Staged PCI of LAD D1 Bifurcation with 2-Stent Technique via Right Radial Approach – Dec 2015

77 year-old male presented with CCS Class I angina. A stress echo revealed inferolateral and apical ischemia with +ETT high DTS of -6. A Cardiac Cath on November 24, 2015 reveleated 2V CAD; 80% proximal & 70% D1 LAD bifurcation (Medina 1,1,1) and 70% LCx – OM2 with normal LV function and SYNTAX Score of 14. Patient underwent successful intervention of LCx-OM2 using Promus Premier DES. Patient is now planned for staged PCI of LAD D1 bifurcation with dedicated 2 stent technique via Right Radial approach.

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Q&A

Q In the Middle East, we feel it is important to learn both - wrist and femoral access? Your comments, please
A. Absolutely agree that all good interventionalists should be proficient in both radial and femoral techniques. Similarly all training programs need to make sure that fellows get full training in both approaches. Yes to learn radial, it will take over 250 cases to become proficient.
Q In the elderly, which guiding catheter do you select for hooking the left coronary artery, in particular when there is tortousity?
A. Left radial approach using VL 3 or EBU 2.5-3 will be the best approach in elderly over 75yrs age especially short stature.
Q What cocktail do you use for spasm in wrist access?
A. Verapamil 2.5mg and NTG 0.5mg is our usual cocktail.
Q Which is your favorite access sheath? What size?
A. Terumo 5-6 Fr slender sheath for radial is preferred And can accommodate 6Fr guide easily.
Q Which is your choice of guide for LAD, LCX and RCA for trans radial access?
A. For LAD/LCX: VL 3 or 3.5 of BSC and for RCA Akari 1.0-1.5 of Terumo are our favorite guides. These are softer guides and minimizes vessel trauma.
Q Same choice with tortuousity in these vessels?
A. For tortuosity, we use stiffer guides of Medtronic EBU for left and AL1/AR2 for right.
Q What are the three most practical techniques you use for reducing radiation exposure in trans radial procedures?
A. Three most important techniques to reduce radiation exposure during radial procedures are; Extra long extension tubing, use of exchange wire to exchange catheters after initial access and keeping pt's hand parallel in close proximity to Pt's body to prevent radiation scatter.
Q Have you completely abandoned first generation DES for bifurcation where you use a two-stent strategy?
A. Yes there is no use of first generation DES in any lesion scenario including bifurcation lesions now. Data have clearly supported use of second generation DES for bifurcation, CTO, ISR and Thrombotic lesions.
Q What is a cutoff diameter of the bifurcating lesion where you will use a second DES?
A. In a planned 2 stent approach, SB diameter of minimum 2.5mm+ is needed. As a bailout, even smaller SB may need to be stented to prevent occlusion. Main vessel diameter is less of an issue in bifurcation PCI as it needs to be stented regardless of the size.
Q All things being equal and Medina classification factored in, which is your favorite bifurcation technique?
A. Minicrush for non LM bifurcation and SKS for LM bifurcation lesions are my preferred 2 stent approach.

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