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? 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

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

Onyx 3.0 x 12 LMS  LCX Runthrough into LCX POBA Trek 2.75 x 15

Biofreedom 3.0 xx 33 LMS  LAD (Culotte)

Biomatrix 2.72 x 28 (prox LAD) Biomatrix 2.5 x 33 (mid-distal LAD)

Result Culotte LMS prior to FKB

FKB (Lacrosse 2.5x15 LAD / Trek 2.0x15 LCX)

Biomatrix Neoflex 3.5 8 in LMS Lacrosse 2.5 x 15 LAD and LCX

Accepted result

Lessons Case 1: Dissection LMS after FKB • Keep it simple • FKB can result in LMS dissection • Immediate diagnosis and remedial is key

Case 2. Acute and late problem

Presentation • 71 yo lady • Severe angina • Rejected CABG • For provisional LMS  LAD

Scoreflex 2.75x15 LAD Ultimaster 3.0 x 24 in prox LAD Ultimaster 3.5 x 18 from LMS  LAD

Plaque shift into oLCX

Reverse crush LCX LAD NC Trek 3.75 x 15 (LAD) / Ultimaster 3.0 12 (LCX) FKB (NC Euphoria 2.5 x 15 / 3.0 x 15) POT (Accuforce 4.0 x 8)

Final result

Happy?!

6 months later angina…

Sapphire NC 4.0 x 10 Re-wiring and IVUS. POBA / DEB LCX Biomatrix alpha 3.5 x 29

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

Case 3. Acute problem

Background • Pt with oLMS and RCA disease

Diagnostic images

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

JL3.5 7F, IABP 34cc, venous sheath Runthrough : wiring from outside

POBA oLMS (Tazuna 2.5 x12) POBA oLMS (NSE Alpha 4.0 x 13)

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)

Final result

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

Case 4. Late problem

• 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

DK crush result

• Presents 16 months later with exertional chest pain

Diagnostic images

Volcano IVUS LCX : fully expanded stent, ISR and clot +++ at ostium Thrombuster 6F clot aspiration Euphora 3.5x 15 LMS  LCX followed by Accuforce 4.0 x 15

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

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

Final result

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

Literature

• 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

• 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

• 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),

• 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

Overall summary • Acute complications include • arterial dissection • arrhythmias • acute vessel closures • Late complications include: • ISR and ST