Q&A
Q.
How many LIMA interventions do you perform each year?
A.
Of the 3800 PCIs we do every year, LIMA interventions are uncommon and makes about 1-2% of PCIs; approximately 30-50 per year. Majority (70%) PCIs are anastomotic lesions and remaining are done in the native LAD after the anastomosis.
Q.
Have you had a dreaded complication?
A.
Yes dreaded complication with severe CV collapse has happened rarely during LIMA intervention; once in every 2-3 years. Minor complications of dissection, chest pains and slow flow occurs in 3-5% of cases and can be managed easily by pulling back the guide wire, vasodilators injections and sometimes by additional stenting.
Q.
What was the biggest anticipated challenge in this case?
A.
Crossing a very tortuous complicated distal LAD lesion using the appropriate wire was the biggest challenge and then advancing the balloon across the lesion and was done masterly by Dr Kini with use of Guidezilla.
Q.
And the unanticipated one?
A.
Yes unanticipated events like LIMA dissections at the origin and in situ LIMA thrombosis has occurred rarely during overall LIMA PCIs.
Q.
Should one avoid imaging for such challenging access, if angiography is adequate?
A.
I agree that for LIMA intervention, imaging has very limited role and rather can cause the complications. Hence angiography is appropriate to judge the LIMA PCI results.
Q.
If the suture, masking as calcification, is expanded with a high pressure balloon, can the vessel perforate?
A.
Yes we have seen in the fresh (less than 3 mths) distal anastomotic lesion of LIMA or SVG, balloon inflation can break the sutures and cause limited localized perforation. That can be easily managed by prolonged balloon inflation or stenting. I have seen this localized perforation rarely in the freshly placed grafts PCI.
Q.
Could a laser or rotablator have been performed in this challenging anatomy?
A.
Yes rotational atherectomy can be done to the calcified LAD via LIMA and we do it in 3-5 cases per year. We have not done Laser via LIMA but yes can be done in the uncrossable lesions.
Q.
What would have been options if the PCI was not successful?
A.
If unsuccessful, will retry for PCI via LIMA as PCI of native LAD CTO was not possible. If still not successful, then only MMT would have been the last resort.
Q.
What factor(s) contributed to the success?
A.
Technical expertise was the most important factor for wiring the LAD and then use of Guidezilla was essential in crossing the lesion by ballon. We routinely don’t recommend using mother and child catheter in LIMA because of concerns about causing LIMA dissection.
Q.
How would you now follow up this patient? Stress test or CT Angio?
A.
This pt will be followed clinically and then will perform stress MPI annually if remains asymptomatic.
