Complex coronary cases
Recanalization of a complex RCA CTO using Antegrade/Retrograde Approach – Oct 2019

Views 1497

50-year-old female with multiple CAD risk factors presented with new onset CCS Class II angina for two months and stress echo revealed moderate inferior ischemia. A Cardiac Cath on October 7, 2019, performed at an outside hospital, revealed 1 V CAD: CTO of prox RCA, which fills via collaterals from left system with non obstructive left system, SYNTAX Score of 9 and LVEF 60%. The RCA CTO is long and calcified with J-CTO Score of 4. Patient is now planned for PCI of RCA CTO using rotational atherectomy and stents via antegrade approach and if failed, then retrograde approach.

Q&A
Q
You have changed your wire escalation strategy? What are your three preferred wires now in the escalation process?
A.

Our CTO wire escalation used to be; Fielder, MiracleBro 6 and Confianza 9-12 (popularly called FMC for teaching purpose) and now is Fielder, Gaia 3 and Confianza 12 (popularly called FGC).


Q
What contributed to the successful CTO today?
A.

Persistence and technical skills, escalation strategy of Confianza guided by contra lateral injections.


Q
Which do you prefer - Guidezilla or Guideliner?
A.

We have observed that Guidezilla performs better then Guideliner in terms of trackability across the angulated vessel segment. Hence Guidezilla has now become our favorite.


Q
Are there newer support catheters that one can consider?
A.

Recently Medtronics has also introduced their support catheter called Telescope; we have used about 10 but did not find it superior to Guidezilla.


Q
What will be your anti platelet strategy for this patient?
A.

Pt was on clopidogrel and was continued as PRU was 188. Yes Ticagrelor could be another choice.


Q
What is your take home message from TWILIGHT?
A.

Clearly adding aspirin on the background of Ticagrelor has no additional antiplatelet effect and can be safely eliminated after 1-3 months of PCI.


Q
Is this the beginning of the end of the remarkable journey of Aspirin for PCI?
A.

Seems that way now after numerous trials recently showing aspirin being a big culprit for bleeding without affecting ischemic events.


Q
As you look at aspirin, were there non platelet events that contribute to its increased bleeding?
A.

Yes GI bleeding is one of them and aspirin is a big culprit. I think GI bleeding by aspirin being an acid, is caused by its direct corrosive effect on gastric mucosa.


Q
Will you begin to translate the results of these new trials into practice?
A.

Yes we have already created a new recommendation in the cath reporting, making 81mg aspirin daily for 1 month, or 3 months in addition to lifelong.


Q
What do you now feel is ideal dose and duration of aspirin for ACS and for stable patient, post DES?
A.

I strongly believe it is One month for Aspirin in ACS as well as stable CAD, as we learnt from Global Leaders trial.


comments

Leave a Reply

Your email address will not be published. Required fields are marked *


By submitting this form, you are consenting to receive marketing emails from: Mount Sinai Hospital, One Gustave L. Levy Place, Box, New York, NY, 10029, https://ccclivecases.org. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact

suggestion
Suggestions
Complex prox RCA CTO Recanalization via Retrograde Approach – February 2021
Views 204

56-year-old male presented with Class III unstable angina and positive stress MPI for significant inferior ischemia. A Cardiac Cath on November 20, 2020 at outside hospital revealed 2 V VAD: 85% mid LAD, 70% D1 and CTO proximal RCA with distal vessel fills retrogradely via septal collaterals (J-CTO Score 3), LVEF = 50% and Syntax […]


High-Risk Complex PCI of Diffuse Multivessel CAD – January 2021
Views 502

  Case and Plan: 45-year-old male with multiple CAD risk factors presented to OSH on November 6, 2020 with unstable angina and positive ETT. A Cardiac Cath on November 9, 2020 revealed extensive 3V CAD: 100% mid LAD, 90% D2, 70% proximal LCx, 100% LCx-OM1, 100% mid RCA with LVEF = 60% and SYNTAX Score […]


Extremely Tortuous Angulated mid LAD Diagonal Bifurcation Lesion – December 2020
Views 664

Case and Plan: 75-year-old female presented with new onset CCS Class II angina and positive stress MPI on November 9, 2020 revealing moderate apical and inferior ischemia. A Cardiac Cath on November 24, 2020 revealed 2 V CAD: 95% proximal RCA, angulated tortuous 95% mid LAD bifurcation lesion, LVEF = 60% and SYNTAX Score = […]


Staged PCI of RCA multilayer DES CTO ISR using rotational atherectomy and IVBT – November 2020
Views 392

Case and Plan: 65-year old male with known long standing history of chronic ischemic heart disease requiring multiple PCI’s over the years after declining CABG, presented with CCS Class III angina and high risk stress MPI for multivessel ischemia. A Cardiac Cath on September 28, 2020 revealed 3 V CAD: 100% proximal RCA due to […]