Questions / Answers
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This is an unusually aggressive case of very early graft closure? Besides PCI, how would you manage this patient? |
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Yes precisely for these reasons, complete revascularization using PCI along with aggressive risk factor modifications(Hg A1C of 6-7, LDL <70mg/dL, HDL >45mg/dL) will be main focus. Also test these pts for Aspirin resistance as sometimes this may contribute to early graft closure. |
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Any role for Prasugrel? |
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YES especially if pt is plavix non-responder. This pt on chronic plavix therapy had 21% inhibition of platelet aggregation as tested by Accumetrics Verify Now assay and hence plavix hypo responder. Certainly these pts will benefit from startingPrasugrel or switching to it (30mg loading followed by 10mg maintenance dose for 12-15mths). |
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Would you increase the dose of Clopidogrel? Have it guided by platelet aggregation studies? |
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Yes that will another strategy making plavix 150mg daily and is supported by OASIS-7 trial. |
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What are the unique attributes of the Venture catheter? |
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Besides tip deflection, it provide the back-up support from the opposite wall. It is also very track able. |
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In what situations do you find it beneficial? |
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In very angulated lesions usually >100 degrees and when angulated branch origin is after a significant lesion. |
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What other catheter is it replacing? |
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There is no other catheter of this kind at present. Cordis JnJ catheter 'Steer-it' did not get much success and has been off the market. |
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How often are you using it? |
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In about 6-8 cases per month of 420-450 PCI (usually 600-700 lesions), we perform monthly. |
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For CTO, when will you not go with contra lateral cannulation? |
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Almost in all cases. Only exception will be when retrograde collaterals are from LAD to Circumflex or vice versa. |
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How often are you using a retrograde strategy? |
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Very rarely. In <2% of CTOs largely because of our current antegrade success of >95% in the CTOs attempted (about 20% have 2nd attempt). |
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How do you determine when to go retrograde? |
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Once there has been extensive antegrade dissection or no visible stump seen. |
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What is your standard wire upgrading strategy for CTO – start with which wire and choices there after? |
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We start with Filder XT wire to see if it can find micro channels and quickly escalate to Cross-it 100 or MiracleBro 3-6. If still no success, then next wire is Confianza or Confianza Pro. All these are Abbott Vascular Inc wires. |
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What is your choice of radio contrast agent? |
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Iopamidol (isovue) in all. We have published that even in diabetic pts with CRI, there is no advantage of Visipaque (Iodixanol) despite being more expensive. |
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You always prefer Isovue? When would you use a different agent? |
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In our cath lab Isovue only for all PCIs and majority of PTAs irrespective of baseline Scr levels. Rare PTA cases Visipaque is used because it causes less pain. |
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What should be a maximal dye load in your experience, for a PCI? |
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Maximal dye load should not exceed 5ml/kg body weight. Ideal minimum dye load in CRI pt should be in double digits (usually 40-70ml). |
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A recent article has stated that you have not had an emergency CABG in your CVL in more than a year? Is this correct? |
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Yes in both years 2007 and 2009 we had no urgent CABG as the PCI complication from the cath lab. This year so far there has been one case. As you well know overall in-hospital mortality in these urgent CABG cases is >60%. |
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What do you attribute this to? |
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High volume PCI operators, planned strategy in complex PCI cases, use of JoMed device for perforations and quick involvement of senior interventionalists in cases with complications has achieved this # '0' many times. |
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What would be some critical lessons about avoiding complications that you would like to point out, so far as it relates to your outstanding results? |
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Most importantly heavily calcified lesions (use of Rotational atherectomy), CTO lesions (use of Angiomax and escalating stiff wires) and bifurcation lesions (SKS technique) have minimized our procedural complications in these complex lesions prone for problem. |
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At some institutions, it is hard to get HMO approval for staged procedure? Do you face these obstacles too? |
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YES Same in NY. We have to justify if pt has to come back for staged procedure; this becomes the part of recommendation in the cath report with potential reasons for staging. |
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Why do you feel that the Xience is your work horse stent? What special attributes does it have? |
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Largely due to it's deliverability, preserving side branches and 1 year of DAPT. |
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What is your final take home message in this partially successful procedure? |
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It's ok to stop when intra-procedural complications occurred and results are not what was expected. Donot push the envelop further in these cases and give the 'second try' in 4-8 weeks. This patient has been scheduled to come back for our Live Complex coronary symposium on June 17th. |
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