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Questions / Answers from January 18, 2011 Case

Questions / Answers

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So far as anti-platelet therapy is concerned, how do you deal with the situation you have today - BMS in RCA and DES in LAD. Is their follow up different too in any manner?
This pt had BMS in RCA only because of MI setting and large vessel (>5.00mm). Of course LAD had DES. As far as f/u is concerned, there is no difference how this pt will be followed. Recent randomized trial Basket-Prove comparing DES with BMS in large vessel (>3.5mm) showed DES to be superior to BMS for long-term MACE and should be preferred.
It is still not clear what criteria you use to choose between Rotablation, CBA and Angiosculpt? What about simple high pressure balloon dilatation for some of these lesions?
Atherotomy by cutting balloon or angiosculpt is sufficient for ostial and mild-moderate calcified lesions. In heavily calcified lesions, Rotablator is strongly recommended. High pressure balloon inflation can be used in some of these situations, but may cause dissection and may even fail to open the lesion fully.
Can you explain exactly what subset of bifurcations, you prefer SKS? Why not for all lesions as the technique is relatively simple?
SKS is recommended when bifurcation lesion involves large side branch (>2.75mm) and lesion is Medina 1,1,1. For others it is not recommended because proximal vessel may not accommodate 2 overlapping stents. At Sinai SKS technique is used in approx 10% of bifurcation lesions, with one stent approach in about 70% and 'T' or 'TAP technique in remaining 20% of cases. We rarely use 'crush' technique.
What features about the carina do you have to pay attention to during SKS?
That both proximal stent markers are perfectly overlapped and carina is well expanded. Also try to make carina as short as possible.
Your strategy to post dilate a Xience with a non-compliant balloon increases the cost needed for an additional balloon?
Somewhat yes from added cost point of view but partly off-set by using less pre-dilatation balloon. On long-term it pays off as this strategy and Xience V DES have the lowest stent thrombosis and TLR. These data are supported by many randomized trials (SPIRIT III & IV, COMPARE, LESSON I) and as well as by publications from out Interventional database.
Have you performed SKS via the radial route? Do you feel any challenges for that?
Only once case as SKS technique requires minimum 7Fr guide catheter which is tricky for most radial approaches. Hence by radial approach if 2 stent strategy is planned, then 'reverse Crush', 'Culote' or 'TAP' will be advocated.
Any issues with guide wire entrapment?
Not at all as long as wire is not in a small branch and radio-opaque portion of the wire is beyond the ostium of the side branch. If there is difficulty in pulling the jailed wire, then advance a balloon on the wire proximal to stent, and then pull, the jailed wire will come out easily. While pulling the jailed guidewire make sure guide catheter is disengaged from the coronary ostium, as there is strong tendency for the guide to get sucked in during this maneuver.
Do your multivessel PCI patients go home the same day too? What criteria do you use for same day discharge?
Yes patients upto 2 vessel PCI are safe to go home same day as long as they strictly fulfill all criteria of Ambulatory PCI. We have not sent a patient home same day after 3 vessel PCI.
Which is your favorite monorail support catheter?

Guide liner of vascular solutions is very useful followed by 2.0/20mm Maverick II or 1.5/12mm Apex balloons of BSC.

Is there any bifurcation lesion that even your institution will turn down for PCI?
Answer is NO. Difficult bifurcation lesions are discussed in advance for the preferred strategy and a plan is formulated; which only rarely needs to be changed during the PCI because of some unexpected developments. If a large sidebranch can't be wired, then that bifurcation PCI should not be done because sidebranch closure will give rise to MI. These cases should preferentially be referred to CABG or to expert centers like ours, who have extensive experience of wiring these bifurcation lesions; Venture catheter (St Jude's) is very helpful in many of these angulated sidebranches.
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