Complex PCI of a Severely Tortuous Ectatic RCA (edited case) – December 2018
62 year old male presented with CCS Class II angina and positive SPECT MPI for basal inferior and inferolateral moderate size area of ischemia and infarction. A Cardiac Cath on August 28, 2018 revealed 2V CAD: 80% long segmental in-stent restenosis after severe proximal tortuosity in mid RCA and 70% discrete lesion in LCx-OM1, SYNTAX Score 12 and LVEF 48%. Patient underwent an unsuccessful intervention of mid RCA as stent couldn’t be delivered despite the use of Guideliner. Patient was optimized on maximal antianginal therapy but still continued to have Class II angina. Patient is now planned for complex PCI of severely tortuous ectatic long mid RCA lesion with guide extender catheter.
A.Guidezilla has an extra polymer coating compared to Guideliner and hence can be easily advanced in the tortuous anatomy.
QAre there cases where one would be preferable? Or it should be avoided?
A.Cases with the tortuous anatomy like one today should be done with either Guidezilla (preferred) or even with Guideliner. I believe these guide extenders have made these complex procedures relatively simple and successful. Also there is no need to deep throating the guide catheter which will minimize guide catheter induced dissections.
QWhat are some of your best recommendations for using the extension catheters?
A.Any tortuous anatomy are suitable for guide extenders and they always should be advanced or telescoped over the balloon.
QHow often do you use these catheters in 6F and in 7F sizes?
A.We use 6Fr guide extenders 92-95% and 7Fr in about 3-5%; later will be indicated when we are planning to advance Atherectomy burrs distally.
QYour review of CABG vs. PCI was superb. Which patients in 2019 should go for CABG?
A.Based on the current guidelines and available emerging data, following pts are most suitable for CABG or at least for Heart team discussion;
1) 3 V CAD with syntax score >32
2) 3 V or 2V CAD in diabetics with syntax score >22 and prox-mid LAD involvement
3) ULM with additional vessels CAD and syntax score >32
4) Any complex CAD Pt with low co-morbid conditions (STS mortality score <5) and issues with the DAPT continuation or compliance
These complex CAD pts should have Heart team discussion outside the Cath lab and then decision be made with keeping pt’s preference on the top after all the data presented to the Pt and family.
QFor elective cases, it is better to do staged procedure than do a multi-vessel intervention?
A.I always believed in multistage PCI and now the data supports this concept as has shown to be associated with lower mortality vs onetime MV PCI. This strategy has resulted in mine lowest RAMR of PCI for last 21 years as per NY State report card.
QWhat about for STEMI?
A.For MV STEMI cases, staged PCI during same hospital admission seems to have the best outcomes.
QAnd for cardiogenic shock?
A.There is new rethinking about the MV PCI in Cardiogenic shock pts since the Culprit shock trial. Many of us are still doing MV PCI if Pt’s hemodynamics don’t improve after culprit vessel PCI. I guess updated guidelines may change our thought process and practice in the future.
QIs it not harder and time consuming to get insurance approvals for staging the procedure? For smaller groups or solo practitioners, this can be an all consuming process?
A.Insurance approval is not an issue for the staged PCI as long as the reason for staging was documented at the time of original PCI. Our cath report always mention the reason for staging which is usually done after 30-days.
QDo AUC fully incorporate the observations from recent trials and data as the VA study of 67 centers by Dr. Sunil Rao?
A.Actually AUC documentation goes largely against staging as pt’s symptoms at the time of staging are recorded and not the original ones. This makes many time PCI inappropriate as pt became asymptomatic after first PCI and 3 vessels now have become 2 vessels. Stress test remains valid for both the procedures.