PCI of RCA via Previous Ostial Protruded Stent – May 2019

61 year old male presented with CCS Class I angina and intermediate risk positive SPECT MPI for inferior and lateral ischemia done as the part of pre-op evaluation for shoulder surgery. A Cardiac Cath on May 7, 2019 revealed II Vessel CAD: 90% mid RCA DES ISR, 80% distal RCA, CTO of small distal LCx, 80% calcified Ramus Intermedius with SYNTAX Score of 20 and normal LV function. Patient underwent successful intervention of Ramus Intermedius using rotablator and Promus Premier DES. Patent ostial RCA stent is protruding 5-6mm outside the ostium causing difficulty in engaging the RCA. Patient is now planned for staged PCI of complex RCA (due to stent protrusion) using rotational atherectomy and DES.

Moderator: Sameer Mehta, MD

1:11:14

Q&A

Q Do you have any recommendations about which viewing option I should use to review cases?
A. In order to effectively utilize the viewers' time, we have created 20 minute abbreviated versions focusing on performance of the live procedure. This was in response to demand by many of our viewers. Hence, if goal of the viewer is just to see the procedure, then the 20 minute version will be ideal. Full webcast including lecture will always remain available.
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Q Does the 20 min short format contain all the tips and tricks that you discuss?
A. Yes, the 20 minute abbreviated video will contain all the interventional tips and tricks utilized in that particular case. Hence, will be very useful for learning which will not be compromised.
Q Can I watch the short format and download slides from the other long format?
A. Yes, presentation slides are always available at the website separately and can be downloaded as usual.
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A. I strongly believe that for the teaching purpose, full length video will be better as will contain numerous other discussion points pertaining to the case and the subject.
Q Are you planning to have both formats in the future?
A. We will provide both formats for 2018 and 2019 cases and then will evaluate their use. If it looks like 20 minute abbreviated videos are also frequently viewed, then we will continue both; otherwise will drop it after the trial run.
Q Is the webcast going to change in any way - you are not planning a shorter format?
A. The concept, theme and ingredients of ccclivecases webcast will continue to remain the same in its content with the added feature of a 20 minute abbreviated video too. Now soon we will be entering our 11th year.
Q Is there stalling of the Rotablator in in-stent segments?
A. Yes, overall Rota burr stalling is slightly more frequent in ISR compared to denovo lesions. Hence, extra care should be utilized during ablation and not to push the burr (no dottering) and slowly advance the burr ablating the intimal hyperplasia effectively and expanding the unexpanded stents.
Q If we did not have the 3DRC guider, which other guider could we use?
A. In RCA Stent protrusion cases, 3DRC, NOTO or AKARI guides are optimal. Rarely AL 0.75 could be an alternate too.
Q Is there another device other than the ostial flash balloon to treat protruding stents?
A. Ostial flash balloon is the only proprietary device available to expand and plaster the protruding ostial stent. In the past we used to use a large balloon (4-6mm) at the ostium and move the guide catheter up and down with inflated balloon to do the similar stent plastering technique; but this was a very crude method.

Comments

One Comment
Edo Kaluski
21 May, 2019

a) In case of emergencies when one does not have time to trial multiple guides there is no penalty to wire via the side of the protruding stent and create a new osteum with balloon dilatation.
b) In extreme cases you can even wire underneath the stent struts and crush the stent with balloon and a new stent
Kaluski E, Hendler A, Klapholz M. PCI of the right coronary artery via or under struts of stents protruding into the aorta. J Invasive Cardiol. 2007 Jul;19(7):E207-9. PubMed PMID: 17620689.

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