Complex coronary cases
IVUS Guided Orbital Atherectomy and DES of Tortuous Calcified LAD – June 2020

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Case and Plan:

72-year-old male presented with rest angina and Non-STEMI, peak TnI 7.6. A Cardiac Cath on February 6, 2020 revealed 3 V CAD: 95% ulcerated proximal RCA, severely calcified 80-90% proximal and mid LAD, 80% proximal LCx, 70% proximal Ramus Intermedius with LVEF 45% and SYNTAX Score of 32. Patient underwent successful culprit vessel PCI of RCA using Atherotomy and Promus Premier DES. Patient did well and continued to have CCS Class II angina on GDMT. A stress echo on June 18, 2020 revealed near normal LV function and significant anterior wall ischemia. Patient is now planned for IVUS guided orbital atherectomy and multiple stents of tortuous calcified LAD lesions.

Please explain the characteristics of the new Viper wire that are favorable?

New Viperwire Flex has Nitinol core body compared to stainless steel in the conventional Viperwire. This makes it more flexible and less predisposed to straightening and dissection in the tortuous coronary arteries. It does provide less support then conventional Viperwire. I suggest to use it in 20-25% of OA cases involving vessel tortuousity.

In what non-Orbital cases can this wire be useful?

In about 20-25% of OA cases involving lesion/vessel tortuosity and angulation, new Viperwire Flex will be appropriate.

How would this wire compare with the Whisper wire for tortuous lesions?

Whisper wire also has the nitinol core and hence will behave similarly but has stronger body being 0.014” compared to 0.012” of Viperwire Flex. Overall both wires are made for the tortuous and angulated lesions.

You made a statement of using only 80K speed for the device. Why?

We had observed that 120k speed of OA is associated with higher coronary perforations then 80k speed and hence have totally abandoned (using It in only 1-2% of cases). Moreover 80K speed OA is very effective in ablating the calcific plaque with subsequent full stent expansion.

What is the problem with the higher speed?

OA with 120K speed Is associated with higher perforation and dissections and hence is not recommended.

What is your best indication for Orbital Atherectomy?

OA works the best in severely calcified lesions In large vessels (>2.5mm size) especially with circumferential lesion calcium on IVUS.

Where would you avoid this device?

OA will not be appropriate in aorto-ostial lesions, extreme tortuous lesions, unexpanded stents and post failed PTCA.

Is there any clear indication for which Orbital Atherectomy is clearly superior to Rotational Atherectomy?

Performance wise both OA and RA are effective but OA will be safer then RA in cases with borderline hemodynamics as it causes less slow flow and hemodynamics compromise. Also RCA intervention where using TPM is difficult, will favor OA use over RA.

Can you extrapolate Twilight benefits to Prasugrel?

We can not directly extrapolate benefit of stopping aspirin on background of Ticagrelor as noted in the Twilight trial, to other antiplatelet therapy of Prasugrel or clopidogrel. I predict that if Twilight type trial is done with Prasugrel, we will have similar lower bleeding benefits of stoping aspirin without any increase in ischemic events.

And to Clopidogrel?

I personally do not think that benefit of stopping aspirin can be extrapolated with use of clopidogrel as overall it is a weak antiplatelet agent and has resistance in 15-20% of cases. These cases will have higher chances of ischemic events post PCI.


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2 thoughts on “IVUS Guided Orbital Atherectomy and DES of Tortuous Calcified LAD – June 2020”

  1. ehsan says:

    i tried to download the cases PPT file but I couldnot so, would you please let me know if there is any other way to download them?

    1. PPT link is working. Thank you.

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