Complex coronary cases
Multivessel Staged PCI of CTO LAD and LCx OM2 using Orbital Atherectomy and DES with OCT Guidance – June 2017
Views 4726

62 year old male with recent onset CCS Class III angina with a positive SPECT MPI for inferior and anterior ischemia. A Cardiac Cath on May 2, 2017 revealed III Vessel CAD: 80% RCA-RPL1, 100% calcified proximal LAD with distal vessel filling via bridge collaterals, 90% calcified LCx OM2 bifurcation and SYNTAX score of 40.5. After Heart Team discussion, CABG was recommended, but declined. Patient underwent successful PCI of RCA branch RPL1 using Promus Premier DES. Now planned for multivessel staged PCI of CTO LAD and LCx OM2 using orbital atherectomy and DES with OCT guidance.

Moderator: Sameer Mehta, MD

1:32:33

Q&A
Q
In reviewing your conference coronary live cases, which of the live cases did you find most instructive?
A.

I found the most educational and instructive case was severely angulated calcified subtotal circumflex which had a potential of causing coronary perforation. This case was done very cautiously after crossing the lesion with Fielder wire and then exchanged for the Rotawire and used 1.25mm burr very cautiously. All went very well and we highlighted various points in performing Rota in these extremely angulated heavily calcified lesions.


Q
And among Structural Heart Disease?
A.

The case of Valve-in-Valve TAVR using Evolut R was very educational providing tips of accurate Supra annular deployment of the Evolut R Valve leading to minimal residual gradient.


Q
While teaching your students, which CTO score do you emphasize?
A.

J-CTO score is s simple and very useful tool in predicting procedural success as well rough time it will take for CTO lesion to cross. I usually ask the interventional fellows to calculate J-CTO score as part of pre-procedure discussion and analysis.


Q
Is the Ellis Proximal Cap Ambiguity a useful practical tool?
A.

Yes, proximal blunt tip, which is the ambiguous proximal cap certainly is an adverse factor for CTO recanalizaion.


Q
Should today's case have been performed with Rotablator?
A.

Both Rotational as well Orbital atherectomy can be used interchangeably in majority of calcified lesions. Hence yes, Rota could have also been used in today's case.


Q
What made you select Orbital Atherectomy?
A.

We have shown Rotational Atherectomy so many times in our live webcasts, hence, we wanted to teach the steps of performing Orbital Atherectomy (OA) correctly. That was simply the reason to use OA in the current case.


Q
In which aspect is Orbital Atherectomy simpler than Rotational Atherectomy?
A.

Orbital Atherectomy is simple to set up, simple to learn and all device parts & controls are on the table (field).


Q
Besides the degree of calcification (less for Orbital) and relative simplicity of use, can you define some indications where Orbital Atherectomy is more effective than Rotational Atherectomy?
A.

Orbital Atherectomy has the advantage of treating multiple lesions in a vessel by single burr by increasing the speed (80,000 to 120,000). Also, there is no need for temporary pacemaker with OA even during RCA or dominant Circumflex ablations. Our study of 20 cases with OCT have shown that in circumferential calcified lesions, Orbital Atherectomy makes deep cuts which results in better stent expansion compared to Rotablator.


Q
How do you find the specialty guide wires for Orbital Atherectomy in comparison to Rotablator wire?
A.

Viper wire by its virtue of 0.012" size, is better steerable and can be advanced in the vessel in the majority of cases rather than exchanging with the workhorse wire which we usually do with Rota wire (which is 0.009" and is very flimsy). Also in some proximal lesions, Viper wire can also be used to deliver balloons and Stents post ablation, avoiding inserting another 0.014" wire.


Q
Have you had any cases of stubborn no reflow with Orbital Atherectomy?
A.

Yes, we have seen some refractory slow flow even with Orbital Atherectomy but it certainly occurs less than with Rota. Treatment of slow flow remains the same with both devices; avoid hypotension, use vasodilators and in some cases IABP insertion for a few hours.


comments

Join the Discussion

One thought on “Multivessel Staged PCI of CTO LAD and LCx OM2 using Orbital Atherectomy and DES with OCT Guidance – June 2017”

  1. Shivan says:

    Excellent you are doing a great job


Leave a Reply

Your email address will not be published. Required fields are marked *

suggestion
Suggestions
Radial PCI of Long Complex Calcified LAD post TAVR – September 2020
Views 43

Case and Plan: 78 year-old-male presented on August 7, 2020 with progressive exertional dyspnea, NYHA class III. Workup revealed severe AS (AVA 0.7cm2), normal LV function and STS mortality of 1.1%. After heart team discussion, patient underwent successful TAVR using 26mm SAPIEN-3 Ultra with excellent results, AV area of 2.0cm2 and no PVL. A coronary […]


Stent Ablation with RA of Underexpanded Multilayer DES – August 2020
Tags: | |
Views 298

63 year-old male with known CAD, CABG x2 (1999) and multiple PCI’s to SVG to RCA and LCx branches presented with CCS Class IV angina and non-STEMI (TnI 1.2U). A Cardiac Cath on June 22, 2020 revealed patent LIMA to LAD, non obstructive LCx branches with patent prior stents and 90% multilayer in-stent restenosis of […]


Imaging Guided PCI of DES CTO RCA – July 2020
Views 639

57 year-old male with extensive CAD and PCI’s presented with crescendo angina on 8/20/2019 and Cath revealed 3 V CAD with DES CTO of RCA and normal LV function. CABG was recommended, but declined and patient did well on MMT. Recently started having angina and underwent Rota DES PCI of LAD/D1 bifurcation. Now planned for […]


IVUS Guided Orbital Atherectomy and DES of Tortuous Calcified LAD – June 2020
Views 683

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 […]