COMPLEX HIGH RISK CORONARY INTERVENTION John Michael Chua Chiaco, MD, FACC Iowa Heart Center Fort Dodge
OBJECTIVES Determine how to risk stratify patients undergoing PCI Understand the concept of complex coronary interventions
COMPONENTS OF RISK STRATIFICATION FOR PCI / CABG Clinical characteristics Coronary anatomy variables Personal preferences
EXAMPLES OF RISK MODELS Risk Model Number of Variables Validated in PCI/CABG Clinical / Angiographic PCI CABG EuroScore 17 0 + + Mayo Clinic RS 17 0 + + ACEF 3 0 - + NCDR 8 0 + - AHA/ACC 0 11 + - SYNTAX 0 11 + + STS 40 2 - + Global Risk Class. 17 11 + + Clinical Syntax 3 11 + - Textbook of Interventional Cardiology, 6 th Edition, Topol E., Teirstein P.
THE ADDITIVE EUROSCORE (CLINICAL) PATIENT FACTORS CARDIAC FACTORS Age (per 5>60) 1 Unstable angina 2 Female 1 Endocarditis 3 Lung disease 1 Critical pre-op state 3 Extracardiac arteriopathy 1 LVEF 30-50% 1 Neurologic dysfunction 2 LVEF <30% 3 Redo CABG 3 Recent MI 2 Creatinine > 200 micrmol/l 2 Systolic PAP > 60 mmhg 2 OPERATIVE FACTORS EuroSCORE risk groups Emergency surgery 2 Low risk 0-2 Other than isolated CABG 2 Medium risk 3-5 Surgery of the thoracic aorta 3 High risk 6+ Post-MI septal rupture repair 4 European Journal of Cardiothoracic Surgery 1999; 16:9
ACEF (AGE, CREATININE, EJECTION FRACTION) SCORE (CLINICAL) The Easier Predicts Better: Multicentric External Validation and Superior Clinical Performance of the ACEF Score Compared to Additive and Logistic EuroSCORE in 29,659 Elective Cardiac Surgery Patients. Ranucci M et, al, J Thorac Cardiovasc Surg. 2011 Sep;142(3):581-6
EYEBALL CRITERIA Low Moderate High
VARIABLES INCREASING RISK OF PCI Acute myocardial infarction Cardiogenic shock Emergent procedure Aortic stenosis (severe) Atrial / ventricular arrhythmias Decompensated heart failure Anemia / active bleeding / anticoagulation Cerebrovascular disease DM / Renal insufficiency / Pulmonary disease Contrast allergy Very small or very large body habitus Cardiac Catheterization Handbook, 6 th Edition, Morton Kern
BLEEDING May drastically increase risk AFTER PCI PCI will commit the patient to indefinite aspirin and DAPT for at least 1 year PCI on a patient with bleeding out of the frying pan and into the fire May turn a symptomatic 80% stenosis into a STEMI after PCI followed by DAPT cessation Aspirin discontinuation can NEVER be SAFELY recommended
PCI HOW IT SHOULD BE
PCI HOW IT SHOULD BE
PCI HOW IT SHOULD BE
PCI HOW IT SHOULD BE
PCI HOW IT SHOULD BE
SYNTAX SCORE (ANGIOGRAPHIC)
TORTUOSITY (AORTOILIAC) Cardiac Catheterization Handbook, 5 th Edition, Morton Kern. Angiography and Endovascular Therapy for Aortoiliac Artery Disease, Fukuda E. Endovascular Today Case Report: The GORE EXCLUDER Iliac Branch Endoprosthesis in a Tortuous Aortoiliac Aneurysm
RADIAL ARTERY LOOP Balloon-Assisted Tracking of a Guide Catheter Through Radial Artery Loop and Spasm. Shah, Ashish et. al. Cath Lab Digest, Volume 21, Issue 2, Feb 2013
CORONARY TORTUOSITY http://www.vascularperspectives.com/cardiology/ptca-guide-wires/asahi-sion-blue.htm
CORONARY TORTUOSITY Cases in Interventional Cardiology: Expert Consult Online and Print, 1 st Edition, Ragosta, Michael
MULTIVESSEL CAD Cases in Interventional Cardiology: Expert Consult Online and Print, 1 st Edition, Ragosta, Michael
MULTIVESSEL CAD Multivessel PCI vs CABG PCI associated with: Large contrast load Extensive stenting (requiring long-term DAPT) Risk of stent thrombosis rare but often fatal Higher rates of repeat revascularization Burning bridges bypass graft cannot be placed over stented area
CHRONIC TOTAL OCCLUSION Utility of Intravascular Ultrasound in PCI of CTO, Galassi, Alfredo; JACC: Cardiovascular Interventions, Volume 9 Issue 19, October 2016
CHRONIC TOTAL OCCLUSION Cases in Interventional Cardiology: Expert Consult Online and Print, 1 st Edition, Ragosta, Michael
CHRONIC TOTAL OCCLUSION Retrograde CTO Crossing Through Invisible Collaterals, Nicholson, William. Cath Lab Digest, Volume 24, Issue 8, August 2016
CHRONIC TOTAL OCCLUSION
CHRONIC TOTAL OCCLUSION Extremely challenging Varying reports of long-term patency / clinical outcomes Lengthy / high contrast load / high radiation / more equipment Most common reason to abort PCI and proceed with CABG
THROMBUS Cases in Interventional Cardiology: Expert Consult Online and Print, 1 st Edition, Ragosta, Michael https://www.slideshare.net/drrahularora2k3/no-reflow-and-slow-flow-phenomenon-during-pci
NO REFLOW Cases in Interventional Cardiology: Expert Consult Online and Print, 1 st Edition, Ragosta, Michael
THROMBUS Rochon B, Chami Y, Sachdeva R, Bissett JK, Willis N, Uretsky BF. Manual aspiration thrombectomy in acute ST elevation myocardial infarction: New gold standard. World J Cardiol 2011; 3(2): 43-47
CORONARY ARTERY CALCIFICATION Cases in Interventional Cardiology: Expert Consult Online and Print, 1 st Edition, Ragosta, Michael
CORONARY ARTERY CALCIFICATION Clinical Utility of Intravascular Imaging and Physiology in Coronary Artery Disease. Mintz, Gary. JACC, Volume 64, Issue 2, July 2014
CORONARY ARTERY CALCIFICATION Lesions very difficult to dilate Stent underexpansion is a cause of stent thrombosis High pressure balloons / atherectomy devices often required DIAMOND BACK ROTABLATOR
UNPROTECTED LEFT MAIN Fatal Subacute Stent Thrombosis Induced by Guidewire Fracture with Retained Filaments in the Coronary Artery. Kim, Tae-Jin et al., (Korean Circ J 2013;43:761-765)
LEFT MAIN Typically performed with hemodynamic support Intraaortic balloon pump Impella Tandem Heart http://www.nmcheartcare.ae/iabp-intra-aortic-balloon-pump-insertion/
BIFURCATIONS
BIFURCATIONS Cases in Interventional Cardiology: Expert Consult Online and Print, 1 st Edition, Ragosta, Michael
BIFURCATIONS: POTENTIALLY LOTS OF STEPS Provisional side branch stenting vs. double stenting Alegría-Barrero, Eduardo & Foin, Nicolas & Chan, Pak Hei & Syrseloudis, Dimitrios & Lindsay, Alistair & Dimopolous, Konstantinos & Alonso-Gonzalez, Rafael & Viceconte, Nicola & Silva, Ranil & Di Mario, Carlo. (2012). Optical coherence tomography for guidance of distal cell recrossing in bifurcation stenting: Choosing the right cell matters. EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology. 8. 205-13. 10.4244/EIJV8I2A34. Coronary Stenting: A Companion to Topol s Textbook of Interventional Cardiology, 1 st Edition. Expert Consult Online and Print.
BIFURCATIONS Complex Increased risk of side branch closure Higher rate of restenosis / stent thrombosis Stent struts often jailing side branch Increased risk of: Stent malapposition Incomplete lesion coverage Delayed endotheliaization E Moore, James & Timmins, Lucas & LaDisa, John. (2010). Coronary Artery Bifurcation Biomechanics and Implications for Interventional Strategies. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions. 76. 836-43. 10.1002/ccd.22596.
WHAT TO DO POST COMPLEX PCI? CONTINUE DAPT! Clear benefit in reduction of major adverse cardiovascular events with long term DAPT use in complex PCI Efficacy and Safety of Dual Antiplatelet Therapy After Complex PCI. Giustino et. al. Joural of American College of Cardiology, Volume 68 Issue 17, October 2016
WHAT TO DO PRIOR TO PCI (NON-ACS, STABLE ANGINA PECTORIS) Stress test if stable Establish diagnosis Define extent / severity of ischemia Braunwald s Heart Disease: A Textbook of Cardiovascular Medicine, Tenth Edition (taken from Circulation, 2003)
WHAT TO DO PRIOR TO PCI (NON-ACS, STABLE ANGINA PECTORIS) Start anti-anginal therapy (at least 2 medications) Beta blockers / Calcium channel blockers Nitrates Sodium channel blocker (Ranexa) Proceed with cardiac catheterization if If moderate / high risk findings noted Persistent angina despite medical therapy with 2 or more meds
QUESTIONS?