Staged Intervention of Multiple Calcified Lesions in RCA using BMS – July 2011
Case: 78-year old male with crescendo exertional angina (CCS class III) and SOB for one month. Patient had recent gastrointestinal bleeding requiring blood transfusion and upper endoscopy revealed duodenal ulcer. Cardiac cath on May 17, 2011 revealed 2V CAD (D2 and RCA) with normal LVEF. Patient underwent successful PCI of D2 using Integrity BMS. Now for staged intervention of multiple calcified lesions in RCA, again using BMS due to gastrointestinal bleeding.
QBesides for reducing DAPT duration, are there any other situations for which you will use BMS?
A.In two other situations; 1) STEMI with large residual thrombus burden despite thrombectomy and 2) large size SVG lesions
QWhich is your BMS of choice? Why?
A.Integrity of Medtronic at present and is largely due to better delivery compared to other BMS.
QWhat is the percentage of BMS used at your institution?
QWhat is the duration of DAPT you recommend for BMS? Would you continue Aspirin though, and at what dose?
A.For BMS DAPT is for 1 month only in cases where surgery is planned; otherwise routinely prescribed for 1 year. Aspirin 81mg daily is continued lifelong.
QAny benefit of Prasugrel instead of Clopidogrel for BMS?
A.Yes as shown in TRITON trial Prasugrel had the same efficacy and lower stent thrombosis advantage over Clopidogrel even in BMS.
QIn a GI bleed post PCI, at what level will you transfuse if the patient is asymptomatic?
A.There is no lower limit now a days and we have managed even Hct of 18-20% without transfusion, as long as pt is not tachycardic/symptomatic. There have been trials to answer the question and have shown that for similar drop in Hct, pts with transfusion do worse vs. managed conservatively.
QHow will your patient now fare, when you have used several DES in a situation where you wanted to use BMS to reduce the risk of GI bleeding?
A.Yes that is a challenge and we will manage the pt more proactively from GI point of view; start PPI and watch out for early sign of bleeding and get upper endoscopy ASAP, GI bleeding is suspected.
QWhat are some key points for the safe use of the Guideliner "daughter" catheter?
A.It just needs to be slowly advanced into the vessel over the guidewire. Also don’t aspirate the guidecatheter while guideliner is in place as it may aspirate air column. Also make sure ACT continues to be around 300sec as it tend to make some blood clots at lower ACTs especially when used in 6Fr guides.
QIn what particular situations do you use it?
A.For extra back up support for stent/balloon delivery in tough, angulated cases (native or SVGs) and CTOs.
QWhat single message do you want to give the viewers on your second anniversary as to why they should watch your webcast?
A.The main theme and focus of the live cast after 24 cases remains the same; Skillful demonstration of procedural technical steps in safely performing the complex cases.