Case and Plan
43-year-old morbidly obese male with ESRD on HD presented with new onset Class IV angina and NSTEMI (pTnI 2:1U). A Cardiac Cath on February 26, 2021 revealed 2 V CAD: multiple calcified 80-99% lesions in extremely tortuous RCA, 90% mid LAD, LVEF = 55% and SYNTAX Score of 27. Patient underwent successful intervention of mid LAD using Xience DES. Patient is now planned for staged PCI of tortuous calcified RCA using rotational atherectomy with guide extension catheter and final OCT imaging.
Q&A
Q
Why do you think Colchicine works whereas so many other anti-inflammatory agents have failed?
A.
I think the reasons for Colchicine efficacy are multi factorial; anti-inflammatory by suppressing production of IL1b, inhibit neutrophil activation and additional antiplatelet activity. These all 3 actions are not present in other anti-inflammatory drugs tested so far in CAD.
Q
What do you think causes excess non cardiovascular mortality with colchicine?
A.
There are some reports of infections, pneumonia, poor immune response, soft tissue tumors and cancer in some pts in the Colchicine group.
Q
In what cases have you been using colchicine?
A.
I started using Colchicine in chronic CAD pt's who continues to be symptomatic on anti-ischemic therapy. I have used it in about 30 pts so far with great success in about 2/3rd of them.
Q
In what dose and duration?
A.
Colchicine 0.6mg daily for 1-12M (0.5mg dose tested in all the trials is not available yet in USA).
Q
Can one expect a guidelines recommendation?
A.
I strongly believe Colchicine use will be a Class 1 or at least 2A indication in ACS and SIHD in upcoming guidelines and as numerous RCT have shown its efficacy.
Q
Where would you not use Colchicine?
A.
I will not use Colchicine in pts with active infection, history of prior or active cancer and immunocompromised pts. Also course if known allergy to Colchicine.
Q
Could today's case be done from wrist access?
A.
I will not consider Trans-Radial approach in today's pt because of the lesion complexity, tortuosity and very distal subtotal bifurcation. We barely could advance our Rota burr distally with all the guide and guide extender support via femoral approach in this complex case. Radial approach likely would have failed and we would have converted to femoral approach.
Q
What was the best teaching point of the case today?
A.
Most important teaching point of today's case was demonstration of advancing Rota burr distally on Dynaglide and use of guide-extender catheter to advance the burr distally into diffusely diseased subtotal calcified RPL.
Q
In what situations do you use the dynaglide?
A.
Dynaglide feature should be used to advance the Rota burr distally and pressing the break release. I recommend to use dynaglide feature, if there is difficulty in bring the Rota burr from the guide to the vessel
Q
What is your criteria for selecting from among the two Rotawires?
A.
The Rota Extra-support wire use is advised in cases of Ostial lesions (where you need to disengage the guide from coronary ostium and will need extra support) and distal lesions to provide extra support to advance the burr distally. Soon we will have new improved Rotawire Drive which is more torque able but gives little less support due to its hydrophilic and stainless steel combination.
Thank you.
Very nice case demonstrating the use & relevance of rotational atherectomy and especially reimposing the faith in Femoral route( high way), special thank to all the team. Great case and excellent two short presentations.