Chapters Transcript Video Current State of PCI Good afternoon, everyone. Hi, I'm uh on one of the new interventionists. Um and uh just a few weeks out of p of training. So I guess this is as current as it gets. Um I have no disclosures. Um and I was asking, Doctor Talia told me that, you know, uh we would be getting some of the newer attendings to speak at a conference uh back when I was at C RT and then uh when I went back there, still a few more months of training left, I spoke to my attending and I'm like, do you have any pearls for me? First conference on a panel? He's like, just showcases you did good or bad. So, uh I'm like, oh my God, you know, will I have enough cases within a couple of weeks? But luckily enough I did. So this was my first first case. This was during my orientation at Lee and it was Dr Cohan who said this was ac and do so why don't you do the case? So this is a 53 year old male past medical issue of hyperlipidemia has known history of C A bar 10 to RC and C and he's on Cialis and he comes in with a progressive Anna for the past four weeks. He's on a couple of antianginals maximally tolerated. Um You know, the manifold is completely new. It, everything's up, is down, down, is up. And uh this was the cat on the 17th, a week out of my and this is what I see. So, um you know, mid RC a stenosis and I'm like, yeah, that could cost a man and then I see this and I'm like, wow, uh is there uh left Main uh great first case for a cat here. Um So, um you know, here, I'm just gonna stop for a second. Um and then pass it over to the panel for a quick 10 seconds. What would you guys do? Uh You, uh you know, I'm actually kind of figuring out where the bathrooms are at this point. Yeah, I mean, that's a, that's actually a great case because I think it's gonna, you know, really require you to utilize the skills that she developed in training. And I think that using a team approach to this stuff and uh having doctor Cohan there to kind of bounce things off of as, as we do routinely with each other is important. But I would tell you that I would deliberately utilize intravascular imaging um here to make sure that I understand the left main before I endeavor on fixing the right coronary artery, um which is more eye catching but potentially less significant prognostically. Ok. Um So, you know, I couldn't give him nitroglycerin and that was my thought is, um, and then I didn't take a spider shot because there was a semi alert in the Ed. So there were two reasons that I couldn't, you know, further do the case. So he wasn't having active chest pain on the table. Uh I stopped the procedure and we said that, you know, we can bring him back and I clearly told him and his wife, no Cialis 72 hours prior to the next Cath. So, you know, to Doctor Levine's Point, uh these are the guidelines, the most updated guidelines for intravascular imaging. Um You know, there's a lot of, there's a lot of talk in some conferences that we really, it has to be a class one with the mountain of data that we have now. But essentially, you know, um especially if it's um assessing a lesion really, you want either IVIS or OCT uh preferably HD IVIS. Um So I bring him back. Um I speak to my attendings um at UVM and I'm like, hey, you know, what do I do if the left main is significant or not significant? Uh how do I approach this? Uh And then as I'm planning, I'm in the P A's room. Uh and this guy is on the table and I'm like, this is a 1230 case. Where is he? I'm going through the list and it looks like he was in the Ed, uh because he had chest pain the night before he came in, uh, and he had a mild tring and he was just in the Ed. We, we just didn't know that he was there. So we go down, see him quickly bring up to the lab. I go groin. Um and uh gave him some nitro, took a picture and this is what I see. Um So his uh left man was probably spasm uh with the guide shot, it was completely fine. So, uh now I'm like, what do I do next? Um um Again, uh if I, uh you know, uh in my head, I'm kind of wa walking through the scenarios that I've spoken to a couple of my attendings and they're like, uh how do I fix the? Right? Uh I had Doctor Alamar in the background. He's like, always have a senior partner there. So that first step was checked. Um I um it was like, ok, what do I do for my guide? What do I do for my wire escalation strategy? How do I use uh more support in terms of micro catheter to wire that uh tough lesion. And uh how do I prep it? Um Right. Um So then I go seven French A L 0.75. Um uh Luckily I was able to wire with a workhorse wire. I pulled out a Corsair pro access but we didn't, uh didn't have to use it, but I had it as a backup. Um I, you know, I was like, let me feel this lesion out first. So we go with the, uh went in with a semi compliant balloon nominal and we were able to get some flow. Um And then I used, uh I wanted to know what I was dealing with here. Um So this was the IVIS run. Uh This is Boston um HDIS. Uh I really wanted the HDIS here because a we, we train more with it in training. But also I really wanted to figure out, you know, my lesion landing zones, uh it was a big vessel. Um And I knew it was going to be calcified. Uh So here you can see that, you know, on the run there's 360 degrees of calcium. The lesion is pretty calcified for over 5 to 10 millimeters. Our distal reference is a pretty big vessel. It's at least a 40 approximately, it's a five which I expected in a, in a, in a man with a dominant, right? And the middle picture there is the lesion that was at its tightest. Um So now, uh I was like, uh and then this was a state of the art review by Dr Truesdell that just came out. Uh But uh essentially the concept is you want to use your imaging for pre pre intervention assessment. Uh How do you prep the lesion, what tools would, would we be using and then really assess if there's anything more to do once you're done with it. Um And uh going back to what we saw in the IVIS uh picking the next tool set depends on uh what we see. Um And this was a validated scoring system uh using our IVIS. And in him, it was at least uh two points because he had 360 degree arc of calcium and he had a significant lesion length uh there as well. Um And then this is really the toolbox that we have for treating these calcified lesions. Uh We have cutting and scoring balloons. Uh We have laser rotational uh all vital high pressure and c and intervascular literatures. Um Essentially in my head, anything in the middle of the screen uh barring the scoring balloon. I really wanted a senior partner with me by my side, especially, this is my first couple of weeks uh starting with uh the first few cases. Uh But everything else was, was really contingent upon was the balloon crossing or not. And uh you know, the balloon did cross. And this is kind of the algorithm we use in the cat lab when we, when we are dealing with these lesions. Um And uh it's, it's, it's a lot about uh which is the best tool set to pick for the best lesion prep. And in him uh because of the amount of calcium we knew we wanted to arthrectomy uh because it was balloon cross. Uh I was confident that I could get a shock wave, lithotripsy balloon and deliver enough pulses. Um So then we predilated with a NC balloon which was a 35 NC prep the lesion a little bit followed by a 40 shockwave balloon. This is one of our specialized balloons that we used to deliver sharks that kind of break up the calcium. It's kind of like shattering the windshield and then using an NC balloon to break, break it up and making it more yielding to the stent expansion. Uh followed by placement of uh two long stands. Um One was a four, they were both four os, but I dilated the proximal center of 50 based on the reference landing zones. Uh We didn't really have to guess because we had that data with our uh intervascular imaging as to what sizes we needed to go to. Uh followed by uh some more NC ballooning. Uh We were, we had decent expansion. Um And then this was our final IVIS run post case. This is the post run and you can see uh there was some calcium but that was really distal to the lesion, but we had an appropriate lumen. So we didn't have to do anything really on the post run. What you're looking for is making sure you don't have any big edge dissections that might want you to put more stents in. Um, you know, this is always a nice uh thing to see post procedure for an interventionist. When you're seeing the ni the stent is nice and well expanded and everything looks round. Uh the patient's blood pressure is OK. And uh he's not having any more chest pain. Um The two, the three things really we look at when we do these procedures is uh apart from the proximal reference loin is we're looking at what is the minimal stent expansion we have. And usually it needs to be uh most trials like the ultimate trial stated that it's either 90% of the distal reference. So if, if our distal reference was a 40 vessel, we wanted our minimal stent to be at least 90% of that. So anything above 3.6 or in a long region, you can do 80% of the average of the proximal in the distal. And uh we got excellent stent expansion of more than 90% in all sides of the artery. So we were happy with the result and Gras and Angio uh hopefully plays for me, but uh you'll have to take my word gra look great. Um So just a couple of slides on some data, I'm not going to bore you with this, but this was a, this was a paper that my cat lab director cited a lot. Um And I I and this was by Ken Bay and this was at MGH back before I was born. Uh But essentially it was a neat paper. And what it talks about is a fundamental concept of interventional cardiology that tells us that your net gain that you get after you send a patient is essentially your offsetting effects of your acute gain that you get from any technical you use here. They used three birds, which we don't do anymore and your late loss that you eventually always get. So essentially, the, the, you know, kind of the point of this paper was just get as big a result as you can when you start out. And that kind of goes on. And this theme is it kind of continues in all of our IVIS trials because all of these trials showed that when you use intravascular imaging and you do it the right way and it's an IVIS or Ibis or Oct guided optimized PC. The outcomes are better, but they're also a lot better because you're using bigger equipment because, you know, you're not flying blind essentially. So this was the IVIS XPL trial which deal with longer lesions. This is the, the, the, the, the 12 month follow up of the trial which came out in Jama in 2015, 1 of the first trials that trials, that kind of put uh you know, I was on the map and you can see that there is a significant difference in outcomes and most of these outcomes are driven by target lesion revascularized. This was the ultimate, the three year results, Doctor Levine showed the 12 month. But because I'm closer out of training, we had to present this journal club. So we have the three year results. And the key point here is, you know, forget about everything. The, the first graph, you know, is not important. It's the second one that's important where you're, they're talking about sub optimal versus optimal PC. And really you want to, we, we try to optimize our PC. It's not enough just using I for the sake of using it, but it's to get that data point to see what more we can do and the curves are really different. Uh And this is good data to tell a patient. So when I'm seeing a patient and I tell them that if I use intravascular imaging and I get a good enough result, your, your risk of outcomes at up to three years is, is not even half, it's less than half, it's closer to a third, which is very good data to tell our patients in the last couple of minutes. I have one last case to show and to kind of highlight uh what is the importance of optimal PC I. Um uh This is a 70 year old male uh came in with uh known C AD drug loing sent to RC. A five months ago, came in with discomfort, which he said was similar to what he had before he swears, he takes his aspirin and uh Effient every day. Um His EKG was unchanged. This was his prior Cath. Uh he had significant uh RC A disease and L AD L AD disease. He got two stents uh to his RC A 225 from proximal to mid and he got one stent to his led, which was a 35 stent. Um So this was his repeat cath. Uh I did have some significant damping uh And let me see if it plays. So this is what I see uh on the C um And everything is instant. His led stent is widely patent. Uh Doctor Levine was in the opposite lab. So I called him Goddess thoughts and um on, you know, what, what would be the best way to deal with this. Um And he said, you know, you, you should ideally fix it. This is why this guy is having chest discomfort. Uh And so Kr 4h Guide Workhorse Wire again, I tried to feel the lesion out, gave him some niCARdipine to make sure there was no spasm. Um And then we went 25, 18 NC high pressure. Um I knew that it was a 225 ST so I could go a little bit higher. And I also was like, he's, he's a man. He has a decent size RC. A. So what are the chances it's smaller than a 25? Probably not So, uh once I ballooned it, we got some decent flow. Um And then uh my next slide as you guys are gonna guess is gonna be intravascular imaging. Um And then hopefully let it just display. Yep. So we use one of our specialized high pressure balloons here. We got decent result, but I still had some damping. Um So this was uh this is a different I A system. Uh The Phillips I A system which is easier to use. And then uh we're just, you know, going down the vessel, get my distal reference was a 30 vessel. So I knew that, you know, the stent was probably undersized for his vessel and his proximal reference was like a 35. And on the far right, you can see the minimal stent. Uh the two, the 2.25 stent went up to a 2.25. It was just too small for him. Um And uh it was a pretty long lesion because he had multiple lesions and he had over 40 millimeters of stent in there. Um So then uh we decided to uh use uh three onc high pressure balloons again, distally. Uh The cat lab staff were fantastic because I rely on their experience as much as I rely on mine. And a lot of them were like, you know, you can go higher pressure, you know, you have to hit that spot again. So that was nice of them. To cheer, cheer me on. Um And then the final result after we did that, this was our final run. As you can see. Now, distally, we have a three minimal Luminal area was seven square millimeters. Approximately we have a 3.5 and the Aus I had to put another stent because he had some and he had some plaques that ballooned and put another 35 stent. But essentially, you know, you know, the most important thing is it's if you just go from eyeballing an angiogram to eyeballing and IVIS image, you're going to make the same mistakes that an angiogram did. But if you know the whole point of intervascular imaging is to take time to kind of measure things out. Um And then if the, if if you were to do that, you really are making the patient a lot better. And this was a case where it was not because of pharmacology failure. It was because of uh you know, a mechanical failure. Um And then all the trials, every data that we've shown uh had an optimal PC I rate as documented by all of these trials of only about 50%. So even in the hands of uh uh you know, the experts that the trials are not meeting what you would want them to meet and going forward, it, it's really imperative that we try to hit those um those landmarks of what we want. Our post PC I results to be like um and this would be my last slide. Uh I would be remiss without giving a shout out to all my attendings who kind of taught me everything I know about uh interventional cardiology and cardiology over the four years. So any Google reviews and yelp reviews go to them. Thank you. Published Created by Related Presenters Anand Muthu Krishnan, MD Cardiology View full profile
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