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Left main intervention: acute and late problems Alexander Loch - - PowerPoint PPT Presentation
Left main intervention: acute and late problems Alexander Loch - - PowerPoint PPT Presentation
Left main intervention: acute and late problems Alexander Loch University Malaya Medical Centre Case 1. Acute problem Presentation 54yo male AMI ST elevation lateral leads History of multiple PCIs Diagnostics What to do?
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Case 1. Acute problem
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Presentation
- 54yo male
- AMI
- ST elevation lateral leads
- History of multiple PCIs
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Diagnostics
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What to do?
Issues:
late presentation LCX likely infarcted…. Any benefit opening LCX? PCI to LCX will jeopardize flow to LAD…. Likely messy…
Options:
- 1. Leave it as it is?
- 2. Stent LAD as prognostically more important
- 3. Try to open LCX and be prepared for bifurcation stenting
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What to do?
Issues:
late presentation LCX likely infarcted…. Any benefit opening LCX? PCI to LCX will jeopardize flow to LAD…. Likely messy…
Options:
- 1. Leave it as it is?
- 2. Stent LAD as prognostically more important
- 3. Try to open LCX and be prepared for bifurcation stenting
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Runthrough into LCX POBA Trek 2.75 x 15 Onyx 3.0 x 12 LMS LCX
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Biofreedom 3.0 xx 33 LMS LAD (Culotte)
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Biomatrix 2.72 x 28 (prox LAD) Biomatrix 2.5 x 33 (mid-distal LAD)
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Result Culotte LMS prior to FKB
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FKB (Lacrosse 2.5x15 LAD / Trek 2.0x15 LCX)
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Biomatrix Neoflex 3.5 8 in LMS Lacrosse 2.5 x 15 LAD and LCX
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Accepted result
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Lessons Case 1: Dissection LMS after FKB
- Keep it simple
- FKB can result in LMS dissection
- Immediate diagnosis and remedial is key
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Case 2. Acute and late problem
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Presentation
- 71 yo lady
- Severe angina
- Rejected CABG
- For provisional LMSLAD
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Scoreflex 2.75x15 LAD Ultimaster 3.0 x 24 in prox LAD Ultimaster 3.5 x 18 from LMS LAD
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Plaque shift into oLCX
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Reverse crush LCX LAD NC Trek 3.75 x 15 (LAD) / Ultimaster 3.0 12 (LCX) POT (Accuforce 4.0 x 8) FKB (NC Euphoria 2.5 x 15 / 3.0 x 15)
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Final result
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Happy?!
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6 months later angina…
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Re-wiring and IVUS. POBA / DEB LCX Biomatrix alpha 3.5 x 29 Sapphire NC 4.0 x 10
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Lessons Case 3: Reverse crush for LCX compromise resulting in ISR
- Expect SB occlusion - even if ostium not (very) diseased
- Reverse crush is bailout option if size discrepancy branches
- Crush leaves a lot of metal
- High index suspicion for ISR (despite FKB, POT….)
- Correction – simple provisional stent … so far so good
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Case 3. Acute problem
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Background
- Pt with oLMS and RCA disease
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Diagnostic images
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Background
- Attempted PCI LMS at another centre (no image record):
– Pt developed bradycardia and APO when wiring LAD – Procedure abandoned – Referred for CABG – CTS declined as considered “too high risk”
- For elective PCI oLMS
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JL3.5 7F, IABP 34cc, venous sheath Runthrough : wiring from outside
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POBA oLMS (Tazuna 2.5 x12) POBA oLMS (NSE Alpha 4.0 x 13)
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Stent placement oLMS (Promus Premier 3.0 x 32) Stent inflation (Promus Premier 3.0 x 32) NC balloon oLMS (Accuforce 4.0 x 8)
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Final result
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Lessons Case 4: oLMS unprepared PCI attempt resulting in bradycardia /APO
- Preparation is key
- Tight ostial lesions:
– IABP – Pacing sheath standby – Wiring from outside – do not engage guide – Fast inflations
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Case 4. Late problem
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- 47yo man
- Textbook DK crush LMS bifurcation under IVUS
– LAD Xience 4.0 x 23, – LCX Xience 4.0 x 18, – FKB 3.5 x15 NC trek in both LAD and LCX, – POT 5.0mm balloon
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DK crush result
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- Presents 16 months later with exertional chest pain
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Diagnostic images
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Volcano IVUS LCX : fully expanded stent, ISR and clot +++ at
- stium
Thrombuster 6F clot aspiration Euphora 3.5x 15 LMS LCX followed by Accuforce 4.0 x 15
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Volcano IVUS LCX : fully expanded stent, clot +++ at ostium Thrombuster 6F clot aspiration Euphora 3.5x 15 LMS LCX followed by Accuforce 4.0 x 15 Clot spill over into LAD ostium after ballooning LCX
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IVUS LAD: fully expanded stent, some clots Sequent please DEB 4.0 x 20 into LCX Euphora 3.5x 15 LMS LAD followed by Accuforce 4.0 x 15
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Final result
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Lessons Case 5: ISR after DK crush
- Even “ideal” bifurcation stenting (DK Crush/IVUS guided)
can develop early significant ISR
- Low threshold for relook
- Simple POBA will often do the job
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Literature
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- Registry data
- 1,353 patients
- early-generation drug-eluting stent (E-DES)
- Contemporary drug-eluting stent (C-DES)
- Primary endpoint MACE
(composite of cardiac death or myocardial infarction, stent thrombosis, target lesion revascularization)
- 3-year follow-up
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- early clinical outcomes
– provisional and planned 2-stent treatment strategies similar outcome
- long-term follow-up ( 3 years)
– rates of cardiac death, MI, and TLR more common with planned 2-stent (14.4% vs 21.2%, adjusted [HR] 0.51)
- Strong benefit toward the 1-stent strategy
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- At 3 years, MACE occurred in 49 patients the culotte group and in 17 patients in the DK crush group
(cumulative event rates of 23.7% and 8.2%, respectively; p < 0.001),
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- TLF within 1 year
– in 26 patients (10.7%) assigned to PS – in 12 patients (5.0%) assigned to DK crush (hazard ratio: 0.42)
true distal LM bifurcation lesions using a planned DK crush 2-stent strategy resulted in a lower rate of TLF at 1 year than a PS strategy
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Overall summary
- Acute complications include
- arterial dissection
- arrhythmias
- acute vessel closures
- Late complications include:
- ISR and ST
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