly (~25%) use GP 2b/3a boluses (Integrilin) for side branch protection as shown by their studies of reducing sidebranch occlusion post stenting.
Q Why should Everolimus be superior to Paclitaxil for managing in stent restenosis - is it the drug, or the stent platform, or both, that are responsible?
A. As we have now learnt from many RCTs that 'Limus' drugs are superior to 'Paclitaxol' coating for preventing restenosis in the native vessel PCI, same will extend to their efficacy in treatment of ISR also. I also believe that once Limus coated drug eluting balloons (DEB) will be available, they will be superior to Paclitaxol coated DEB.
Q Limited future for drug-eluting balloons (DEB) in view of recent data?
A. Yes DEB have limited role in the treatment of ISR at present and may be indicated in a very focal lesion or where DAPT continuation can not be assured. DEB are still being investigated in the bifurcation lesions for the treatment of sidebranch stenosis.
Q What is the protocol for switching from prasugrel to brillinta. do u need to load with tricagrelor?
A. Yes if we need to switch from Prasugrel to Ticagrelor loading dose of 180mg is recommended as both agents works on different platelet receptors. If switch need to be made in pts on clopidigrel, Prasugrel load of 30mg will suffice (Triology trial) or Ticagrelor 180mg load (Plato trial) will be needed.
Q Is FFR reliable in Acute coronary syndrome?
A. FFR of the non- culprit vessel in ACS is reliable but we do not have data on the culprit vessel FFR.
Q How frequently do u do iFR and what is its future?
A. We use iFR in <2% of cases such as in AS pts or asthmatic pts and hence a limited role and future.

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