74 year-old male with new onset crescendo CCS Class III angina had high risk stress MPI for severe inferior and moderate lateral wall ischemia. A Cardiac Cath on October 31, 2014 revealed III Vessel CAD; 90% calcified distal RCA, 60% calcified mid-LAD, 90% proximal LCx, 80% OM1 and 90% OM2 with normal systolic LV function; SYNTAX Score 22. Patient underwent rotational atherectomy and two Promus PREMIER DES to distal RCA with excellent results. Patient is now planned for staged PCI of proximal LCX, OM1 and OM2 bifurcation with planned two stent strategy.
Q&A
Q
When using multiple stents, how important do you feel it is to use the stents of the same brand that have the same drug?
A.
There is no clear scientific answer to this question, but it makes sense to use the same brand DES at one sitting, in order to track the outcomes. Certainly if one DES does not cross and correct size stent is not available in the lab, then other DES can safely be used even in overlapping fashion. Only adverse data of overlapping DES was with TAXUS DES (likely paclitaxel drug) which we do not use now.
Q
For staged procedures, do you search for which DES stent (and drug) was used before?
A.
Even for the staged procedure, as long as there is no intervening stent related issues (thrombus, edge dissection), our policy is to use the similar DES used for the first PCI for the reasons explained above; easier follow-up and tracking the results. Hence interventional fellows have to know the DES brand used first time before the staged PCI. Our usual policy for DES in-stent restenosis (ISR) is to use a different brand stent possible, although there are conflicting reports in literature about using the same (Homo-stent) versus different (Hetero-stent) DES for DES ISR.
Q
How often are you switching to newer oral anti-platelet agent for patients already on Clopidogrel?
A.
If there is a clinical need to switch to newer anti-platelet agent (such as high risk lesion, allergic reaction or stent thrombosis) in pts already on Clopidogrel, policy is to load 30mg of Prasugrel (Triology trial) or 180mg of Ticagrelor (Plato trial) followed by respective maintenance dose. It occurs in approx. 20% of PCI cases.
Q
Is that always preceded by platelet function assays?
A.
In most of these switch cases, we do perform platelet function assay as PRU by ACCUMETRICS device; cutoff for switch being PRU of >230.
Q
You sometimes balloon dilate a segment distal to the stent to improve distal flow. Are you not concerned about leaving such lesions without stenting as the intimal lining has been balloon-disrupted?
A.
My usual policy of dilating the distal stent edge with same stent balloon for 30 sec at 2atm is largely done to compress vertically redistributed plaque distally in cases of mild-mod diffuse disease. This practice of low pressure inflation has neither been associated with restenosis nor dissection, rather it makes lesion look better most of the time.
Q
Overall, do you prefer a single stent strategy for bifurcations?
A.
In our cath lab of all coronary bifurcation lesions, 80% are done with 1 DES and 20% are done with 2 DES (mostly planned and not bailout) which is the optimal working policy.
Q
Is there an absolute angulation degree for which you will not use Rotational Ablation?
A.
There is no absolute angle where Rotablation (if clinically indicated for heavy calcium) can’t be done using small size burr. Certainly Rota should be avoided in extremely angulated lesion >70degree unless lesion is very calcified and chances of PTCA failure are high.
Q
Is downsizing the burr a viable option in these cases?
A.
Yes these cases should be done with a smaller Rota burr (B:A ration of 0.3-0.4), best being use of 1.25mm Rota burr.
Q
Do you routinely administer intracoronary nitroglycerine before taking final angiograms post-PCI?
A.
Yes IC Nitro 100-200mcg or IC Verapamil 250mcg is routinely given before the final cine without guide-wire to avoid any spasm caused by device manipulation. Also DES size is determined by baseline pre-PCI shot done after IC vasodilators to assess the correct vessel size.
Q
Would you let a fellow independently perform this intervention?
A.
This case was a very complex case and will not allow the interventional fellow to do the case unless they have done 300+ cases independently. That rule will also apply when they become independent practitioner after graduation.
