Case and Plan:
64-year-old male with known extensive CAD and prior PCI’s presented with CCS Class III angina and positive SPECT MPI for multivessel ischemia. A Cardiac Cath on March 8, 2022 revealed 2 V CAD: multiple severely calcified RCA lesions with in-stent restenosis of proximal RCA and RPDA, 80% calcified proximal LAD with SYNTAX Score of 25. Patient underwent successful intervention of proximal LAD using rotational atherectomy and Xience DES. Patient is now planned for staged PCI of multiple RCA lesions using rotational atherectomy and re-DES with OCT guidance.
Q&A
Q
What made the case so challenging?
A.
Anterior and superior take-off of RCA and then significant angulation of RPDA due to prior stent, made the case very challenging.
Q
Could a stronger guide, such as AL! help? Perhaps, even avoided extension catheters?
A.
Different guides like SCR or ALs can provide better support in some anomalous RCA origin take offs. We thought about the AL 0.75 guide catheter but felt that will not fit better due to upward angulation. Also irrespective of the guide catheter, we needed guide extender for delivery of devices in RPDA.
Q
Please explain the most appropriate strategy for using guide extension catheters?
A.
There should be low threshold for using guide extenders as they will greatly help in balloon and stent delivery. First an appropriate size and length balloon to be advanced in the vessel, inflated to nominal pressure and then advance the guide extender catheter during balloon deflation. This way guide extenders can be advanced in the vessel distally without causing vessel trauma/dissection.
Q
What precautions should be taken?
A.
Most important precaution is to advance the guide extenders over the deflated balloon and not bare.
Q
Which is your favorite guide extension catheter?
A.
Guidezilla II from BSC inc is our favorite due to hydrophilic coating and better pushable shaft.
Q
Have you experienced any severe complications with guide extension catheters?
A.
Yes we had 2 cases of LM dissection caused by inadvertent advancement of guide extension catheter during injection and about 4 cases of LIMA dissection. Hence extreme care should be used by holding the guide extension catheter during coronary injections. Also avoid using guide extension catheters in LIMA to LAD PCI. Rarely there could be clot formation in the guide extension catheters.
Q
How will Class 1 recommendation for Radial route affect interventional cardiology?
A.
ACC/AHA Class 1 indication for radial approach in STEMI pts to reduce mortality and vascular complications, is supported by numerous RCTs. Making Class 1 recommendation for radial access in SIHD to reduce vascular and bleeding complications, is appropriate but could be troublesome in a legal case involving vascular complications during femoral access.
Q
Will femoral access become extremely challenging once it is not the preferred technique?
A.
Yes it has been shown that cath lab with increasing radial cases (>80%+), reports slightly higher femoral vascular complications compared to if radial volume is 50-60%; 'Compeau Paradox'. Hence we need to continue to do femoral cases in 20-40% of cases. Proper femoral technique is essential for large bore access (Impella, BAV, TAVR) and IABP.
Q
What will be the impact, if any, of changed recommendations for LV support devices?
A.
LV support devices remains Class IIa recommendation and should be used with strict institutional protocols in high risk complex coronary cases and EF <35-40%.
Q
No mention in guidelines for IVL?
A.
Yes IVL is not mentioned in the 2021 ACC guidelines because IVL was not FDA approved at the time of writing the recommendations. I am sure, IVL use for calcified lesions will be the Class 1 indication in the next updated PCI guidelines.
