CCC Live Cases
Questions / Answers from February 15, 2011 Case

Questions / Answers

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How long did your 104 years old PCI patient availed the benefit?
Unfortunately that (104 yrs old) patient about 9 mths after successful complex stenting (Rota+ DES to RCA and LAD) fell from the stairs while coming back from temple, hit his had and developed big intracranial bleeding and died few days later. But many more pts will benefit from revascularization for symptom relief, if they are otherwise healthy, even in that age group.
If your patient can cooperate and stay still why do you need sedation as it takes away your warning parameter of iatrogenic mishap?
Most of the pts especially during live cases, should be sedated and we should carefully monitor all the vitals and hemodynamics. Light sedation allows us to perform our task fully and yet can get the pt's input when need arises.
What is your reason not to accept suggestion of two small stents of Ist Operator?
Certainly we could have used smaller stent, but even small stent may not have gone despite aggressive predilatation. Another high pressure dilatation with a bigger balloon (3.5/20mm Quantum Apex) and use of Guide liner catheter, allowed the same long
stent (28mm) delivered distally.
With left main stenting and kissing stent; What is your recommendation for Antiplatelet therapy and for how long?
Our recommendation of DAPT for 12-15 mths even after ULM and SKS techniques. If recurrent restenosis has occurred, then we will recommend DAPT atleast for 3 yrs or longer (if no bleeding issues).
The LAD stent is crushing relatively the proximal cells of the Diagonal stent (TAP technique) like a PEPSI can? Don't we have to kiss balloon LAD/D1 again?
Absolutely yes for the final kissing balloon dilatation after 'TAP' technique and was done in this case.
May I ask who makes the guide liner?
Vascular Solution Inc. makes the Guide liner which provides extra support in difficult cases (tortuous and CTOs).
Would you infuse this patient aggrastat/ Integrelin post procedure?
In view of complex intervention, GP IIb/IIIa bolus only (Aggrastat, Integrilin or Abciximab) is recommended to decrease peri-procedure myocardial injury, side-branch closure but at cost of slightly higher bleeding even in the presence of Bivalirudin. Also GPI should be administered after rotational atherectomy; after risk of device related perforation has minimized.
What is wrong with medical management for this elderly patient?
Yes that is always the possibility; but this pt is symptomatic and has significant LM disease which clearly has shown to have poor long term outcome even at present time with maximal medical therapy (Recent data from APPROACH registry).
Do you maintain any age cut off for your patients for PCI?

Cutoff of age is based on the functional and mental status of the pts (physiological) and not the chronological age for PCI.
What appears more critical to you for care of the elderly patients - vascular complications or renal impairment?
Both but certainly renal impairment more than vascular complications as many of these pts are being done Trans-radially.
Any concerns about elderly patients and Radial access?
Not at all; contrary it may even be beneficial by reducing vascular complications, yet slightly more difficult and slightly higher procedure time.
Have you used Prasugrel for the elderly? How would you justify that?
Yes in few cases beyond the age of 75yrs at the 5mg maintenance dose as long as there is no H/o of CVA. I have used prasugrel in 2 pts (age 82 and 87yrs) with H/o CVA, both had events while on Clopidogrel and were non-responder on platelet inhibition testing (Verify Now assay by Accumetrics).
What is your sedation recommendation for the elderly?
Low dose IV Versed (0.5-1.0mg) or IV halo (2.0mg) is routinely given and repeated Q30 minutes as needed.
Any stent that you find beneficial for the elderly patient?
One which will need shorter duration of DAPT; hence Xience V DES will be preferred.
With the increased likelihood for bleeding in the elderly patients, can you offer some practical tips to manage their DAPT?
Aspirin dose should be 81mg and prasugrel be 5mg daily. Also use of GP IIb/IIIa inhibitor bolus only in complex cases.
How should we manage interrupting DAPT in the elderly due to a multitude of reasons needed to discontinue these drugs?
We have presented our data of DAPT interruption after minimum of 6mths post DES and 2 weeks post BMS; and is safe with low incidence of stent thrombosis. Preferred DES will be Xience V/Promus or Endeavor.
Were you surprised at how much struggle there would be with this case?
Yes I was somewhat surprised by the struggle even post Rota; but was clearly due to use of undersize burr (1.5mm). It is likely that rota with 1.75mm burr would have made procedure simpler.
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