Ensuring Procedural Safety and Good Long-term Results in Complex PCI Procedures
Dr Nicolaus Reifart from Frankfurt, Germany, gave a presentation focussing on CTO and complex PCI procedures. Before undertaking PCI, all risks need to be addressed, and other options such as optimal medical therapy should be considered. Case selection should also be tailored to level of experience of the operator. Dr Reifart suggested that a level C operator is one who has undertaken less than 500 PCIs and should only undertake PCI of simple lesions and simple bifurcations. A level B operator has undertaken 500–1000 PCIs and can therefore attempt more complex procedures such as complex bifurcations, moderate calcified lesions and some cases of CTO. Only a level A operator, i.e. one who has performed more than 1000 PCIs, including 300 CTO, might undertake complex cases such as long and highly calcified lesions and complex CTOs including retrograde. If a level C operator attempts a level A task, he/she is less likely to be successful and may cause harm to the patient.
Other considerations for procedural safety are the use of premedication and the amount of contrast used. The volume of dye used in a PCI procedure should not exceed 4–6 x the glomerular filtration rate (GFR). In terms of procedural time, completion within 60 min in 90 % of cases is expected. It is important to prepare for complications such as pericardial effusion. Finally, stent selection is important; the operator must decide which stent type and size is appropriate for the patient and the lesion. Contemporary DES should be considered for all CTO procedures.
Live Case from Instituto Cardiovascular/ Hospital Clínico San Carlos – Madrid, Spain
Case 1: RCA CTO in multi-vessel disease. Operators: George Sianos, Antonio Fernandez-Ortiz
A case was presented of a 78 year-old man with hypertension, effort angina over the last month and resting chest pain. He had a severe calcified lesion in the proximal left anterior descending artery (LAD) and total occlusion of the right coronary artery (RCA). His SYNTAX score was 30. The LAD was treated fırst and the RCA was deferred for a second procedure performed lıfe durıng the meetıng.
A PCI procedure of the RCA was undertaken, with the aim of implanting the Coracto™ sirolimus-eluting stent wıth bıodegradable polymer. The right femoral access approach was taken using a 7 Fr guidıng catheter for the donor artery and the right radial artery usıng a 6 Fr guıdıng catheter for the occluded artery. The CTO length was 10-15 mm with presence of some calcification. A procedural plan was presented: if one approach failed the next would be tried. An antegrade approach was initially used, with a plan to shift to retrograde if needed. During the procedure, the antegrade wire entered the subintimal space, and the wire could not cross to the distal true lumen, necessitating the retrograde approach to achıeve fınal success. Two Coracto™ sirolimus elutıng stents were successfully implanted wıth a very good final result.
Live case from Instituto Cardiovascular / Hospital Clínico San Carlos - Madrid, Spain
Case 2: LAD CTO in single-vessel disease. Operators: Javier Escaned, Luis Nombela-Franco
This case was a 63 year-old man with a single-vessel CTO. The coronary angiogram showed occlusion of the LAD at a bifurcation of a large fırst diagonal branch.
A PCI procedure of the LAD was undertaken, with the aim of implanting the Cre8 amphilimus polymer free elutıng stent. The procedure started with the use of IVUS to guide the puncture of the proximal cup wıth contemporary CTO guidewires. The procedure was not conceded during dedicated transmission tıme and continued further, but later had to be abandoned for a second attempt in the future.
The publication of the article was supported by Alvimedica.