Case and Plan:
87-year-old male s/p TAVR (March 2022) presented with NSTEMI. A Cardiac Cath on July 18, 2022 revealed 3 V + LM CAD: 80% calcified RCA with unexpanded in-stent restenosis, 90% distal LM bifurcation with SYNTAX Score of 34. Patient underwent successful interventions of LM bifurcation using atherotomy and single crossover stent from LM to LCx and did well. Patient is now planned for imaging guided staged PCI of calcified RCA unexpanded DES ISR using a combination of ELCA, RA and IVL.
Q&A
Q
How should this case be handled in sites that lack imaging?
A.
Careful review of the prior angio in this pt showed that protruding ostial RCA stent was compressed by the Sapien valve balloon at the time of TAVR procedure. Hence major mechanism of restenosis in this pt was external compression of the RCA stent by the Sapien balloon and high pressure NC balloon dilatation with or without IVL/ELCA will give excellent angiographic results. That exactly happened in this pt. Hence in lieu of lack of intracoronary imaging, PCI can safely and optimally be guided by angiogram alone.
Q
How would you compare IVUS vs OCT in this case?
A.
In this case both IVUS and OCT will be comparable as there was no calcification. Ostial lesions are imaged better with IVUS and calcified lesions images better with OCT.
Q
Any role for physiological assessment, before or after the procedure?
A.
We have learnt that once coronary obstruction is 90%+ visually, FFR/iFR are always low (+) and hence is not necessary. This practice is also supported by the recent ACC Revascularization guidelines. The role of post-PCI physiology is still under investigation with some value support by small trials but no conclusive recommendations yet.
Q
Could this procedure be performed via wrist access?
A.
Yes this pt could alternatively, safely and easily undergo PCI via radial access as RCA lesion was proximal. Value of femoral access really comes in complex cases using 2 stents or when needs extra guide support for distal tortuous lesions.
Q
Where do you see the role for DCB in such lesions?
A.
Once available, DCB will be ideally suited for small vessel DES ISR and all BMS ISRs. Most of the studies have supported reDES for first episode of DES ISR.
Q
When do you consider surgery for in stent restenosis?
A.
As described in our recent State of the art paper on Coronary ISR, CABG (as long as medical condition is appropriate) for DES ISR is best suited for LM ISR, multi-layer DES ISR in proximal vessels and CTO ISRs. Additionally I personally recommend CABG in pts with early (<6mths) multivessel DES ISR, indicating that there are significant biological issues and subsequent stent procedure is likely to fail again.
Q
Any pharmacological maneuver that can help in stent restenosis?
A.
Actually besides aggressive control of CAD risk factors, no other pharmacological approach has definitely shown to be beneficial to reduce ISR episodes. Better glycemic control has correlated with lower incidence of ISR.
Q
Does your practice follow the observations from the DEFINITION study?
A.
Yes we routinely describe our bifurcation lesions into simple vs complex groups and then plan subsequent strategy focusing on 2 stent approach in complex lesions.
Q
Do any observations from the DEFINITION study different from existing guidelines?
A.
Recent guidelines have favored DK-Crush over other 2 stent techniques, largely based on the excellent long term data of DK-Crush V trial.
Q
What is the recommended DAPT strategy for in stent restenosis?
A.
DAPT after ISR is still recommended for one year except after IVBT procedure where DAPT is continued for 3 years. I suggest lifelong DAPT in Pt's with recurrent ISR as well frequent coronary events.
