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

Stent Regrets, I’ve 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

Disclosures Abbott Vascular, Inc (Speaker’s Bureau)

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

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

A few days later, , A different operator.. .. Guide • #7 AL1 guide; Impella • Intent was to perform rotational atherectomy Guideliner • 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 Courtesy of Naeem Tahirkheli MD

Fin inal Result After Attempt # 2

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

Result after Rotational Atherectomy

“Dog - boned” Balloon Orbital Atherectomy

Guideliner After Orbital Atherectomy, using Guide Extension to deliver stents

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

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

Excimer Laser MSA 3.8 mm 2 3.75mm NC @ 30 atm 1.4mm laser with contrast Final result after 3.75 mm NC @ 24 atm MSA 10.7 mm 2

OCT Imaging Following Rotational vs Laser Atherectomy After Rotational atherectomy After Laser with Saline After Laser with Contrast Ashikaga T, et al. CCI 2015; 86: 946-949

Shockwave Lit ithotripsy Lorenzo A, et al. Eurointervention 2019

Options for Stent Regret Device Mechanism Limitations Laser Vaporization of calcified lesion beneath the Severe underlying calcification stent struts: photo-mechanical effect Extensive RA (Larger burr) needed for effect to Burr entrapment in recent stent, Rotational reach underlying calcification distal embolism of stent strut atherectomy Shockwave Sonic energy distributed uniformly addressing Higher crossing profile (0.043” - calcium irrespective of its 0.046”) Lithotripsy circumferential/eccentric location May require PTCA/atherectomy first

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

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

Final Result

5 days later.. .. Inferior STEMI

PCI Details • 3.0 X 12 mm PTCA • IVUS: Under-expanded pre-existing (3.0 mm stent) with MSA of 2.0mm 2 , 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 mm 2 (doubled)

Fin inal Result – ST segments normalized

25 minutes later.. .. Hard to win against an under-expanded stent! Once a Stent Regret → (Almost) always a Stent Regret! Inferior ST-elevation again

Next Steps… • Aspiration thrombectomy • Eptifibatide • 4.0 x 12 mm NC balloon @ 16 atm • MSA improved to 5.5 mm 2

Final Result ASA + Ticagrelor Doing well 11 months later

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 mm 2 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.