Staged PCI of Native LAD via LIMA – Oct 2011

72-year old female with prior 2V CABG in 1985 and CCS angina class III had high risk stress MPI for multi-vessel ischemia. Cardiac cath on June 6, 2011 revealed, 3V + LM CAD, patent LIMA to LAD with 90% lesion in native LAD after anastomosis, patent SVG to RCA and 95% lesion in native LPL and LVEF 60%. Patient underwent PCI of LM and LPL using Promus DES. Now planned for staged PCI of native LAD via LIMA.

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Q&A

Q Did you repeat the stress test after the PCI in June?
A. We did not repeat stress MPI after the first PCI as decision for complete revascularization using staged PCI approach was decided at the outset. That is what was done in the FREEDOM and SYNTAX trials; no repeat stress MPI between the stages.
Q Are you planning to use FFR in this situation?
A. Not as pt had mod-severe anterior and apical ischemia on stress MPI with a 85% angiographic lesion.
Q Are there issues of concern in the use of FFR for SVG/LIMA interventions?
A. I have not done but yes could be tricky sometimes as FFR wire is not very trackable and 1:1 torque response.
Q What precautions would you cite for cannulating LIMA with the guiding catheter?
A. Always look for the pressure tracing before injecting.
Q Which views are the most optimal for LIMA interventions?
A. AP cranial 45 degree or Lt lateral 90 degree.
Q Roadmapping lesions must be critical for LIMA interventions?
A. Yes as sometimes LIMA develop accordion after advancing the devices and distal vessel and lesions can’t be visualized.
Q What pharmacological agent serves the best for eliminating vasospasm in LIMA interventions? Which anti-coagulation do you prefer for LIMA interventions?
A. All cases are done with Bivalirudin now a days and has been associated with overall lower bleeding/vascular complications.
Q Have you performed Rotational Ablation via the LIMA?
A. YES total of 23 cases in last 10 years; of which 6 were done in live conferences. The indication for Rota was extremely calcified mid-distal LAD.
Q When would you consider the Left Radial access site for LIMA intervention?
A. Cases where there is poor guide support despite using a 45cm long sheath.

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