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Questions / Answers from September 15, 2009 Case

Questions / Answers

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Why was this patient not considered for cardiac surgery?
Because of old age (88yrs) patient refused CABG. Otherwise, distal LM bifurcation should routinely be referred for CABG.
Would you have considered the Impella device in this situation?
Because LV function is >35%. LV assist devices are good for low LVEF pts. Complex coronary anatomy with LVEF >40% could undergo PCI safely with safety and great success.
What criteria are you using for choosing between IABP and Impella?
LVEF <35% gets Impella and higher LVEF could be done with IABP.
How much would be the duration of DAPT for this LMCA patient?
Minimum 1 year but preferably 3 years.
What has been the long-term experience of MSMC for treating bifurcating LMCA?
We now have done >400 LM bifurcation DES with 99% clinical success rate, 1% subacute/late stent thrombosis,10-12 angiographic restenosis and 6-8% TLR (of which 2% CABG at F/U). 
What angiographic characteristics are you using to choose between Rotational Atherectomy and Cutting Balloon?
Heavily calcified lesions ('tram-track') should undergo rotational atherectomy and mild-mod calcified lesions are appropriate for cutting balloon (also ostial lesions).
What is the rate of Rotational Atherectomy use at MSMC?  Is it increasing, staying the same or decreasing?
For last 4 years use of Rotational atherectomy at MSMC is 6-7% (approx 400 cases per year).
Have you abandoned the step-up burr strategy for Rotablator?
Yes for majority (>95% time) single burr is used. In rare cases of large heavily calcified vessels, step second burr is utilized.
Which DES do you prefer for LMCA? Why?
Xienxe V/Promus is our workhorse DES for LMCA except calcified ostial LMCA where we still use Cypher DES and post-dilate by 4-4.5mm high pressure balloon. Present generation Everolimus DES do not provide tough radial strength and hence are not recommended in ostial LMCA (in majority).
Would you bring this patient back for surveillance angiography?
Yes. All LMCA PCI cases have a 4-6 month f/u surveillance angiography date and a written sheet with scheduled date is given to them at discharge.
What criteria are you using to choose between SKS and other techniques for bifurcating LMCA?
As I showed in my presentation: if circumflex is large or small but disease free -then stent across, if circumflex is small but diseased -then Crush or T technique and if Circumflex is large and diseased the SKS technique is preferred.
Where would you use the crossover LAD stenting for LMCA?
As mentioned when Circumflex is not diseased.
Did you use Abciximab in this case?  What are your recommendations for using it for LMCA interventions?
Yes. Half bolus of abciximab because of old age. In complex and bifurcation LMCA abciximab is recommended despite use of Angiomax in all these patients.
Would you be using IVUS for this case?  Do you use IVUS routinely for LMCA stenting?
Yes. We used in this case in the end to see the adequacy of DES deployment and carina expansion. There are few reports in literature now, to support the routine use of IVUS in LMCA PCI.
How Long do you recommend Dual AntiPlatelet RX with Xience SKS these days?
We are continuing DAPT in Xience SKS for more than one year and perhaps 3 year. We have routinely prescribed DAPT with Cypher for minimum 3 years. This policy has eliminated late SATs in these cases.
What do you think about Prasgral for bifurcation stenting?
I will recommend use of Prasugrel as a substitute for plavix in suitable cases (>60Kg, <75yrs age and no prior CVA history). With that note we will use Prasugrel once available at our center, in these bifurcation cases.

Is this V stent or SKS?
We have published that if Carina is <2mm then it is 'V' stenting and if >2mm than SKS. This case has Carina of about 5 mm and hence will be called 'SKS' technique.
What is the advantage of SKS over crushing method?
We do not use crush technique at our center but Crush will be good is SBr is angulated and is of moderate size (<2.8mm). There is no randomized trial comparing Crush vs. SKS technique. There has been a randomized trial which compared 'Crush' vs. 'Culotte' technique (NORDIC Bifurcation II Trial) and reported a statistically non-significant trend towards lower
MACE and TVR with Culotte compared to Crush technique.
Is new carina in single gigits?
Yes. It seems to be about 5mm in length.
In bifurcating lesions, how concerned should one be about jailing guide wires?  Any recommendations?
We are not concerned at all of jailing the wire in the side branch as long as: it is not a hydrophilic wire and wire is not looped and is not in a small branch. It is easy to pull the jailed wire psot stenting with guide dispalced out of the ostium (as it will be sucked in during jailed wire removal). In rare cases where there is difficulty in pulling the jailed wire, then advance a balloon (monorail or over-the-wire)  in the vessel way proximal to the stent and then wire pull will be very effective in removing the jailed wire.
In bifurcation lesions, how do you decide to use Cutting Balloon, Rotablation, Angiosculpt or simply, a balloon?
Based on the lesion calcification and degrees of stenosis, our algorithm is as follow:
Heavy calcium- Rotablator, >70% 10mm lesion length- Cutting balloon (may be Angiosculpt) and 50-70% long lesion then non-compliant balloon. We have found that Cutting balloon is more effective than Angiosculpt in ostial plaque modification. Angiosculpt is good for treatment of ISR.
What criteria are you using to use a particular DES – for all lesions, not only the bifurcations?
Xience/Promus has become the DES of our choice in our cath lab being used in 80-85% of DES (82% DES and 18% BMS). We use Cypher in about 15% of cases especially for long lesion length (33mm) and bifurcation lesions. Also large ostial lesions such as left main Cypher gives the tensile strength which is not provided by XienceV DES. Also we use Endeavor DES in rare cases where we have to stop DAPT in less than 6 months but after minimum 3 months.
How much concerned are you about the balloon overhang with DES with stent types that use compliant balloon materials?
Yes. That has been a factor for Cypher DES especially proximal edge while it has been a problem with Xience/Promus because of very compliant balloon material causing edge dissections. To circumvent this problem we deploy Xience/Promus at 8-12 atm and post dilate with a short non-compliant balloon at 16-20 atm. This policy has eliminated the issue of edge dissection with XienceV DES.
What are your rates of restenosis with bifurcating lesions?
About 5% clinically which is consistent various published Trials of DES in bifurcation lesions (NORDIC, CACTUS, SKS-PRECISE). Key technical points are final kissing balloon dilatation if you have crossed via the stent struts to dilate the side branch post stent deployment. SKS technique eliminated this issue of post-dilatation and recrossing the stent struts as it is rarely needed.

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