Q&A
Q.
In hindsight, 1.75 burr?
A.
I agree that 1.75mm Rota burr (rather than 1.5mm burr used) would have done the better severely calcified plaque modification and made the subsequent procedure easier.
Q.
Would Orbital be a choice?
A.
Yes Orbital atherectomy could have been used too and it does better plaque debulking by deep wall cuts.
Q.
Laser?
A.
Laser (ELCA) in severely calcified lesion is suboptimal and hence will not be the choice. Laser is used in uncrossable lesions and unexpanded ISRs.
Q.
What was the cardinal event that led to a successful result and excellent outcome?
A.
Rather then a single sentinel event for the excellent procedural results, it was the aggregate of multiple small steps of increasing the NC balloon size, IVL use and cutting balloon in the Diagonal and then covering the Diagonal ostium by MiniCrush 2 stent strategy. All along the case, IVUS helped tremendously in the decision making.
Q.
What are the major issues with IVL delivery and device?
A.
IVL being bulkier device, didn’t reach the distal part of prox LAD. But it did work at the ostial LAD part.
Q.
How often are you using IVL?
A.
Our overall IVL use is 32-35 per month (10% of PCIs); of which half is after Rota (RotaTripsy) and other half is stand alone in lesions like underexpanded ISRs, 70-80% proximal lesion in 3mm+ vessels etc.
Q.
De novo or as an adjunct to Rotablator?
A.
As stated above, half and half after Rota and stand alone. IVL use has almost eliminated the use of 2nd stepped Rota burr; 2% now vs 10% pre IVL.
Q.
Of the newer ablation technologies, which holds the largest promise?
A.
Newer ablation technologies are, Laser IVL, Forwarding looking IVL without wire for CTOs, RF IVL, New Rota burr with added ablative surface in proximal half, & many more. Of these Laser IVL is most promising due to lower balloon profile and added energy (15) cycles. The device got CMS approval for their Fracture Trial; we will be starting it in next 1-2 months.
Q.
Could OCT have been used in this case?
A.
OCT could have been used too but unlikely would have not changed the difficulties we encountered. Decision of 1.5mm rather than the 1.75mm Rota burr was the biggest contributor to our procedural challenges. But in the end, we got the best results of RotaTripsy and MiniCrush Stenting of LAD/Diagonal as circulated in the eblast announcement.
Q.
Any ablative therapy on the horizon with imaging coupled in the device?
A.
Apparently Shockwave is working on a combined IVL and IVUS device. I am sure in coming years we will have a handful of these combined technologies.
