PCI of CTO of Anomalous RCA Originating from Left Coronary Sinus – March 2014

76 year-old-woman with new onset CCS Class III angina, exertional dyspnea and positive ETT presented on March 3, 2014. A cardiac cath revealed native 3 vessel coronary artery disease (RCA, LAD, LCx; SYNTAX score of 17) and normal LV function. Patient had successful intervention of mid LAD and distal LCx using Promus Premier drug eluting stents. Now planned for PCI of chronic total occlusion of anomalous RCA originating from left coronary sinus.
Moderator: Sameer Mehta, MD



Q For an anomalous RCA, what would be your first choice of catheter?
A. AL1 will be first choice but lot will depend on the exact RCA orifice origin.
Q Please mention the catheters of choice for the anomalous RCA in positions A-D.
A. Position A (above LCA ostium)- FL3, Position B (below LCA ostium)- FCL3.5, Position C (just Rt of midline)- VL 3.5, Position D (around the midline)- AL1 (this is most common anomaly).
Q In which situations with anomalous coronary arteries, will you unequivocally send a patient for surgery?
A. Only if SCD survivor or significant ischemia on stress MPI and RCA cannot be engaged for PCI.
Q What is your favored support catheter presently?
A. Guideliner by far.
Q Do you have a particular strategy for selecting support catheter or the Guideliner?
A. Guideliner as work horse device and some un-crossable cases Corsair.
Q Always 6 F for a Guideliner?
A. Yes in majority (>90%) 6Fr Guideliner and 7Fr in remaining 10%.
Q What is your distribution of use among the newer DES available in your cath lab?
A. Approximate DES distribution in our lab is as follows; 60% Xience Xpedition, 35% Promus Premier and 5% Resolute Integrity.
Q Any situations where you would still use a BMS?
A. Yes >5mm vessel (rare RCA or SVG) or in AMI setting where large residual thrombus burden or not sure of pts DAPT compliance. Rare case of semi-urgent non-cardiac surgery to be done in 1-2 mts, pt will also get BMS.
Q Which DES do you prefer in the longest length?
A. In my opinion all newer DES are comparable with similar efficacy and ST rates; we prefer 38mm long Xience Xpedition.
Q And for the shortest diameter?
A. Small Xience Xpedition leads the pack in our lab.


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