Complex PCI of LAD CTO and Diagonal Bifurcation using Mini-Crush Technique – November 2021

Case and Plan:
34-year-old obese male multiple CAD risk factors presented with NSTEMI. A Cardiac Cath on July 26, 2021 revealed 3 V CAD: 100% mid LAD (J-CTO Score 2) with 80% D1 bifurcation, 90% LCx OM1, 90% distal RCA with SYNTAX Score of 28. Patient underwent successful intervention of distal RCA using Promus DES and LCx OM1 using Promus DES. Patient is now planned for staged PCI of LAD CTO and diagonal bifurcation using Mini-Crush technique as part of complete revascularization.


Q Congratulations about the new apps. Help us with some criteria how you choose among the 8 guidewires you recommend for CTO?
A. We always have emphasized to select the preferred 3 CTO wires, which can be escalated during most of the CTO PCIs. Of course if not successful, then try other stiffer wires. For us it is, Filder, MiracalBro 6 and then Confianza 9-12.
Q Is tip load the only criteria?
A. Tip load is the main criteria followed by tip width and then hydrophobic/hydrophilic property.
Q What about tortuosity?
A. Clearly hydrophilic CTO wires are preferred in the proximal tortuousity followed by CTO.
Q Between the micro catheters, what is your preference?
A. Finecross is our preferred microcatheter due to its low profile, less stickiness with the guide wires and relatively low price $350 (vs others costing from $450-700).
Q Does a monorail microcatheter have advantages?
A. Yes monorail microcatheter like Twinpass do have slightly higher profile, but have two advantages; distal delivery of vasodilators and wiring the sidebranch in an angulated lesion. Cost is around $700.
Q Are you planning to address guide extension catheters in a future app too? They seem to have an important role?
A. Guide extension catheters have really made our complex procedures simpler and shorter and are used in about 20% of PCIs. We will include them in our future app of 'Interventional devices'.
Q Why should one switch from FFR, iFFR to QFR?
A. Only advantage of QFR is no instrumentation of the coronary artery and it gives the physiological read out by cine angiograms in 2-3 views. It still has to be compared against the traditional invasive FFR or iFR. It also cannot point out the actual pressure drop in multiple lesions. Hence QFR is yet far from clinical use in daily routine.
Q Do you feel QFR will become the new standard of care?
A. As I said QFR has a long way to prove against invasive physiological testings before getting incorporated in the daily routine of the cath lab.
Q Still unclear about the role of POT? Which lesions benefit?
A. Based on the recent first RCT comparing POT vs KBI in non-LM lesions (POTPRO trial), routine POT technique was not beneficial and rather increased the procedure time and slightly higher contrast usage.
Q Which lesions should avoid POT?
A. All non-LM lesions treated with with 2 stents are not appropriate for routine POT technique. Rare situations of inability to wire the sidebranch, POT may be needed to shift the carina favorably. Hence most of the bifurcation lesions, do not require POT technique.


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