Staged PCI of LMCA and LAD/LCx using Imaging and Mini-Crush Technique – January 2022

Case and Plan:
68-year-old female presented with new onset CCS Class III angina and positive SPECT MPI for multivessel ischemia. A Cardiac Cath on December 20, 2021 revealed 3 V + LM CAD: 80% distal LM (1,0,0) with 70% proximal LAD, 90% proximal LCx, 95% proximal RCA, 90% RCA-RPDA with SYNTAX Score of 32 and normal LV function. After Heart Team discussion, patient underwent successful intervention of proximal RCA and RPDA branch using Promus Elite DES. Patient is now planned for staged PCI of LMCA and LAD/LCx using imaging and Mini-Crush technique.

Q&A

Q It seems your POT use is low. Can you comment on it?
A. We believe and published that POT concept (except for LM PCI) is over emphasized without solid data to support this practice. Pro-Pot trial was a classical example where routine POT strategy had no benefit over conventional strategy in the RCT setting. Hence we use POT in <5% of non LM OCI cases.
Q Where do you see the most benefit of POT?
A. In LM PCI, it allows proximal optimization and in non LM PCI, may help in crossing the wire and balloon into the side branch.
Q Where should it not be used?
A. POT technique should not be used if main vessel stent covers <5mm length as there is no short balloon <5mm length. We also believe that rePOT after KBI is not required.
Q Congratulations for your hospitals' excellent volume and results. What is the percentage of "complex coronary cases" that are done at your institution?vvvvvvvvvvvvvv
A. We have defined complex PCI cases consisting of LM, CTO, Calcified, Bifurcation, Vein graft and use of 3+ stents. This complex PCI number traditionally represent 55-60% of PCIs at MSH. In 2021, complex PCI number was 58%. Yes we had tremendous growth of PCI (and TAVR) in this post COVID era due to establishment of various protocols of pre testing and reassuring pts of the safe care at MSH.
Q Is there a breakdown of these complex lesions?
A. Following is the breakdown of these complex cases in 2021 at MSH; LM (6%), CTO (12%), Calcified (24%), Bifurcation (22%), Vein graft (6%) and use of 3+ stents (12%); many of the complex lesions had >1 features.
Q How much is the approximate use of debulking technologies at your institutions; RA, IVL, CB, OA, ELCA, Angiosculpt and HPB?
A. In 2021 at MSH, atherectomy was used in 24.4% of cases (RA 19%, OA 4.5%, ELCA in 0.9%). IVL use started only in Q3 2021 and has been used as adjunct technology in total 52 cases in 2021.
Q How do you feel will be the impact of IVL?
A. With the new device code for IVL as of November 2021. I believe IVL will make 6-8% of the PCI volume (either sole or adjunct) at MSH in 2022.
Q What was the turning point in today's case?
A. It was expected/predicted (by me) that to have full lesion coverage, you have to do minicrush technique even if ostial LCx is not involved. That is exactly what happened in the case.
Q Would use of RA have been beneficial in this case given the presence of moderate calcification?
A. In today's case, RA was not indicated, but yes IVL use could have been appropriate due to moderate calcification.
Q If all your steps had failed with wiring of the LCX would you have moved to use the guide extension catheters?
A. Next step to help wiring the LCx would have been to use the angulated Catheters like Venture or SuperCross 120. That would have succeeded in wiring the LCx.

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