Staged PCI of Totally Occluded Extremely Tortuous RCA – May 2021

Case and Plan:
66-year-old female presented with unstable angina and high risk positive SPECT MPI for multivessel ischemia. A Cardiac Cath on April 15, 2021 revealed 2 V CAD: totally occluded extremely tortuous distal RCA lesion with another 90% proximal RCA lesion with spontaneous dissection, 80% calcified mid LAD, LVEF = 60% and SYNTAX Score of 22. Patient underwent successful intervention of mid LAD (PTCA, Atherectomy and Xience Sierra DES). Patient is now planned for staged PCI of totally occluded extremely tortuous RCA.


Q For collateral/septal surfing, what is the preferred wire?
A. For septal collaterals, Fielder FC is the wire of choice.
Q Do you lean on collateral physiology before planning CTO interventions?
A. Yes that is correct that we always look at the collaterals size, anatomy and physiology before proceeding to CTO intervention.
Q What are your plans for this patient with failed CTO attempt?
A. Today's case with failed attempt at CTO recanalization, will not be tried again as we did not make any progress at all. If pt remains symptomatic despite MMT, we will refer him for one vessel CABG.
Q So, what is the advantage of 325 mg aspiring after the recent trials?
A. Actually, there is no advantage of 325mg aspirin po daily at all in stable CAD pts and hence is not recommended.
Q Any subgroup where 325 mg is preferred?
A. One group which was not particularly studied in the current ADAPTABLE trial, pts with prior CVAs; that group is routinely advised full 325mg po daily (vs 75-81mg daily). Hence pts with prior non-hemorrhagic CVA/TIA may still continue to get 325mg aspirin po daily. Rest all CAD/MI/PCI cases should get 75-81mg po daily.
Q Results of these trials further support TWILIGHT findings and conclusions?
A. TWILIGHT trial studied the totally different group of pts; post PCI pts where stopping aspirin after 3M was better than continuing for 1Y on the background of Ticagrelor in all pts.
Q Are these trials further confirming a demise of aspirin from PCI?
A. That is correct that many trials now have confirmed that we can safely stop aspirin from 1day to 1M or 3M post PCI. This aspirin discontinuation strategy is associated with lower bleeding with no increase in MACE.
Q Are you practicing a de-escalation strategy?
A. Prasugrel de-escalation just validated what has been my practice over the years that 5mg po daily dose of Prasugrel is safe and cause less bleeding.
Q For what patient sub-types?
A. We use Prasugrel 10mg MD in pts with >100kg weight and who have received 3 DES. Rest all get 5mg po daily.
Q How would you implement knowledge about calcified nodule and ACS?
A. Current study showing presence of calcific nodule in causation of ACS, will not change any procedural technique. It has just emphasized that we need to be extra vigilant about treating Calcified lesions evens in ACS by appropriate use of atherotomy and atherectomy devices.


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