PCI of LAD-D1 Bifurcation using Rotational Atherectomy – September 2017
82 year old female presented with new onset CCS Class III-IV angina and exertional dyspnea; no stress test done. A Cardiac Cath done via right radial approach on September 5, 2017 revealed III Vessel CAD: 60% proximal RCA, heavily calcified 90% mid LAD and 80% D1 bifurcation, 95% ulcerated LCx-OM1 with SYNTAX Score of 22 and LVEF = 60%. Patient underwent successful intervention of LCx-OM1 (Xience DES). Patient is now planned for FFR guided staged PCI of LAD-D1 bifurcation using rotational atherectomy of both branches and dedicated two stent technique.
QMany operators would have immediately sought a surgical solution after seeing the Left Main Dissection that seemed to extend ante grade? Acceptable response?
A.In current day and age, if we encounter only LM dissection but good distal flow, we should be able to manage those pts with additional stenting(S). I agree that if LM dissection is causing hemodynamic compromise and requires hemodynamic support, CT surgery should be called while we are trying to stabilize/tack up the LM dissection. Hence calling CT surgeon is acceptable but should be selective and need not to make it a general policy.
QDid you consider seeking a surgical opinion?
A.As mentioned above, since pt remained hemodynamically stable, we did not call any CT surgeon. Pt did well and had no CK-MB elevation and went home next day on DAPT.
QThe complication would have been a completely different situation if the patient was hemodynamically unstable?
A.I fully agree that if LM dissection causes hemodynamic compromise, then one attending should continue to do PCI and other attending/fellow should insert hemodynamic support device of IABP or Impella. At the same time CT surgery should be paged/called STAT.
QIt was both surprising and relieving that the patient remained so completely stable despite an extensive LMCA dissection and greatly reduced flow down the LCX?
A.Yes pt remained stable largely as it was a large LM (size 5-5.5mm) and dissection was on the roof of the LM. Overall it gave us a time to complete the stent in mid and distal LAD and then stent the LM with a 5/15mm Onyx DES.
QDoes Abciximab have a role in this situation, particularly, after stenting?
A.Yes GP IIa/IIIb inhibitor of Abciximab bolus or 2 boluses on Eptifibatide, if not contraindicated due to old age (>80yrs) or bleeding issues, should be routinely given in this scenario. We did not give these agents to our patient as she is 82yrs old and there were no residual chest pain or EKG changes.
QWhat is the immediate plan for this patient?
A.Pt did well and went home next day without any sequalae. There were no CK-MB elevation.
QLong-term - would a stress test be adequate or a coronary angiography should be performed?
A.Current practice will be not to do routine angio after LM stenting and follow them clinically and by stress MPI in 6-9 months.
QTEE in CCU?
A.Echo is not required if there is no ongoing chest pain or EKG changes. Exactly no Echo was done in this pt.
QWhat do you think caused the dissection?
A.Two most plausible explanation for the LM dissections are; guide catheter induced LM dissection and forward Guidezilla movement during coronary injection taking LM flap further. Both these processes were seen on close look at the cine injection.
QHave we forever closed the chapter on BVS?
A.Yes we have fully closed the chapter on Abbott BVS but other BVS technology in the pipeline are having promising results and may come to the market in near future. MeRas 100 of Meril life science has completed 1-2 year clinical, angiographic and OCT imaging data and results are very promising. But we have learnt that we need to wait for 3 years before we can declare BVS technology as a viable option.