Q&A
Q.
Are we seeing more calcific nodules because we are more familiar with it but were previously dismissing it as severe calcification?
A.
It is correct that we are now describing calcifies nodule which in the past used to be severe calcium alone. Overall its incidence is 25-40% in various reports of severely calcified lesions.
Q.
Is increased imaging picking up more nodules?
A.
Yes since calcified nodule is an independent entity, imaging is helpful in reporting its exact prevalence and we are carefully looking for it and describing it.
Q.
Clinically, does a nodule behave differently from a severely calcified lesion?
A.
Calcific nodules behave differently in two ways; 1) they are difficult to treat routinely unless atheroablative or IVL techniques are used; 2) they are associated with higher incidence of coronary perforation, mainly due to need for high pressure balloon dilatation to attain the optimal linen gain
Q.
Is its clinical course different?
A.
Clinical course of calcific nodule is similar to any calcified coronary
lesion with two distinct types; eruptive in ACS and non-eruptive in CCS.
Q.
As its treatment strategy, mostly RotaTripsy?
A.
Yes best treatment for calcific module is combining atherectomy (RA or OA) + IVL. This helps in adequate shaving of the nodule followed by calcium features by IVL, for optimal luminal gain.
Q.
How should a Rotablator be approached for a calcified nodule?
A.
Rotational atherectomy needs to be done as usual with additional 3-4 passes even after crossing the lesion to do better shaving of the nodule. Most importantly, avoid using ultra high pressure (>22atm) post RA or post stenting; which can cause coronary perforation by over stretching the opposite non- calcific wall.
Q.
Regarding the PROCTOR trial, do you think this will change guidelines?
A.
Yes I hope that being the first RCT which favored graft PCI over native vessel PCI, current guidelines of IIA should change to mention at least stating that both approaches for PCI in post CABG pts are feasible. If we have one more RCT duplicating the PROCtOR trial results, then graft PCI has a reasonable shot of becoming Class I by the guidelines.
Q.
This landmark trial dramatically changes the approach to SVG?
A.
Actually I have been practicing the approach of SVG PCI over native vessel PCI in my career. Now many more Interventionalist will prefer this approach.
Q.
How do the recent trials change the landscape for IVL? It has found more competitors, and additionally has more new competing devices?
A.
Three RCTs presented in TCT, comparing IVL with other devices especially cutting balloon, by en large showed similar acute success, lumen gain and complications but at a lower cost. Hence IVl ‘hype’ is on a downward spiral. By 2026 end, I expect at least 2 more IVL devices in the market clinically and thereby will reduce the device cost from currently $4700 to about $3000 in future.
Q.
With the lesion modification field now split wide open, Rotational Atherectomy becomes the King?
A.
Undoubtedly rotational atherectomy is clearly emerging as the winner for treatment of calcified lesions and in many cases is needed before other devices (IVL) can be used. Hence RA has a bright long term future.
