Staged PCI of Severely Calcified RCA Lesions – November 2018

53 year old male with CKD on HD, known extensive inoperable severe calcific CAD and s/p SAVR in Nov 2017, now presented with NSTEMI and TnI 8.5. A Cardiac Cath on October 30, 2018 revealed severe calcific 3 V CAD: new totally occluded calcified prox LCx, known CTO of D1 & Ramus and multiple 80-90% lesions of mid, distal RCA and RPDA with SYNTAX score of 53 and LVEF 45%. Patient underwent successful intervention of culprit calcified proximal LCx using Rotational Atherectomy and DES (5/18mm Resolute Onyx). Patient did well and continued to mild angina and dyspnea. Patient is now planned for staged PCI of severely calcified RCA lesions using Rotational Atherectomy (step burs) and multiple drug eluting stents.

Moderator: Sameer Mehta, MD



Q Could this case have been done with any other atherectomy device?
A. Yes. Orbital atherectomy (OA) could have also been used but final results may not have been this excellent because large RCA vessel size (4mm); 1.25mm OA crown, can give lumen of 1.6-1.7mm only. Laser atherectomy will be less effective in this heavily calcified lesion in large vessel.
Q Could a high pressure balloon obviate the use of atherectomy?
A. This kind of severe calcification usually will not yield with high pressure non-compliant balloon dilatation or atherotomy by cutting balloon or Angiosculpt.
Q How often are you using a >2mm Rota burr?
A. In about 5% of the total Rota cases. Most common are 1.5mm and 1.75mm; both around 40% each. We use 1.25mm burr in 10-12% of Rota cases.
Q What would be the DAPT strategy for this patient?
A. Since this pt is in Afib, our recommended strategy is Clopidogrel 75mg daily for lifelong with Warfarin daily to keep INR around 2 lifelong for Afib. If needed, we can switch clopidogrel to aspirin 81mg after one year. We do it advocate triple therapy post DES. Our usual DAPT strategy in pts requiring AC is Xarelto 15mg daily and plavix 75mg daily. This pt could not get approval for NOAC from the insurance and hence is on warfarin.
Q As you look back over 2 decades, has rotational ablation become easier?
A. The advent of RotaPro device has made the equipment simpler now.
Q What are the present drawbacks?
A. Drawback of RotaPro are; big harness cable, separate activation knobs for burring and for Dynaglide, lack of tactile feedback as burr seems to advance with little resistance.
Q How much has Orbital Atherectomy (OA) impacted Rotational Atherectomy (RA) in Mt. Sinai?
A. Actually, overall atherectomy use at MSH has gone up from 16-17% in 2013 to 24-25% today; 75% RA and 25% OA.
Q In your mind, what seems to be the best anti-inflammatory agent today for RIR?
A. We do not have any approved commercially available anti-inflammatory agent, and in the current available agents, high dose statins with added Ezetimibe or a PCSK9 inhibitor still remain the best (only) agent for RIR.
Q How important is the role of statins?
A. High dose statins are very important to suppress vascular inflammation.
Q Is NIR obsolete for any research regarding inflammation?
A. NIR is a great device to identify TCFA and lipid contents of the plaque. It’s utility remains in the research arena. NIR is making a comeback in USA with a new reformed catheter with a Japanese sponsor. It still needs to be seen, where it’s actual role will be in the future.


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