Case and Plan
A 72-year-old male with known CAD and prior CABG in 2013 presented with DOE after a positive SPECT MPI revealing severe anterolateral and apical ischemia. A Cardiac Cath on November 6, 2023 revealed severely calcified 3 V CAD: mid RCA CTO with patent SVG to RCA, 80% proximal LAD, 70% mid LAD and 95% calcified lesion in tortuous distal LAD, LCx-OM1 CTO with patent LIMA and normal EF. Patient is now planned for PCI of severely calcified tortuous LAD lesions using rotational atherectomy and multiple DES.
Q&A
Q
From all the data that you showed today, Rotational Atherectomy (RA) is live and well?
A.
I fully agree that Rotational atherectomy (RA) will remain alive, good and well even in the era of IVL Shockwave popularity. There is hardly any other device currently other than RA, which can deal with the tortuous long calcified severely stenosed lesions. In my opinion, Orbital atherectomy (OA) has a limited future.
Q
Are there clear areas where RA should be preferred?
A.
Severely calcified and >80-90% stenosed, long lesions are the optimal lesions for RA using a small Rota burr. About 30-50% of these lesion will require IVL after RA to get adequate plaque modification.
Q
Any indication for which cutting balloon or Orbital emerged better?
A.
Cutting balloon is good for moderately calcified lesions, ostial lesions and focal ISRs. OA is also good for most severely calcified non tortuous lesions. Use of RA vs OA is usually dependent on the operator’s experience and comfort level.
Q
However, in 2024, is IVL superior to all calcium ablative therapies?
A.
IVL is simple and effective default strategy for the treatment of calcified lesions usually after predilatation with the NC balloon (in about 65% of cases). In 20-40% of cases (based on the referral practice) atherectomy (RA or OA) will be needed for calcified lesions as a lesion preparation pre IVL or final sole treatment followed by NC balloon PTCA before stenting.
Q
For combining modalities, should Rotatripsy become the default management?
A.
Yes in about 50% of RA cases using a small burr (B:A ratio 0.3-0.4), IVL should be used to optimize lesion preparation followed by DES. In other half RA cases, lesion can open by NC balloon and then stenting.
Q
Should IVL also be the default treatment for calcified ISR with unexpanded stents and calcification behind the struts?
A.
Yes calcified ISR and unexpanded DES (freshly deployed or ISR) are suitable for IVL with excellent results. Excimer laser also can be used in this scenario. Rare case RA can also be used in treatment of under-expanded stents.
Q
In today's case, would performing FFR for the LCX be a good idea?
A.
Yes FFR is a useful tool to assess lesion significance of the side branch but a prospective RCT DK crush-6 failed to show the utility of the FFR guided PCI over angio guided PCI in bifurcation lesion intervention. Hence decision to dilate/stent or not of the side branch currently, is based on angiographic features (>80% stenosis or slow flow or dissection) and clinical scenario of chest pain or EKG changes rather then on FFR value.
Q
What is the best imaging guideline for sizing IVL?
A.
Angio guided sizing for IVL balloon is optimal with IVUS guidance being more precise to select media to media sizing.
Q
How are you selecting different inflation pressures for IVL?
A.
We start with 4atm followed by shocks and then go to 6atm before deflation. In larger vessel or if balloon remains expanded, 6atm followed by 8atm before deflation can be used.
Q
Are you willing to speculate results of ECLIPSE?
A.
I speculate that there will be higher 30day MACE with OA but will be lower TLR at 1 year f/u; overall MACE will be equal in 2 groups. Hence I predict it to be a negative trial; just I predicted negative for the Ilumien 3 trial.
