Q&A
Q.
What made you decide to withdraw the guide to enable the advancement of the 1.25 Rotabur?
A.
When we had difficulty in advancing the Rotaburr, with the usual guide positions (pushing them), pulling the guide back to better align the guide making it coaxial to LM helps, like in this case. It also makes Rota wire in the center of the vessel lumen avoiding wire bias too. Then we were able to advance the burr to the trouble spot with effective stent ablation and the subsequent successful procedure.
Q.
Do you believe this was the sentinel moment of the case?
A.
Yes it is with stent ablation by RA, PCI became successful; otherwise would have unsuccessful as even ELCA also failed cross the lesion and even 1mm balloon barely crossed and ruptured. Hence successful RA with guide pull alignment was the sentinel moment of last Tuesdays live case.
Q.
What did this precise action do - ablate through an obstructing strut?
A.
Yes Rota ablated the crisscross multiple stent struts, which were obstructing the forward passage of any device. Aligning the guide by pulling and removing wire bias were the simple ways for our RA to succeed.
Q.
Or ablate neoatherosclerotic calcification?
A.
Yes part of the obstruction in addition to the metal stent struts could also have been the calcified neo-atherosclerosis.
Q.
As you reflect on the case, was it probably better to use rotational ablation instead of the laser?
A.
Yes my choice in this case based on my earlier personal experience, would have been Rota-ablation as the first strategy; right from the get go.
Q.
What is the biggest technical takeaway from the case?
A.
Simply take away message from today’s case is that RA is your friend in tough complex cases and should be liberally used when appropriate and early in the process.
Q.
If the procedure had been performed at another institution, would you have approached device use differently?
A.
Now a days it’s very easy to get hold of the old angiograms from other institutions and then our procedural strategy would have been similar.
Q.
How do you recommend following up with this patient? CTA?
A.
This pt should come back for angio follow up as if restenose (very likely)5, then IVBT can be used.
Q.
What are the risk stratification goals for this patient?
A.
Pt has reasonably controlled CAD risk factors, hence not much more can be suggested, except for adding the PCSK-9 inhibitor.
Q.
Is CABG permanently avoided?
A.
Chances of CABG in this pt still remain on the horizon being 15-25% due to recurrent ISR. Pt csn get Robotic LIMA to LAD & Diagonal.
