Staged PCI of Distal RCA CTO via Antegrade/Retrograde Approach – Sept 2014
42 year-old male presented with new onset CCS Class II angina and positive stress MPI for moderate inferior and inferolateral ischemia. A Cardiac Cath on September 4, 2014 revealed II vessel CAD; total occlusion of distal RCA with collaterals filling via LAD and 80% lesions in LCx branches- OM2 and LPL1. Patient underwent successful Ambulatory PCI of LCx branches- OM2 and LPL1 with Promus Premier DES and did well. Patient is now planned for staged PCI of distal RCA CTO via antegrade/retograde approach.
QWhat are the major developments in the BVS device design?
A.Bio-resorbable vascular scaffold (BVS) field with Absorb DES as first in the series is just the beginning and this field will continue to evolve with having newer BVS with higher tensile strength and thinner struts in future.
QWhat are further advancements we can expect?
A.Better stent delivery system and thinner struts will be the key design changes in future.
QWhat will emerge as the best imaging modality for BVS?
A.OCT by far will be the best imaging modality to document stent dissolution and intima-medial growth after BVS.
QWould the present anti-platelet and anti-coagulant recommendations change for BVS?
A.Since ST rate with BVS is about 1% which is just twice of the current metal DES (0.4-0.5%), DAPT duration should not be shortened then <1year. Yes after one year, there should not be any need for prolonged DAPT use.
QWould BVS offer any advantages for the diabetic patient?
A.It is possible that normal endogenous endothelium after BVS dissolution will be protective for future atherosclerosis especially in diabetic pts, but needs to be confirmed by the ongoing long-term studies. I doubt there will be differential efficacy (lower TLR/TVR) of BVS in diabetics vs. non-diabetics.
QWhich ablative device will be more beneficial to prepare calcified lesions for BVS?
A.Any type of atherectomy (Rotational or Orbital) should be liberally used for lesion preparation prior to BVS implantation in the calcified lesions.
QAny perceived role of BVS for ACS and for STEMI?
A.Yes there are trials on going in STEMI pts with BVS use and data are awaited.
QWhat so you feel is the optimal inflation pressure for BVS?
A.Optimal post dilatation inflation pressure should be slightly higher than our metal stents because of thick struts of BVS; 20-22atm for BVS vs 18-20atm with metal DES.
QAre you aware of other BVS besides Absorb that are showing good data?
A.No other drug-eluting BVS besides Absorb has come in the phase II clinical trials yet. In my opinion all major device companies have to have the BVS program to compete in the interventional filed. BVS-Absorb is likely to get FDA approval after the results of ABSORB III trial next year even if Absorb stent does not show superiority over the metal Xience DES.
QWould you expect a wide spread switch to BVS once the device is available in the U.S.?
A.I need to exert caution on the statement of BVS share of the DES market in US once available, as it will be driven by the cost and
trial results. In my opinion BVS will be appropriate for younger pts with lesions (even calcific) in prox to mid vessels.