74 year old male with CKD Stage III presented with CCS Class II angina and positive stress MPI for moderate inferoapical ischemia. A Cardiac Cath on July 6, 2018 revealed 3 V CAD: subtotal mid LAD (Medina 0,1,1) with 95% bifurcating LAD-D2, 90% proximal LCx, 95% RPDA and 80% RPL with SYNTAX Score of 22 and LVEF = 60%. On July 6, 2018 patient underwent PCI to RPDA and RPL1 using two Promus Premier DES and then successful PCI of prox LCx using Promus Premier DES. Patient continues to have CCS Class II angina on tolerated medical therapy. Patient is now planned for staged PCI of mid LAD-D2 bifurcation using dedicated 2-stent technique.
Moderator: Sameer Mehta, MD
Q&A
Q
What would be the top 3 indications for Cangrelor today?
A.
Top 3 indications for IV Cangrelor use are; bridge to noncardiac or cardiac surgery, ACS with hemodynamic instability, PCI in stable CAD pts (antiplatelet naïve) with high risk angiographic features such as thrombotic, bifurcation, Calcified, LM lesions or multiple stents.
Q
Do you believe there should be a comparison between Cangrelor and Integrilin for a subset of PCI patients?
A.
I don’t believe that we need any more comparison studies between IV Cangrelor vs GP IIb/IIIa inhibiotrs (Integrilin or Tirofiban). In my opinion the important issue of need of IV Cangrelor during PCI in ACS or stable CAD pts loaded with Ticagrelor or Prasugrel, has not been resolved and will like to see some more clinical outcome data in these pts.
Q
For a complex PCI subset, not STEMI, when would you begin Cangrelor and when would you stop it?
A.
Based on the recent publications, if a pt has >3 high risk angiographic features (long, bifurcation, CTO, LM, thrombotic, calcified, multiple stents, multivessel PCI), it will be appropriate to start IV Cangrelor and continue infusion 2 hrs post PCI and give clopidogrel loading at the end of PCI.
Q
Regarding today's case, what options would an operator have to treat the diagonal branch, if there was no Rotablator?
A.
The diagonal lesion was very calcified and even 1mm balloon went but ruptured and hence we were left with limited options besides Rotablator, such as laser or orbital atherectomy. Another technique proposed is called ‘Ganadoplasty’ where you intentionally rupture a balloon once it engages the lesion but can’t open it, with a concept of causing intimal dissections during balloon rupture and then subsequently lesion giving way likely by expanding the balloon dissections in subintimal space. Other option could have been to leave it un-intervened and manage it medically with all other vessels opened.
Q
No way a cutting balloon or Angiosculpt would cross the lesion?
A.
Clearly, cutting balloon or Angiosculpt balloon would not have crossed the lesion due to their higher profile. As you know 1.5/12mm low profile compliant Apex push balloon did not cross the lesion.
Q
Or Orbital Atherectomy?
A.
Orbital atherectomy was certainly another viable option in this uncrossable/undilatable heavily calcified lesion where guidewire has crossed the lesion..
Q
There were some papers at TCT exploring the role of Lithotripsy for calcified lesions? Any thoughts?
A.
Lithoplasty balloon trial in calcified coronary lesions is set to start in USA in January 2019 (it is being used OUS). But again a bulky lithoplasty balloon would not have crossed this lesion.
Q
Which is the smallest balloon that is now in your cath lab?
A.
Saphire II Pro 1mm made by OrbusNeich medical and distributed by CSI in USA is the lowest profile balloon available in USA. It is followed by MiniTrek 1.2mm by Abbott, SprinterLegend 1.25mm by Medtronic and then 1.5mm Apex/Emerge by BSC. This whole line of balloons have made crossing the lesion close to 99.8% once guidewire has crossed the lesion.
Q
Going forward, in 2020, what would you predict your DAPT composed of? No aspirin?
A.
I predict that in future we will limit the use of DAPT for 1day to 1month only.
Q
Same question regarding anti-coagulants?
A.
Anticoagulants (warfarin or NOACS) must have either clopidogrel or aspirin as antiplatelet agent in ACS, MI and PCI scenarios. In these clinical conditions, we need antiplatelet inhibition in the background of anticoagulants. Also 3 trials have shown that only single antiplatelet therapy is required with anticoagulants and not two.
as per your conventional teaching side branch should only be stented in bifurcation lesion if its bigger than 2.75. what thought process made you to consider this dedicated bifurcation rather than provisional.
Dr.Kini has raised many important practical questions
Applaud many practical points raised by DR. kini.
1. cost of cagrelor vs integralin
2. Role of cangrelor in modern era preloaded with potent rapid acting p2y12 receptors appears to be limited
3. Cost of cangrelor has to be considered
Role of cangrelor has minimal role in current case since patient on plavix and assuming PRU checked.
Focusing on live hands- on technique is more important than didactics.
Having 2 screen showing live screen case and another didactics might need to be considered. So we don’t miss hands on technique by DR.Kini.
Excellent presentation and case
We learn a lot with you.
Thanks Masters
What was the total radiation dose in this case
Please give some insights about radiation safety and when to stop in such long cases.
Also, if possible so some cases of rotablation of LIMA…that would be really a treat to watch and learn
Thanks for such a great teaching initiative…