PCI of LAD-D1 and LAD-D2 Bifurcation using Double Mini-Crush Technique – February 2024

Case and Plan:
75-year-old male with CCS Class III angina, negative SPECT MPI, but CTA with significant 2 V CAD. A Cardiac Cath on January 19, 2024 revealed 2 V CAD and anonmalous LCx: 95% proximal RCA, 80% mid RCA, long 80-90% moderately calcified LAD lesion with large size 80% D1 & moderate size 90% D2 bifurcation lesions, SYNTAX Score of 22 and LVEF 60%. Patient underwent successful interventions of RCA using two DES and did well. Patient is now planned for staged PCI of LAD-D1 and LAD-D2 bifurcation using double mini-crush technique.


Q Is this your first live presentation of two mini-crush procedures in a single vessel?
A. Yes that is correct as needing 2 MiniCrush in a pt is very unusual as it requires 2 SBr of >2.5mm size originating from the long lesion of the MV. This was my only 4th case of this type ever but is very innovative and interesting approach. And was the 1st live case involving 2 MiniCrushes.
Q What should be the overriding concern in attempting such a case?
A. Most important concern is ability to advance the second SBr stent as main vessel stent, even deflated, may pose the hurdle in advancing the 2nd SBr stent.
Q For such cases, does access matter?
A. We absolutely will prefer Femoral approach being 7Fr guide requirements and better guide support, but it can also be done via Radial approach by the experts.
A. IVUS is preferred for its ease of use and not requiring extra contrast injections but OCT can also be done. Although OCTOBER trial of OCT guided bifurcation trial showed better outcomes with OCT vs angio guided alone.
Q 7 or 8 French guider?
A. 7Fr guide will suffice like we did in our case. If only 6Fr Guide is the choice then, it has to be either double DK-Crush or double step crush technique for individual SBr Stenting before advancing the MV stent.
Q Should we altogether replace SPECT Thallium with CT angio?
A. My opinion in this field and supported by the society guidelines, strongly suggest CTA and Ca+ score as the first screening test for CAD; preferred over SPECT MPI.
Q If there is a direction to do so, do you not lose out on the benefits of the physiologic aspects of a stress test?
A. It is correct that stress test gives us more physiological information about the pts overall cardiac health over CTA and is recommended if some plaque is detected on CTA. In my opinion MPI has an important role in following the pt post-PCI or post-CABG.
Q For post-PCI monitoring, have you replaced stress testing with CT angio?
A. CT angio still has not been very accurate to detect stent patency with over-reading of ISR. Hence post-PCI monitoring is best done by stress MPI every 1-2 years.
Q How far is CT angio from identifying a vulnerable plaque with accuracy?
A. Current CT angio plaque detection can accurately determine and predict vulnerability by showing positive remodeling, low plaque attenuation, napkin ring sign and spotty calcification. There are now 2 AI models of CT angio to report plaque characteristics in addition to FFR; CLEARLY and HEARTFLOW.
Q What are you using as anti-platelets in the ER for short D2B STEMI?
A. Ticagrelor 90mg with chewable aspirin 325mg is our anti-platelet therapy of choice in STEMI pts; part of STEMI pack with Atorvaststin 80mg, s/l nitro and IV heparin 5000U.


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