Staged PCI of LCx/OM1 Bifurcation (Medina 1,1,1) – March 2013

73-year old male with multiple CAD risk factors, CCS Class III angina and high risk MPI presented on 2/8/13. Cath revealed 3V CAD and LVEF 55% (SYNTAX Score 25). Patient has moderate to severe MR on echo. CABG and MVR was recommended but declined even after Heart Team consultation. Patient underwent PCI of proximal LAD and Ramus Intermedius using Xience Xpedition DES. Now staged for PCI of circumflex/OM1 bifurcation (Medina 1,1,1).

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Q&A

Q We note your prefered technique is SKS - in what specific bifurcation lesion subsets do your recommend it?
A. SKS is preferred in the large bifurcation lesions (where side-branch is >2.75mm) especially of distal LM.
Q Are you concerned with double lumen during SKS?
A. Now we have enough follow-up that double lumen of SKS technique does not cause any problem at long term and if needed we can advance various devices thru them distally..
Q Are proximal dissections a problem with SKS?
A. That is correct that proximal dissection is very problematic in SKS technique and if significant then will require making a long crush. But it was needed in <0.2% of our SKS cases, once done correctly and did not deploy stents at high pressures.
Q Do you alter your anti-platelet strategy for bifurcating lesions?
A. Not really as Clopidogrel is standard in majority and some high risk cases gets Prasugrel.
Q For which lesion subsets could orbital atherectomy be superior to rotablation?
A. I do not know yet as there has been no comparison done so far. Perhaps lesions with side-branches and perhaps multiple calcific lesions of varying ref vessel size will be better served with Orbital atherectomy device (because one device can fit to the majority of vessel sizes).
Q Will orbital atherectomy work for a concentric 360 degree calcification?
A. YES and we have data from ORBIT II trial to prove this efficacy.
Q For which lesions will you not use DK crush?
A. DK crush will be preferred when side-branch disease is long and diffuse and 2-2.75 size vessel.
Q For which lesion will you not use SKS?
A. If long proximal disease before the bifurcation, then SKS is not recommended as it will make a long carina. Although a modification by first inserting a proximal stent and then insert 2 stents distally in SKS fashion can be done and has been described by us.
Q Have you found any use for the Extended V technique?
A. Not really and hence should keep 'V" as little as overlap possible proximally.
Q What percentage of your bifurcation lesions are double stents?
A. Of the approximately 100 bifurcation lesions we do per month in our cath lab, about 1/3rd requires 2 stent strategy. Majority of 2 stents strategy in our lab is planned based on the bifurcation lesion characteristics and rarely it is done as the bailout strategy.

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