PCI of Tortuous LAD/Diagonal Bifurcation using Rotational Atherectomy and Mini-Crush Technique – November 2023

Case & Plan:
69-year-old female presented with CCS class III angina and positive SPECT MPI for anteroseptal & inferior ischemia. A Cardiac Cath on August 29, 2023 revealed 3 V CAD: 95% calcified non-dominant RCA, subtotal occlusion of calcified mid LAD with tortuous 90% LAD-D2 bifurcation (1,1,1), subtotal occlusion of LCx-OM1 with SYNTAX score of 20 and LVEF 60%. Patient underwent successful intervention of LCx-OM1 using Xience DES. Patient is now planned for staged PCI of tortuous LAD/Diagonal bifurcation using rotational atherectomy and Mini-Crush technique.


Q It seems that Mini Crush has become your favorite technique for tackling bifurcation cases
A. Yes MiniCrush is our preferred bifurcation technique for last 10+ years with excellent acute, short and long term results.
Q Why is that so, considering DK Crush is also very popular?
A. We prefer MiniCrush over DK crush because of 4 less steps needed and don’t have problems of recrossing for the FKBI.
Q Is it the elimination of several redundant steps that make Mini Crush attractive and efficient?
A. That is correct that total steps needed in DK Crush bifurcation are 12 which can safely be reduced to 8 of MiniCrush. Long term results are excellent and comparable with both techniques.
Q What are the absolute essential steps in Mini Crush?
A. Most essential steps of MiniCrush in order of magnitude are, 7Fr guide catheter. adequate lesion preparation, minimal overlap of SBr stent in MV, removal of SBr wire before MV stent inflation and FKBI.
Q How much difference has the new IVL catheter made?
A. New IVL catheter change is only to proved 4 extra cycles to 12 from earlier 8. Hence it has made difference in 15-20% cases especially in calcified MV PCI.
Q What further improvements are possible with the IVL procedure? There are several new catheters emerging that have synergies with IVL or a combination of ablative mechanisms.
A. Yes we need to improve the current IVL Catheter by making it more flexible, lower profile and RBP of 10 atm instead of 6 atm now, where some IVL balloon ruptures once go beyond 8 atm. There are 3 IVL catheters are in development which I am aware, one of them utilizing laser energy. The whole IVL field is going to explode in next few years.
Q Any technical areas where there may be simplifications while performing IVL?
A. Overall IVL procedure is already very simplified and can safely combine with atherectomy (Rota or Orbital). Key issue remains in the IVL delivery at the lesion and hence adjunct POBA is needed in 60% of cases and Atherectony in 20%.
Q Should RotaCut Trial have an IVL arm?
A. Actually RotaCut trial was based on the device synergy concept and failed to show higher MSA with CB after Rota. Since it was just a pilot study, we did not want to go to the next level of comparing it with IVL. Yes I can envision a future trial comparing RotaCB strategy with the IVl strategy.
Q PECTUS Obs study has exposed some fundamental flaws in solely relying on FFR and physiology that simply ignores the dynamics of a vulnerable plaque and plaque rupture.
A. That is correct and it explains the mechanism of cardiac events in FFR- lesions.
Q Is it not baffling to accept that FFR at the point of care will predict future events when there is absolutely no consideration of plaque morphology?
A. I fully agree that in future we need to incorporate OCT in FFR - pts especially in diabetics for proper risk stratification.


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