Staged PCI of Calcified LAD-D1 Bifurcation using Rotational Atherectomy and Absorb BVS in LAD and Metal DES in Diagonal – Aug 2016
64 year-old female presented with new onset Class III angina and CTA revealed significant calcified LAD and Ramus disease. A Cardiac Cath on August 2, 2016 revealed 2V CAD: 80% calcified proximal LAD and diagonal bifurcation lesion (Medina 1, 1, 1) and 95% Ramus Intermedius with normal systolic LV function; SYNTAX Score of 21. Patient underwent successful interventional of Ramus Intermedius using Promus Premier DES. Patient continued to have Class II angina despite maximal medical therapy. Patient is now planned for staged PCI of calcified LAD-D1 bifurcation lesion using Rotational Atherectomy and Absorb BVS in LAD and metal DES in diagonal.
A.Yes data are emerging that post PCI FFR of <0.90 is associated with higher MACE rates in otherwise successful PCI. Hence, we should aim for FFR of >0.90 (or at least >0.86) especially in vessels with diffuse and multiple lesions.
QSame for DES and BVS - FFR of 0.90?
A.Yes FFR of >0.90 should be the goal in DES and BVS cases.
QOr should one be more conservative to about 0.85 with BVS?
A.Based on the published data, minimal FFR even with BVS should be >0.87.
QWhat is the biggest single learning lesson you have learnt about BVS?
A.Most important learning point in BVS implantation technique is that high pressure post-dilatation (20-22atm) is required to fully expand the BVS scaffold. Hence post-dilatation is a must and should be done in 100% of BVS cases.
QPlease explain the rationale for mini-kiss for BVS?
A.There is a real documented concern of strut disruption once balloon is inflated thru the scaffold struts. Hence recommendation post BVS even with 2 stent approach is, either no KBI (kissing-balloon inflation) or do a mini KBI (1:1 size NC balloon in MV at 18-20atm and a small 1.5-2mm Compliant balloon in SBr at 8-12atm). In SBr lesions using only BVS in MV, routine KBI should be avoided unless there is comprised flow in the SBr.
QAnd its technique?
A.As explained above appropriate size NC balloon at high pressure in MV and small size Compliant balloon at medium pressure in SBr.
QWith overlapping of BVS and DES, are there any issues about the overlapping segment?
A.We should do a minimal overlap of 2 BVS or one BVS with DES because of extra material in the overlap segments. Therefore BVS marker should not be side by side the other BVS or DES marker, rather should be 1mm apart. This will still allow enough coverage of the lesion with the stent struts.
QHow often are you seeing edge dissections with BVS?
A.We are deploying BVS at 10-12 atm and then post-dilating with NC within the BVS markers. Even then we have seen 5 edge dissections in 30 BVS cases; all on OCT. Three of these dissection cases were tacked up by metal DES (largely as dissection length on OCT was 1.7mm+) and other 2 (very short length) were left alone. There has been no clinical consequences in any of these pts.
QWere they angiographically visualized or with OCT?
A.All 5 cases of edge dissection with BVS were seen on OCT and one case had a hint on angio in terms of slight haziness distal to the BVS; otherwise they were angiographically silent.
QWhen do you decide to place another stent for the edge dissection?
A.In view of higher scaffold thrombosis (ScT), our recommendation is to cover all the angiographically evident dissections and >1.7mm long dissection on OCT. We also recommend to use metal DES in these cases, to minimize the concerns of bulky scaffold overlap.