Stent Regrets, Ive Had a Few! Faisal Latif MD, FSCAI, FACC Director - - PowerPoint PPT Presentation

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Stent Regrets, Ive Had a Few! Faisal Latif MD, FSCAI, FACC Director - - PowerPoint PPT Presentation

Jan 20, 2024 269 likes •546 views

Stent Regrets, Ive Had a Few! Faisal Latif MD, FSCAI, FACC Director Cardiac Catheterization Lab, VAMC Associate Professor of Medicine Governor, Oklahoma Chapter of ACC Associate Program Director, CV Fellowship University of Oklahoma

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Stent Regrets, I’ve Had a Few!

Director Cardiac Catheterization Lab, VAMC Associate Professor of Medicine Governor, Oklahoma Chapter of ACC Associate Program Director, CV Fellowship University of Oklahoma

Faisal Latif MD, FSCAI, FACC

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SLIDE 2

Disclosures

Abbott Vascular, Inc (Speaker’s Bureau)

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SLIDE 3

Case #1

  • 75 year-old with LVEF 10-

15%

  • Severely calcified RCA
  • LAD with 70% stenosis
  • Operator couldn’t get any

balloons across mid-RCA

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Stented ostial RCA with 2.0 .0 x 12 mm DES!

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SLIDE 5

A few days later, , A different operator.. ..

  • #7 AL1 guide; Impella
  • Intent was to perform rotational

atherectomy

  • Lesion crossed with a pilot wire
  • Tried various balloons but >2.0mm

balloon wouldn’t get across the stent

  • Tried to get a laser catheter in, but

couldn’t cross Guide Guideliner

Courtesy of Naeem Tahirkheli MD

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SLIDE 6

Fin inal Result After Attempt # 2

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Im Impella left ft in place, , 3 days later

  • 1. #8F Guide system, JR4 guide
  • 2. Whisper wire to cross and turnpike

LP advanced (key was guide co- axiality)

  • 3. Exchanged for rotawire
  • 4. 1.25mm → 1.5mm burr @ 175k

rpm

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SLIDE 8

Result after Rotational Atherectomy

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“Dog-boned” Balloon Orbital Atherectomy

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SLIDE 10

After Orbital Atherectomy, using Guide Extension to deliver stents

Guideliner

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Final Result After 2.75 x 38, 3.0 x 38 and 3.5 x 22 mm DES!

In ostial RCA, a 3.5 x 22 mm stent inside a previous 2.0 x 12mm DES

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Stent Regret

  • Stent regret = Stent underexpansion/malapposition
  • Can results in ISR or Stent Thrombosis
  • Essentially, it is either an “atherectomy-regret” or “imaging-regret”
  • How to prevent:
  • Imaging a priori (IVUS or OCT) to determine size/degree of Ca++
  • The combination of large calcium arc (>270°) and thickness (>670 μm)

predicts non-dilatable lesions

  • Balloon angioplasty commonly used, but unlikely to yield durable

results unless stent recently implanted

Mehanna E, Abbott JD, et al. Circ CV Interv 2018

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SLIDE 13

1.4mm laser with contrast Final result after 3.75 mm NC @ 24 atm

Excimer Laser

3.75mm NC @ 30 atm

MSA 3.8 mm2 MSA 10.7 mm2

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OCT Imaging Following Rotational vs Laser Atherectomy

Ashikaga T, et al. CCI 2015; 86: 946-949

After Rotational atherectomy After Laser with Saline After Laser with Contrast

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SLIDE 15

Lorenzo A, et al. Eurointervention 2019

Shockwave Lit ithotripsy

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Options for Stent Regret

Device Mechanism Limitations

Laser

Vaporization of calcified lesion beneath the stent struts: photo-mechanical effect Severe underlying calcification

Rotational atherectomy

Extensive RA (Larger burr) needed for effect to reach underlying calcification Burr entrapment in recent stent, distal embolism of stent strut

Shockwave Lithotripsy

Sonic energy distributed uniformly addressing calcium irrespective of its circumferential/eccentric location Higher crossing profile (0.043”- 0.046”) May require PTCA/atherectomy first

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Case 2

76 year-old man with previous RCA stents CCS 3 angina despite GDMT Inferior ischemia on MPI LVEF 25-30%

Courtesy of Talla Rousan MD

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2.75 x 12 mm PTCA 3.0 X 18mm DES 3.25 X 12 mm NC post-dilatation

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Final Result

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5 days later.. ..

Inferior STEMI

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PCI Details

  • 3.0 X 12 mm PTCA
  • IVUS: Under-expanded pre-existing (3.0

mm stent) with MSA of 2.0mm2, and 1.6 mm minimal stent diameter

  • 3.5 x 22mm PTCA @ 22 atm → 3.5 X 10

mm Angiosculpt @ 18 atm

  • IVUS: MSA 4 mm2 (doubled)
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Fin inal Result – ST segments normalized

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SLIDE 23

25 minutes later.. .. Hard to win against an under-expanded stent!

Inferior ST-elevation again

Once a Stent Regret → (Almost) always a Stent Regret!

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Next Steps…

  • Aspiration thrombectomy
  • Eptifibatide
  • 4.0 x 12 mm NC balloon @ 16 atm
  • MSA improved to 5.5 mm2
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SLIDE 25

Final Result

ASA + Ticagrelor Doing well 11 months later

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Avoiding Stent Regret: Practical Tips

  • Stent ≤ 2.75 mm: predictor of DES under-expansion
  • Use intravascular imaging frequently to optimize
  • Without post-dilation, only 36% stents expand

adequately: POST-IT trial

  • Second guess yourself if:
  • MSA < 5.0 mm2 or < 90% of the distal reference

lumen area

Abbott DJ, et al. Circ CV Interv. 2018;11:e006813. Brodie BR, et al. CCI 2003 Jun; 59(2):184-92 Taherioun M, et al. ARYA Atheroscler. 2014 Jan; 10(1): 13–17.