Complex coronary cases
PCI of Heavily Calcified Unprotected Distal LM Lesion using Atherectomy and 2-Stent Approach – July 2014

86 year-old-male with mechanical aortic valve prosthesis and prior PCI’s of LAD and RCA presented with crescendo leading to rest angina. Cardiac Cath on July 7, 2014 revealed 90% calcific distal left main bifurcation lesion with patent prior stent sites. Echo revealed LVEF 50% and normal functioning aortic prosthesis. CABG recommended but declined due to age and re-do surgery. Patient is now planned for PCI of heavily calcified unprotected distal left main lesion, using atherectomy and two stent strategies and possible IABP assist.

 

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Q&A
Q
Based upon the recent data, and your comprehensive presentation from today, do you feel IVUS should be used for all ULMCA interventions?
A.

I would support the use of routine IVUS in ULM PCI using 2 stents technique. But I still would not make it a ACC class I indication or recommendation.


Q
Any situations regarding unprotected LMCA where OCT may be of any help?
A.

There are very little data to support OCT during ULM PCI.


Q
When will you perform FFR for LMCA interventions?
A.

ULM lesion at ostium alone or ambiguous lesions in dLM are the best lesions for FFR.


Q
While performing LMCA interventions, do you always wire both the LAD and LCX?
A.

I would recommend routine use of wires in both the branches even with the crossover technique of 1stent use in ULM PCI.


Q
If there is no LCX disease in the presence of severe distal LMCA, should have have a preferential strategy of stenting across the LAD?
A.

Aggressive lesion preparation prior to stenting to decrease plaque shift should be routinely done.


Q
Are you tending away from kissing balloon for LMCA interventions?
A.

Data support that routine kissing balloon inflation after 1 stent technique does not provide any additional benefit during ULM stenting. Kissing balloon inflation after 2 stent technique of ULM should be mandatory.


Q
Always debulk LMCA prior to stetting
A.

Yes debulking of some sort should be be routine in ULM stenting. We do debulking in over 90% of ULM PCI at Mount Sinai Hospital.


Q
Any situations to use BMS for LMCA stenting?
A.

Only cases where pt needs non cardiac surgery in less then 3 mths or pt can not take DAPT, will be appropriate for BMS.


Q
Do you have an algorhythm for debulking with Rotablator, Angiosculpt, Orbital Atherectomy or Cutting Balloon for debulking LMCA?
A.

I recommend Rotational or Orbital atherectomy in heavily calcified lesions and others using Cutting balloon or AngioSculpt will be optimal. Orbital atherectomy should be avoided in the calcified ostial LM lesions


Q
What do you feel will be the next guideline recommendation for unprotected LMCA?
A.

I strongly believe that PCI of isolated ostial ULM lesions and ULM lesions with Syntax score <33 even if pt is a good surgical candidate, should also get ACC Class I recommendation.


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