CASE & Plan:
69-year-old male with cirrhosis presented with CCS Class III angina. A Cardiac Cath at OSH on December 27, 2022 revealed extensive 3 V CAD: multiple calcified RCA lesions with ISR of RPDA and RPL1, trifurcation lesion of 90% proximal LAD, 90% LAD-D1, 70% proximal LCx-OM1, 80% Ramus with SYNTAX Score of 39 and LVEF 60%. After Heart Team discussion, CABG was declined due to liver cirrhosis and recommended high-risk multivessel PCI. Patient underwent successful PCI of multiple RCA lesions using three Xience Skypoint DES and did well. Patient is now planned for imaging guided complex PCI of LAD/LCx/Ramus trifurcation.
Q FFR was the turning point for deciding regarding the LCX. Agreed?
A. Yes many times there is a discordance in angio looking lesion 50-80% and FFR; and FFR use avoid unnecessary stenting. Many trials support this strategy with good short and long-term results.
Q Why is there such a change in the recommendations for IVUS/IVI?
A. Over the last 2-3 years, since the publication of ACC revascularization guidelines 2021, multiple registries and randomized trials have supported Intravascular Imaging (IVI) to improve short and long-term outcomes especially in complex, ISR and LM lesions. Hence ACC council recommendations have come timely to push IVI guided PCI further which at present is being done in 16-18% of PCIs only in USA (ACC-NCDR data).
Q The entire process and recommendations for IVUS/IVI are essentially the same or is there an upgrade?
A. Current ACC council recommendation for IVI use is for complex lesions, LM lesions and ISR; little more broader than earlier recommendations. Therefore making it a kind of Class I recommendation is upgrade from earlier IIa recommendation of ACC revascularization guidelines of 2021.
Q Would you agree that the greatest value for imaging is to assess post intervention results?
A. I am of strong opinion that 90+% of the IVI value lies in post PCI results optimization; stent expansion, stent apposition, any dissection, plaque protrusion etc. Rarely it may be helpful in preprocedure planning such as intermediate LM lesion, questionable thrombotic lesion, mechanism of ISR lesion and borderline calcified lesion on angio for better characterization.
Q Do you expect your imaging use to increase?
A. Our IVI imaging use has seen the uptick over last 5 yrs; from 5-6% in 2018, 8-9% in 2020 to 14-15% in 2022. Hence it likely to grow further in coming years; perhaps 40-45% by 2024.
Q Specifically, do you think IVUS use at your institution will increase?
A. In my opinion IVUS use will grow further than OCT use just because of the simplicity and avoid extra dye blouses injection. We are using more OCTs in the ongoing clinical research trials in the cath lab; Yellow-3, Unexpanded stent, ISR restenosis mechanism.
Q Will greater use of imaging increase the overall cost of the procedure?
A. That is correct the adding IVI will add $700 to the PCI cost which is absorbed as the part of procedure DRG for Inpts but for outpt PCI, receives the added reimbursement upto $1500.
Q How would greater emphasis on imaging affect physiological assessment of the lesion?
A. Clearly physiological assessment using FFR/iFR will not change as their value is in preprocedure lesion assessment for significance. We use FFR/iFR in about 62-65% of PCIs; some are not done especially if lesion is clearly >90% stenoses angiographically, or graft lesion or MI lesions.
Q For patients with liver disease, what is your anti-platelet strategy?
A. Liver disease (cirrhosis) pt usually have esophageal varies, higher GI bleeding and thrombocytopenia, hence single APT of clopidogrel 75mg daily is our routine recommendation avoiding aspirin due to its gastric erosion effect. This strategy has worked very well ell in liver disease pts so far us at Sinai which is a big liver transplant center.
Q Any strategy for anticoagulation during the procedure?
A. Anticogulation during PCI in these pts is preferably done using Bivalirudin because of reported lower bleeding rates with this strategy vs IV heparin.