High-Risk Complex PCI of Diffuse Multivessel CAD – January 2021


Case and Plan:

45-year-old male with multiple CAD risk factors presented to OSH on November 6, 2020 with unstable angina and positive ETT. A Cardiac Cath on November 9, 2020 revealed extensive 3V CAD: 100% mid LAD, 90% D2, 70% proximal LCx, 100% LCx-OM1, 100% mid RCA with LVEF = 60% and SYNTAX Score of 50. After Heart Team discussion, CABG was recommended, but declined by the patient. Patient continued on optimal medical therapy, but remains in CCS angina Class II. Patient is now planned for high-risk complex PCI of LAD/D1 and LCx/OM1 with Impella on standby for hemodynamic deterioration.


Q Did you consider first tackling the RCA - using the logic to try opening the hardest lesion first?
A. This pt has refused CABG and hence we thought re-canalizing LAD will be most important and proceeded accordingly. We will plan RCA PCI in few months. Now with both LAD and LCx open, even if we are unsuccessful with RCA CTO PCI, he will not require CABG. If we would have failed LAD CTO PCI, then will have gone back to pt with strong recommendations for CABG.
Q Is this your normal practice to leave a portion of the diffuse segment not stented for future surgical revascularization?
A. That is correct, especially with CTO recanalization, that leave the diffuse disease segment untouched, which will improve with flow mediated vasodilatation and also could be the target for future bypass grafting.
Q Are most surgeon's appreciating this practice?
A. Most CT surgeon are pleased with that practice of not putting the stents in distal diffuse vessels as stentectomy is very complicated surgical procedure and very few CT surgeons do it.
Q The surgeon's identify this segment by angiography and by visual inspection during surgery?
A. To bypass the target vessel is initially done visually by coronary angiogram. CT surgeons also palpate the vessel epicardially and do pass the probe on the OR table to evaluate the status of distal vessel; especially if it is small.
Q What aggressive risk modification do you recommend for such aggressive disease?
A. Aggressive CAD risk factor modification in this non-diabetic pt will include to bring his LDL to <60-70mg/dL, loose weight and regular graded CV exercises.
Q With now a lowered Syntax score, this patient will move on the very acceptable part of the AUC grid?
A. Yes this pt now has Syntax score of 22 (vs 50 at start) and now we have to show that he is either symptomatic or has ischemia in the RCA territory before planning PCI as per AUC guidelines (due to CTO)
Q To what patient subgroups are you referring to coronary CT?
A. In my opinion, coronary CT angiography (CCTA) should be the screening test to evaluate CAD status in pts with CAD risk factors. Hence I order CTA in many pts to r/I or r/o diagnosis of CAD. CCTA is also good to evaluate the status of bypass grafts 2-5yrs post CABG and then every 1-3 yrs. CCTA is not optimal to evaluate the status of coronary stents due to common blooming artifact of the stent metal.
Q Any gender differences?
A. It all depends on the CAD risk factors and age of the pt rather than gender difference in ordering CCTA. As a general rule men after 40yrs of age and women after 50yrs of age should get CCTA every 5-7 years based on the CAD risk factors and finding on the first CCTA.
Q So what is the recommendation for low EF patients now?
A. Low EF pts should preferentially undergo CABG as long has low STS score (<4) and have good bypass targets. Because of multiple comorbid conditions, many of these pts undergo PCI with LV assist (IABP or Impella).
Q What kind of randomized trial can clarify the situation for this important subgroup of low EF and multi-vessel CAD?
A. There is a clear cut need for RCT comparing CABG vs PCI in pts with 2-3 V CAD with intermediate to high syntax score (22+), low EF (<35%) and low STS risk (<4). Of course Heart team has to agree for the equipoise of CABG vs PCI in these pts before randomizing.


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