Complex PCI of LM Bifurcation and Distal LAD – July 2013

67 year old male with long standing CAD and multiple prior PCIs, presented on July 14, 2013 with progressive crescendo angina. Cardiac cath revealed 3V + LM disease (syntax score 32) with mild LV dysfunction. Cardiac surgical consultation done and CABG declined (due to poor distal targets). Patient underwent PCI using Rota + PTCA of distal RCA DES ISR. Now for complex PCI of LM bifurcation and distal LAD.

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Q&A

Q How much do you further expand a 4.0mm DES?
A. Studies have shown that you can expand a DES to additional 1mm size without compromising it's integrity. Hence 4mm DES can safely be expanded to 4.75-5.0mm size. Hence EXCEL trial has excluded LM size >4.75mm.
Q If the LMCA is between 5.5 - 6mm, what is your strategy?
A. To use BMS if LM size is <5mm, is the usual strategy.
Q Any condition in which you will still use a BMS for LMCA?
A. Yes if pt needs non cardiac surgery in <3mths so that DAPT can safely be interrupted after one month. Same way if pt is noncompliant with DAPT, BMS will be used.
Q Do you feel IVUS is mandatory for LMCA interventions?
A. IVUS is not mandatory but recommended as some registry data have shown LM PCI with IVUS to be superior to LM PCI without IVUS. We use IVUS guided LM PCI in about 25% of cases at Mount Sinai. We perform approx. 25 LM PCIs per month.
Q Can Excel be a game changer?
A. Not really as many cases of low to intermediate (<32) Syntax score LM pts are currently undergoing PCI. This practice is supported by current guidelines. Yes if results will be against PCI, then recommendations may change in favor of CABG.
Q How long, do you feel, are we from getting a broader indication for LMCA interventions?
A. EXCEL trial results will settle that issue. It still will not help us in high Syntax score (>32) LM pts, as those have been excluded from the trial.
Q Do you perform plaque modification for most LMCA? In what cases will you not perform plaque modification?
A. Yes majority of LM disease cases gets plaque modification; about 70% Cutting balloon and 20% Rotablator. Moderate (50-70%) noncalcific LM lesion in the body of LM, can safely undergo stenting without plaque modification.
Q The absolute mandate for a hybrid procedure must include a LIMA-LAD, correct? As this is the best surgical reason for CABG?
A. That seems to be the prevailing practice but rarely CABG vessel could be other then LAD if lesion is very complex such as a CTO and LAD lesion is simple.
Q Do you see any role of OCT in LMCA interventions?
A. While IVUS data have been well incorporated in our practice of LM PCI (PCI if lumen CSA is <6mm2 and post PCI minimal lumen should be >9mm2), we have very few data with OCT. I do think OCT is very useful to assess LM stent endothelization, if question of DAPT interruption arises within one year of LM DES placement. If DES is endothelized well as shown by OCT, then IVUS can safely be interrupted.
Q In which LMCA cases do you recommend IABP support?
A. LM pts with LVEF <30% and complex intervention requiring 2 stents and/or rotational atherectomy or if RCA is totally occluded, should undergo LM PCI with IABP (or in some cases with Impella) support.

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