Complex coronary cases
IVUS/OCT Guided Rotational Atherectomy and DES of CTO RCA BMS ISR – June 2016

55 year-old female presented with CCS class III angina and positive stress MPI for moderate ischemia in the anteroseptal and inferoposterior segments with mild inferior infarct. A Cardiac Cath on May 6, 2016 revealed 2V CAD: 95% prox RCA, total occlusion of distal RCA BMS instent-restenosis (ISR) filling via LAD collaterals, 90% mid LAD with normal systolic LV function; SYNTAX Score of 16. Patient underwent successful intervention of mid LAD using Promus Premier DES. Patient is now planned for IVUS/OCT guided rotational atherectomy and DES of totally occluded RCA BMS ISR.

Moderator: Sameer Mehta, MD


For which patient subsets in 2016 are you using shortened DAPT?

We have cautiously started 6M DAPT in only selected pts such as single DES in prox- mid large (>3mm) vessels in stable CAD pt. I am sure with due course of time and gaining our own experience, more lesion subgroups will get short DAPT.

For which patient subsets in 2016 do you recommend longer DAPT?

Pts with LM, Bifurcation lesions with 2 stents, >3 stents and low EF (<30%) are still getting 3yrs or longer DAPT at our center.

Are you teaching your fellows to practice individualized DAPT approach?

Yes on the lines I have described above.

What is your proportion for Clopidogrel, Prasugrel and Ticagrelor?

AIn stable CAD PCI, Clopidogrel is 60% and Prasugrel and Ticagrelor each 20%; usually in complex cases.

How would this ratio be different for ACS?

For ACS PCI, Clopidogrel makes 20% with Prasugrel 30% and Ticagrelor 50%.

Very disturbing reports about three quarter patients having wrist impairment - did you suspect the numbers would be so high?

I think this was one report of its kind and we certainly do not see this high degree of hand dysfunction in our clinical practice. In my opinion hand dysfunction may occur in about 10-15% of TRI cases.

How high do you feel are these numbers?

I think real number for wrist impairment is 10-15%; not 75% of cases as reported in this EuroPCR study.

This should greatly negate the proposed benefits of wrist access?

We certainly have to wait for some more prospective trial data before making any final conclusions. But yes having hand/wrist dysfunction and higher femoral vascular complications in predominantly TRI centers, is a matter of concern and needs to be properly addressed.

Do you feel we need a meticulous exploration of the wrist impairment issue - before guidelines rush to change recommendations favoring wrist access?

I believe that RCTs have shown survival benefit of radial over femoral access in ACS and lower vascular bleeding/complications in all cases. These benefits of radial access will out way the hand dysfunction and should continue to be our primary message. Of course needs to be vigilant about the hand dysfunction.

It remains very troublesome how such a frequent complication escaped our attention?

Clinically we were encountering this wrist/hand dysfunction problem in 5-10% of cases especially in cases of radial occlusion after TRI. Current report has just high lighted the issue and more prospective work needs to be done in this regard.


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