Complex coronary cases
FFR & OCT Guided Intervention of LAD, LCx and LM using Atherectomy and DES – Dec 2013

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69-year-old male presented on November 4, 2013 with unstable angina. Cardiac cath revealed 3V + LM CAD (95% calcified ulcerated proximal-mid RCA, 80% calcified proximalLAD, 60% mid LAD, 70% proximal LCx and 60% distal LM) with LVEF 50% and SYNTAXscore 45. CABG was recommended but declined after Heart Team discussion. Patient underwent orbital atherectomy and DES x2 of proximal and mid RCA and did well. Patient still has CCS Class II angina and now planned for FFR & OCT guided intervention of LAD, LCx and LM using atherectomy and DES.

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Q&A
Q
How will Orbital Atherectomy be employed for PCI?
A.

Orbital Atherectomy (OA) will be useful in treatment of heavily calcified lesions prior to stenting. Both Rotational Atherectomy (RA) and Orbital atherectomy will be used to treat these calcified lesions and soon we will provide the algorithm for preferred use of RA or OA in heavily calcified lesions in a particular clinical/angiographic scenario.


Q
How do you think Orbital Atherectomy will position vis a vis Rotablator Atherectomy?
A.

Both OA and RA will be useful for the calcified lesions with OA having the advantage of easy simple setup, quick learning curve and one size (1.25mm) for most of the lesions.


Q
Do you feel benefits of Orbital Atherectomy come from superior technology or ease of use?
A.

I will say for OA, it is the superior technology over ease of use.


Q
What are some of the tips about sizing of the device?
A.

At present only one 1.25mm OA burr is available which can treat any vessel size from 2.25 to 3.5mm and differential speed will provide different lumen gain: 1.5-1.6 mm MLD at 80,000rpm and 1.8 -1.9mm MLD at 120,000rpm.


Q
Specific contraindications for Orbital Atherectomy?
A.

Most important contraindications for the use of OA are extreme angulation (>90degree) and intimal flaps.


Q
Do you see Orbital Atherectomy more as a competing device for Rotational Atherectomy or the AngioSculpt?
A.

Clearly OA will be directly competing with RA in the treatment of calcified lesion space.


Q
Regarding OCT, are you seeing it gradually replace IVUS for most indications?
A.

OCT is still being used predominately as the research tool and hence I don’t see it replacing IVUS for most PCIs. Yes in follow up of ABSORB stents and stent endothelization, OCT will continue to be superior to IVUS because of higher resolution (10 micron vs. 100 micron for IVUS)


Q
What specific precautions must one take to prevent the situation of VF that you encountered?
A.

Since large amount of contrast (12-15cc) is injected into coronary system, it is very important that there is no guide catheter dampening during injection allowing quick washout of the contrast. Otherwise Vfib can occur as happened in our case.


Q
For your neoatheroma classification, do you need to employ both OCT and Infrared Spectroscopy?
A.

Yes to define neoatheroma in vivo, we need to establish 2 important components; lesion cap and presence of lipids. Hence both OCT and Near Infrared spectroscopy (NIRS) will be required to accurately define and classify neoatheroma.


Q
In what specific situation are you finding Infrared Spectroscopy useful?
A.

So far, NIRS is more of the experimental and research tool and it’s clinical utility is being evaluated in a prospective PROSPECT II trial. NIRS certainly can measure effectiveness of a lipid modulating therapy in altering the plaque’s lipid content.


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