PATIENTS Richmond, VA DISCLOSURES No Relevant Financial - - PowerPoint PPT Presentation

TRANSRADIAL APPROACH: ATHERECTOMY IN COMPLEX PATIENTS

Manu Kaushik, MD Bon Secours St Mary’s Hospital, Richmond, VA

DISCLOSURES

No Relevant Financial Disclosures

CHALLENGES TO ACCEPTANCE OF TRA AS 1ST LINE

Lack of operator comfort with cPCI

TRA avoided in complex patients

 Elderly  CKD patients with calcification  Low EF  Moderate/Severe valve disease

▪Patients with magnified advantages of TRA

▪ACS/STEMI ▪Elderly ▪CKD ▪Frail/Underweight

HOW TO ASSESS CALCIFICATION/NEED FOR ATHERECTOMY Pretest predictors predictors of calcification

 Age  Previous failed PCI/Difficulty delivering stents  Post CABG/radiation  CKD  Severe AS: Pre TAVR

Intraprocedural predictors of calcification

 Calcification in other coronary segments  Aorto ostial disease  Angiography: Digital angiography - Train you eyes  Gold standard for identification of calcification is intravascular imaging

TRA FOR ATHERECTOMY

Attitudes and Concerns(Myths)

 “I can do it without atherectomy”  Equipment not compatible  Not enough guide support  Bailout options not deliverable

CASE 1: 82 YEAR OLD, PRESENTS WITH CCS III ANGINA REFRACTORY TO MEDICAL THERAPY, EF 40-45%, PRIOR PARTIALLY SUCCESSFUL PTCA (INCOMPLETE BALLOON EXPANSION) TO MID RCA 3 YEARS AGO (STENT COULD NOT BE DELIVERED-TFA). INFERIOR-INFEROLATERAL ISCHEMIA

82 YEAR OLD, PRESENTS WITH CCS III ANGINA REFRACTORY TO MEDICAL THERAPY, EF 40-45%, PRIOR PARTIALLY SUCCESSFUL PTCA(INCOMPLETE BALLOON EXPANSION) TO MID RCA 3 YEARS AGO (STENT COULD NOT BE DELIVERED- TFA). INFERIOR-INFEROLATERAL ISCHEMIA

Options

 Attempt as routine PCI  ?? Lesion preparation

 Modified balloons: Scoring or cutting  Atherectomy  Rotational atherectomy or orbital atherectomy

ATHERECTOMY VS MODIFIED BALLOON ANGIOPLASTY

82 YEAR OLD, PRESENTS WITH CCS III ANGINA REFRACTORY TO MEDICAL THERAPY, EF 40-45%, PRIOR PARTIALLY SUCCESSFUL PTCA(INCOMPLETE BALLOON EXPANSION) TO MID RCA 3 YEARS AGO (STENT COULD NOT BE DELIVERED-TFA), INFERIOR/INFEROLATERAL ISCHEMIA

82 YEAR OLD, PRESENTS WITH CCS III ANGINA REFRACTORY TO MEDICAL THERAPY, EF 40-45%, PRIOR PARTIALLY SUCCESSFUL PTCA (INCOMPLETE BALLOON EXPANSION) TO MID RCA 3 YEARS AGO (STENT COULD NOT BE DELIVERED-TFA), INFERIOR/INFEROLATERAL ISCHEMIA

▪ 6 Fr Slender Glidesheath Left radial ▪ 6 Fr AL 0.75 Guide ▪ 1.5 mm Rota burr; 4 passes at 170000 rpm for 15-25 seconds ▪ No pacemaker ▪ Mid RCA 3.0 stent dilated to 3.25 ▪Prox RCA 4 stent dilated to 5.0

CASE 2: 94 YEAR OLD MALE WITH CCS III ANGINA, EF 30% (MULTIFACTORIAL), MODERATE TO SEVERE AS(AVA 1.1 CM2)

▪Left system without significant disease ▪Critical ostial disease with heavy

• calcification. Mid segment

ectatic, with no significant distal disease ▪Planned to perform PCI

94 YEAR OLD MAN WITH CCS III ANGINA, EF 30%(MULTIFACTORIAL), MODERATE TO SEVERE AS(AVA 1.1 CM2)

▪Right Radial

▪7 Fr Terumo Glidesheath Slender

▪7 Fr JR4 Guide catheter for coaxial

• rientation

▪Primary wiring by airmailing viper wire ▪Diamondback orbital atherectomy with classic coronary crown ▪2 passes for 20 sec at low speed(80k); 1 pass at high speed(120k) for 15 sec

94 YEAR OLD MAN WITH CCS III ANGINA, EF 30%(MULTIFACTORIAL), MODERATE TO SEVERE AS(AVA 1.1 CM2)

94 YEAR OLD MAN WITH CCS III ANGINA, EF 30%(MULTIFACTORIAL), MODERATE TO SEVERE AS (AVA 1.1 CM2)

▪OAC with 3 passes 1.25mm crown ▪4 mm by stent ▪5 mm NC balloon ▪Final results

ORBITAL ATHERECTOMY VERSUS ROTATIONAL ATHERECTOMY

ORBITAL VERSUS ROTATIONAL ATHERECTOMY: MY PREFERENCE

▪Orbital atherectomy

▪Very large vessel(>3.5 mm) ▪Coaxial device orientation ▪Balloon/microcatheter uncrossable lesion: primary wiring with atherectomy wire

▪Laser Atherectomy

▪Under-expanded stent due to external calcium

▪Rotational atherectomy

▪Everything else

ATHRECTOMY USING TRA: SET UP

▪ 6-7 Fr slim body sheaths ▪ May use sheath-less guide systems ▪Room set up similar to TFA ▪Guide Shapes: Support(except when ostial

• nly disease)

▪Left: EBU/XB/CLS ▪Right: AL, HS, MAC

▪Guide size

▪ Largest burr likely to be used (burr to artery ratio 0.5-0.6) ▪Bailout options (GraftMaster 6 Fr/Papyrus 5 Fr)

In Inches Device/ sheath OD Manufaturer Recommended Minimum Guide Minimum recommended ID OAC 1.25 mm crown 0.058 6 0.066 Rota 1.25 mm burr 0.058 6 0.060 Rota 1.50 mm burr 0.059 6 0.063 Rota 1.75 mm burr 0.069 7 0.073 Rota 2.0 mm burr 0.079 8 0.083 Rota 2.25 burr 0.089 9 0.093 Launcher 6 Mach 6 Vista brite 6 Launcher 7 Convey 7 Vista Brite 7 Guide extender 7 Min ID(inch) 0.071 0.070 0.070 0.081 0.081 0.78 0.62

CASE 3: 68 YEAR OLD DIABETIC WITH ANTERIOR/APICAL ISCHEMIA WITH ANGINA, INTRAMYOCARDIAL LAD, EF 45%

CASE 3: 68 YEAR OLD DIABETIC WITH ANTERIOR/APICAL ISCHEMIA WITH ANGINA, INTRAMYOCARDIAL LAD, EF 45%

▪True bifurcation disease, 1:1:1 ▪Planned 2 stent strategy ▪IVUS difficult to extend into diagonal ▪Started with balloon dilatation of D1

▪Suboptimal dilatation of balloon

▪Switched to Atherectomy strategy

CASE 3: 68 YEAR OLD DIABETIC WITH ANTERIOR/APICAL ISCHEMIA WITH ANGINA, INTRAMYOCARDIAL LAD, EF 45%

▪ 1.75 mm Burr in both LAD and D1 ▪ 2 passes each ▪ DK Crush, POT, SKB ▪4.5 prox LAD, 3.5 mm mid LAD, 3.25 D1 ▪Final Results

SUMMARY

▪ Atherectomy makes it easy

▪ To deliver stent ▪ To ensure proper stent expansion(aorto-ostial lesions) ▪ To optimize for durable results(bifurcations/2 stent strategy) ▪ More helpful in radial procedures

▪Radial approach for atherectomy

▪Safe(r) than femoral approach ▪No more difficult that femoral approach