Live Relay: Complex PCI - October 2021
Vložit
- čas přidán 24. 10. 2021
- Middle-aged hypertensive and diabetic male presented with angina on exertion Class III. ECG showed STT changes and LVEF was 55%. coronary angiogram revealed LAD CTO from prom segment and LCx had OM bifurcation disease. RCA did not show significant stenosis. As the patient refused CABG, angioplasty of LAD CTO and LCX/OM was done on staged basis because the LAD angioplasty was complicated with thrombus formation.
Great case. More simplification - less complication. Nice result. Excellent for patient. Thank you. 🙏
Dr. Kinni is rocksteady like an anchor. Big props to her.
Best hands and minds with excellent learning points. Thank you very much.
Procedure-
The proximal LAD has a bifurcation lesion with D1- Medina 1 1 1. D2 ostium has a tight lesion- 0 0 1.
Plan is to stent from proximal LAD to D2. This is because D2 is a big vessel, even bigger than the LAD, and also because D2 ostium is tightly diseased while LAD, at this point, is disease free.
So this stent (from proximal LAD to D2) will have two side branches- a diseased D1 and a non diseased LAD.
Since D1 is diseased, it will be stented using mini crush technique. Mini crush is the technique used in this cath lab for 95% of cases- they use DK crush very sparingly.
Since LAD (which is a side branch for the stent) is disease free, it will not be wired. Unless it develops > 70% lesion or less than TIMI 3 flow or ECG changes happen or chest pain occurs, it will not be recrossed after stenting. This is because studies have shown that it is unnecessary and also because there is risk of dissection of the vessel and also because stent deformity due to this dilation can lead to thrombosis (Nordic bifurcation 3 trial and EXCEL trials).
First LAD to D2 was wired- this was easy. Then wiring D1 was tried with a Fielder wire first and with a Miracle wire later- Miracle wire was tried because it keeps the distal angle. Both wires could not be passed to D1.
Then it was decided to do plaque modification- a Wolverine cutting balloon of size 2.75 x 6 mm was used. This balloon was used because the chance of dissection is lesser (how?).
Now that plaque modification was done, there was greater chance of wire going into the side branch. The plan was to try first with wire alone, and if wire does not do, then to try with Venture catheter or Supercross catheter. Venture catheter is used by clockwise rotation of the knob to turn the tip. It was not used in the beginning itself (when wire failed to pass) because it needs some space to go and so can be used only after space is created by ballooning.
Without needing any special catheter, the side branch could be wired after plaque modification.
Then the operator tried to pass the previously used cutting balloon to D1. But it would not pass due to wire intertwining in proximal LAD. So it was removed. A small size NC balloon was next tried- this passed across the intertwined zone and went into D1.
2.5 x 12 stent was positioned in D1 with 1 mm into the main vessel (mini crush/nano crush). 3.5 x 18 stent was positioned from LAD to D2.
D1 stent was deployed. Then the balloon was deflated. The balloon was pulled back partially and inflated to 20 atmos- this is a variant used by these operators.
Then LAD to D2 stent was deployed crusing the D1 stent.
Now they did not do POT before rewiring the side branch. Why POT was not done is not very clear. From later discussions, it seems that the stent was already sized for proximal vessel and not sized to distal vessel as is the teaching. So, since 3.5 mm size of the stent is assured to be touching vessel wall of proximal LAD, the operators must have felt that the next wire would not be passing sub stent. Ideally, they shoud have sized the stent based on D1 diameter which is 2.75 mm. They should have taken a longer size stent to allow for POT. Then they should have done POT to proximal stent and then only should they have tried to rewire D1. Skipping these steps was probably purposeful as patient was unstable.
Recrossing to the side branch is better tried with the original side branch wire as it may be having memory of the side branch.
Mini trek 2 mm compliant balloon was used to recross into the side branch. Then 2.5 mm compliant balloon was placed into side branch. Then 3.5 mm ballooon was tried to pass to main branch, but it would not go. The side branch balloon was dilated- anchor balloon technique- and then the main branch balloon passed.
Then kissing balloon dilation was done. Result was good. D1 flow was good. Distal LAD flow was good. As preplanned, distal LAD was not rewired.
Discussions-
DK crush 6 study showed that FFR of side branch is not useful for decision making.
POT after FKB is needed only if it is LM. Otherwise, FKB is enough. There was an earlier concept that FKB causes oval proximal stent and so POT is needed to make stent circular. This has been disproved by imaging studies.
In an unstable patient, we should reduce steps as much as possible. That is one reason the LAD was not wired. It would have led to more wire interwining.
IVUS or OCT was not used at the beginning of the procedure. There is study data that if angiographic calcium is not significant, microscopic calcium seen in imaging is not going to add any further value. Also passing these imaging catheters may damage the vessel. Imaging pre procedure is not usually very useful. Post stenting, it is very useful to make sure that stent is properly apposed.
This patient had low EF. IABP was used- and turned out to be useful as BP kept falling during ballooning. Impella was not used as there was LV apical thrombus. The policy in this lab is to remove the IABP/Impella as soon as procedure is over and apply femoral closure device (before shifting out of the cath lab) unless patient is in cardiogenic shock.
The website cardiologyapps shows all bifurcation steps in detail.
If balloon does not pass into side branch after crushing, use anchor balloon technique. Pass a balloon into distal part of main branch stent. Dilate this at low pressure. Now we will be able to pass a balloon into the side branch.
In this cath lab, if radial approach is used, they do DK crush or reverse crush.
Thank you for elaborating on the procedure.
Nice vedios which helps me to know the case
Congrats. Nice case.
Great case !
Thank you very much
Great case, agree to not do pre-imaging and leave the LAD as it. Duration is less, chance of complications is less ...
Amazing, thanks
Did you hear about new Oscar System for PVI from Biotronik? Did you get your hands on it already?
Great case. Agree that imaging is totally unnecessary pre PCI.
Wjsj❤️🩹
Wmrt❤️🩹