Complex PCI using RA of both LAD and D1 Bifurcation & Mini-Crush Stenting – July 2023

CASE & Plan:
72-year-old male presented with new onset CCS Class III angina with paroxysmal Afib, recent GI bleeding and prior PFO closure. A Cardiac Cath on June 8, 2023 revealed 2 V CAD: heavily calcified 80% proximal LAD, 90% LAD-D1 bifurcation, calcified 90% LCx-OM1 with SYNTAX Score of 21 and normal LV function. FFR was + for both LAD and LCx. Patient underwent successful Rota DES PCI of LCx-OM1 with excellent results. Patient is now planned for complex PCI using rotational atherectomy of both LAD and diagonal bifurcation followed by Mini-Crush stenting.


Q What are the postulated benefits of POT?
A. A: Proximal vessel expansion, circular lumen and further opening of the stent struts for easy sidebranch wiring are the potential benefits of POT. These actions will avoid passage of the Guidewire behind the stent struts and will also facilitate the sidebranch wiring.
Q Why is there so much variability for its use?
A. OT procedure actually has its origin from Europe and then strong support from European Bifurcation Club (EBC). While it makes sense doing POT in every LM bifurcation lesion involving 2 stents, but there is very little clinical evidence for its utility in non-LM bifurcations. A single RCT comparing POT vs Kissing ballon dilatation in non-LM bifurcation (ProPot trial) and our imaging data have failed to show its superiority over just KBI. Hence lot of variability in POT use in non-LM bifurcation lesions.
Q Why is your rate of POT low?
A. We actually are the non believer of doing POT in non-LM bifurcations; based on the literature and our imaging data. We do POT routinely in the LM bifurcation and strongly advocate it in this setting.
Q Does POT have potential complications?
A. Yes perforation, over expansion and proximal edge dissection due to balloon overhang are the potential rare complications.
Q How do you compare DK Crush with MiniCrush for ease of use and long-term results?
A. In view of the lack of direct comparison of DK Crush with MiniCrush in a RCT so far, we believe done correctly, both approaches have similar short and longterm outcomes along with excellent acute angiographic results. DK Crush may facilitate easy sidebranch wiring but has 4 extra added steps, then MiniCrush. For all these factors, we prefer MiniCrush over DK Crush. We do 90% MiniCrush and 10% DK Crush in Sinai cath lab; later usually in the radial cases with 6Fr guide catheter.
Q Is nano crush a mere nice sounding term?
A. NanoCrush is a modified DK Crush where after advancing the stent in the sidebranch, 1:1 size main vessel NC balloon is first inflated, then sidebranch stent is pulled to tug against the MV balloon and deployed. Then stent balloon is pulled into the main vessel, inflated first, then kissing ballon inflation followed by both balloons deflated. Then MV balloon inflation to crush the small protruded SBr stent struts, then KBI followed by stenting of the MV and the final KBI. We see no advantage this technique over MiniCrush and hence do not use it. Little modifications of NanoCrush is Reverse Crush which also can be done using 6 Fr guide.
Q Should Rotablator be used primarily with the 1.5 mm burr size?
A. We now have been teaching to use 1.5mm Rota burr as the default strategy and if needed, combine it with appropriate size IVL irrespective of the vessel size. This synergistic strategy is very effective and minimizes the Rotational atherectomy (RA) complications.
Q Are there a few situations where Orbital has advantages over Rotational ablation?
A. Yes Orbital atherectomy (OA) causes less slow flow and hence should be used over RA in severely calcified lesions is pts with borderline hemodynamics and in pts with low EF <30%. Also cases of multiple lesions in a vessel, can be best treated by single OA crown.
Q With ultra low struts, does BVS have a future?
A. BVS is making comeback with 4 companies (except Abbott) have brought the BVS to clinical trials and one of them (MeRas 100 of Merrill Lifesciences) has been approved in India and got CE mark approval for clinical use after 3 years of solid followup data.
Q Is 0.3 burr to artery ratio not losing out on the larger benefits of Rotablator?
A. We know that larger Rota burr has no advantages over smaller Rota burr especially now when we can combine with IVL adjunct. Small Rota burr with B:A ratio of 0.3 will have lower slow flow and perforation.


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