Distal LAD/D3 Bifurcation PCI via LIMA – September 2022

Case & Plan: 64-year-old male with prior CABG presented with CCS Class III angina, HFrEF, multivalvular disease and positive stress MPI for multivessel ischemia and infarction. A Cardiac Cath on April 25, 2022 revealed extensive severe 3 V CAD with occluded SVG to RCA, SVG to OM, patent LIMA to LAD with 80-90% distal LAD & D3 bifurcation lesion and EF 30%. Patient underwent hybrid CT surgery with SVG to RCA, radial graft to OM, MV repair and TV repair. Patient is now planned for hybrid complex PCI of distal LAD and D3 bifurcation via LIMA using step crush technique.


Q What are the considerations for using a guiding catheter for LIMA interventions?
A. For LIMA interventions, we need selective LIMA cannulation preferably by the LIMA guide (NOTO guide for LIMA origin from the straight or angle part of subclavian) and of shorter length of 90-100cm. We suggest to cannulate the Subclavian with the diagnostic JR catheter and then exchange to guide catheter over 300cm guide wire. For obvious reasons of direct proximity, left radial access is the preferred approach.
Q Are there a few strict "no" while performing a LIMA intervention?
A. Care should be taken to advance or rotate or inject via LIMA guide while looking at the pressure tracings. Also do not push the guide. We strongly recommend not to use guide extension catheters for device deliver as can cause dissection and ischemia.
Q What is the specific danger using Guide Extension catheters in a LIMA intervention?
A. Guide extension catheters in the LIMA body can cause ischemia &/or dissection. Hence we almost never use them in LIMA intervention.
Q If even the smallest balloon did not dilate, what would have been your other options?
A. If small balloon can not dilate the lesion, 1.25mm Rota burr can be used. Rare cases, ELCA can also be tried. Otherwise it will be an unsuccessful procedure.
Q Between IVUS and OCT, would one be preferable for LIMA interventions?
A. We personally suggest to avoid imaging in LIMA interventions due to inherent tortuousity. If needed, IVUS will be better then OCT (which requires forceful injection with guide engaging the LIMA)
Q For guidewires, any special attributes that come in handy for LIMA interventions?
A. Most LIMA interventions are done using hydrophilic guide wire (Fielder, Whisper) to avoid LIMA body plication and pseudo lesions.
Q Is surveillance stress testing even out for complex LMCA interventions?
A. Based on the Post-PCI study, all high risk PCIs including LM does not benefit from routine stress testing at 12 and 24 mths; hence just clinical followup is what is recommended now.
Q How do we resolve issues raised in Revived BCIS-2? A larger trial?
A. We just need to duplicate the REViVE-2 type trial in USA in pts with Low EF to evaluate the impact of PCI on LV function improvement and longterm outcomes.
Q Or a different protocol?
A. Only additional point will be to use liberally the MCS devices to get best optimal PCI results.
Q Are we back in the ISCHEMIA frame of mind again with the REVIVED trial?
A. Yes both trials have negatively impacted our PCI credibility and field. But we need to learn the new lessons and move on; means that PCI is good for symptomatic pts irrespective of ischemia.


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