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

TRANSRADIAL APPROACH: Manu Kaushik, MD ATHERECTOMY IN COMPLEX Bon Secours St Mary’s Hospital, PATIENTS Richmond, VA

DISCLOSURES No Relevant Financial Disclosures

CHALLENGES TO ACCEPTANCE OF TRA AS 1 ST LINE ▪ Patients with magnified Lack of operator comfort with advantages of TRA cPCI ▪ ACS/STEMI  TRA avoided in complex patients ▪ Elderly  Elderly ▪ CKD  CKD patients with calcification ▪ Frail/Underweight  Low EF  Moderate/Severe valve disease

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 orientation ▪ 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 In Inches Device/ sheath OD Manufaturer Minimum Recommended recommended ID Minimum Guide ▪ May use sheath-less guide systems OAC 0.058 6 0.066 ▪ Room set up similar to TFA 1.25 mm crown Rota 1.25 mm burr 0.058 6 0.060 ▪ Guide Shapes: Support(except when ostial Rota 1.50 mm burr 0.059 6 0.063 only disease) Rota 1.75 mm burr 0.069 7 0.073 ▪ Left: EBU/XB/CLS Rota 2.0 mm burr 0.079 8 0.083 ▪ Right: AL, HS, MAC Rota 2.25 burr 0.089 9 0.093 ▪ Guide size ▪ Largest burr likely to be used (burr to artery Launcher Mach 6 Vista brite Launcher 7 Convey 7 Vista Brite Guide 6 6 7 extender 7 ratio 0.5-0.6) Min ID(inch) 0.071 0.070 0.070 0.081 0.081 0.78 0.62 ▪ Bailout options (GraftMaster 6 Fr/Papyrus 5 Fr)

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