Case: 51-year old male with prior PCI’s in 2004-2006 presented with crescendo angina and high risk stress echocardiogram for multi-vessel ischemia. Cardiac cath revealed 2V CAD (95% prox LAD Taxus DES ISR and 80-90% calcified mid RCA with distal branch diseases). Patient underwent atherectomy using AngioSculpt balloon and re-DES using XIENCE V of proximal LAD. Now planned for complex PCI of mid RCA, RPDA and RPL.
Q&A
Q
Would the ISR strategy employed for the LAD your standard strategy, of using Angiosculpt and DES?
A.
Yes. This is our usual strategy of using either cutting balloon for focal and Angiosculpt for diffuse ISR followed by re-DES in diffuse and CTO ISR.
Q
How about radiation? Completely abandoned?
A.
Yes. Brachytherapy/radiation is only being used at one center in USA; Washington Hospital Center in Washington DC by Dr Waksman and his team. We abandoned brachytherapy in 2004 and has referred only one case 3 years ago for radiation after 3 times DES restenosis; that patient reclosed the DES after radiation in 4 months.
Q
If you have availability, would you have used a drug-coated balloon?
A.
Absolutely YES for the use of drug-coated balloon for DES restenosis. PACCOCATH and PEPCAD II trials showed that drug-coated balloon are superior to PTCA for BMS ISR, but we don’t have a randomized trial to answer this for DES ISR. There are case series and registry data to support this strategy.
Q
Is it preferable to use a different type of DES?
A.
A small randomized trial by ISAR group have shown no difference in outcomes by use of same DES coating or different coating (such as paclitaxel for sirolimus/everolimus ISR). There were some earlier non-randomized data supported the routine practice of hetero-stent vs. same homo-stent for DES ISR.
Q
In that situation, what makes the difference, a different drug or a different polymer or the stent platform? Or, all?
A.
I believe it will be the different drug rather than polymer or stent design. In my opinion many of DES ISR are simply under-deployed or under-expanded stents and hence high pressure balloon dilatation with a bigger balloon may suffice (without re-DES). In some cases we do use Rotablator to fully expand the DES.
Q
For the RCA, are you planning a single Burr strategy?
A.
YES. Over 96% of our Rota cases are single bur strategy; even a small 1.25mm burr in a large tortuous 3.0mm+ vessel.
Q
Have you abandoned Amplatz guiders? What is your preferred guiding catheter for the RCA where a large support is needed?
A.
Amplatz 0.75 is the preferred for RCA PCI where extra support is needed. We don’t use Amplatz guides for left sided PCI.
Q
How will you follow this patient so far as the anti-platelets are concerned?
A.
This patient was on Clopidogrel and had PRU of 208 (63% inhibition) and would suffice. In some high risk cases (even stable non-diabetic pts) we have been using Prasugrel with 60mg load and 5mg MD (10mg MD only in pts over 110Kg). In many of these pts we, soon will start using Ticagrelor because of dependable platelet inhibition and not much increased bleeding and of course reduce mortality.
Q
You mentioned about culprit only PCI for STEMI? Any exceptions to that approach?
A.
Yes possibly 3 exceptions in cases where non-culprit lesion >90%; 1) hemodynamic instability despite opening the culprit vessel, 2) Financial reasons as second procedure will add extra expanse to the pt (especially out of US where pt has to pay from their pocket) and 3) In pts whom we think pt may not return for F/u staged procedure (non-insured, alcoholics, drug addicts pts etc.).
Q
Would FFR be useful in the acute stage to determine a second vessel PCI with STEMI?
A.
Actually literature describes to the contrary that in acute setting, FFR may be abnormal due to vaso-constrictive state of STEMI and initially +FFR may become negative at F/U.
Q
When do you refer ISR DES for CABG ?
A.
More than 3 times DES ISR especially diffuse type or total occlusion.
Q
What role does MSCT have for follow-up in re-DES for ISR?
A.
MSCT may not be accurate in identifying neo-intima due to multiple layers of DES, hence SPECT will be preferred in this type of pts.
Q
When we treat ISR and place a second stent we now have 2 layers of stent. So my question is how many layers of DES are you happy to have?
A.
Two layers are ok but we always try to avoid putting the third layer; in some cases it may be rarely required.
Q
For BMS ISR we use a DES and if there is ISR again we use another DES but we worry about delayed and incomplete endothelium layers which predispose to stent thrombosis, ISR and stent CTO.
A.
Yes these all are valid concerns in these pts and hence if pt has developed multiple DES ISR even first time, consideration for CABG may be appropriate.
