Issue 2, October 2013
Dear Doctor, Welcome to the second edition of Vascular Voyage – An update on vascular interventions. From the time Frossmann and others triggered this zeal in treatment of obstructive vascular disease via minimally invasive technique, the field of vascular interventions has attracted the best brains to apply concepts in engineering, material science, polymer technology, pharmaceutical sciences and bio-technology to bring rapid yet clinically relevant changes in order to alleviate human suffering. We are now witnessing changes in the field of vascular interventions which are propelled not just by the general enthusiastic flavor for development in science and technology but also by this primal need to surpass disease and perhaps even delay death! Asimov's 1960s thriller Fantastic Voyage has inspired and intrigued the lovers of vascular interventions. Riding the “Proteus” to treat a disease from inside has perhaps been a secret fantasy of every individual connected to this field. Your copy of Vascular Voyage comes as a communication, written with an objective to disburse scientific information not just on developments talking place in Meril's own research stable, but also on best practices in the field of Endovascular interventions – Coronary, Peripheral, Neurovascular, Structural Heart disease, Congestive Heart failure and in Renal Denervation. Readers will have the pleasure of being face-to-face with the “Grants and Coras” of this world as they share from the distillate of their acquired wisdom in day-to-day clinical practice. The contents includes – latest in vascular interventions, current treatment trends, difficult cases, complications and how to avoid them and a special feature pertaining to 'day-in-the-life-of…' some of you. Vascular Voyage is available both in print (distributed by Meril) and on-line as a downloadable pdf version from our website www.merillife.com. We are very happy to announce and distribute this edition of Vascular Voyage. This issue discusses the Live case broadcasted during EuroPCR 2013 of a long, calcified LAD which was treated with 2.75 X 48mm long BioMimeTM - Sirolimus Eluting Coronary Stent System from Meril, we hope you enjoy the read. Do send in your feed back at
[email protected].
Complex Cardiovascular Interventions and New Techniques – Master LIVE demonstration by Dr.Farrel Hellig and expert panel discussion during EuroPCR 2013 Chairpersons: Dr. Marie-Claude Morice, Dr. Philip MacCarthy Panellists: Dr. Marko Noc, Dr. Tom Johnson, Dr. Petr Kala, Dr. Nicolaus Reifart, Dr. Alexander Ghanem, Dr. Upendra Kaul
Expert Operator Dr. Farrel Hellig, Sunninghill and Sunward Hospital, Johannesburg, South Africa Case Summary Background: A 62 year-old male patient complaining of angina, heavy smoker, dyslipidemic. Investigation: Laboratory tests, ECG (normal & stress), coronary angiography. Diagnosis: Long LAD lesion, trapped diagonal between lesion, heavy calcification, EuroSCORE II - 0.59% and Angiographic Syntax Score - 30. Treatment: PCI with IVUS images of LAD and good lesion preparation with rotational atherectomy. Stenting LAD and FFR/iFR of RCA.
Patient Information
Ø
ProBNP
62 years old male with BMI 27, with strong family
Ø
Cholesterol (total) = 6.1 mmol/L
history of CAD (father and brother suffered from AMI
Ø
HDL
= 1.0 mmol/L
at young age and brother underwent PCI). A heavy
Ø
LDL
= 4.3 mmol/L
= 200 pg/mL
smoker, dyslipidemic, non-hypertension and non diabetic.
Non-invasive evaluation Echocardiography showed a
Patient living in an apartment, 6th floor of a building
preserved Left Ventricular function with ejection
with no elevator. An active life style but no formal
fraction of 70%, mitral and aortic valve were normal,
cardiovascular exercise. He has a good psychological
right ventricle was not dilated and pulmonary artery
status with no prior cardiac history or medical
pressure was found to be 24 mmHg.
problems. He presented typical angina during effort (CCS Class II)
Patient was on Clopidogrel (75mg), Aspirin (100mg),
and with pain lasted for 10-15 min with associated
Simvastatin (40mg) and Bisoprolol (2.5mg).
nausea and sweating. Laboratory investigation showed the following:
Rest ECG was normal. At Stress ECG patient could
Ø
Hb
= 15.3 g/dl
perform 5 min of standard Bruce protocol and
Ø
Glucose
= 5.8 mmol/L
developed chest tightness and shortness of breath
Ø
HbA1C
= 6.0%
with lateral ST segment depression.
Ø
Creatinine
= 91 µmol/L
Ø
Creatinine clearance = >90ml/min
Issue 2, October 2013
VASCULAR VOYAGE
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Baseline Angiography RCA showed dominant RCA with a lesion of uncertain significance in proximal RCA just above the first bend (Fig. 1A). LCA shows a long lesion of LAD with aneurismal dilatation in proximal LAD and diffused disease in LCx. The calcification is noticeable in the
A
fluoroscopy in LCA caudal view (Fig. 1B). LCA cranial projection shows extensive, long, tortuous and calcified lesion. Diagonal in 2nd part of the lesion (Fig. 1C). On risk evaluation, EuroSCORE II was found to be 0.59% and Angiographic Syntax Score was found to be 30. The patient was advised to have bypass surgery due to
B
high Syntax Score, long LAD lesion, trapped diagonal between lesions, heavy calcification and good LAD surgical target. But despite repeat consultations with the heart team the patient choose PCI. Hence rotational atherectomy and stenting of LAD and FFR/iFR of the RCA was planned as a treatment strategy.
C Treatment details IVUS images were taken to understand the
Figure 1. Baseline Angiography A) RCA view B) LCA Caudal view C) LCA Cranial view
morphology of the lesion in LAD (Fig. 2). A heavy load of calcium on the proximal LAD was seen in IVUS images. A BMW guide wire (Abbott Vascular, USA) was placed to measure the lesion with the help of radiopaque segment (30mm) and the radiopaque marker (15mm) of a guide wire. It was found that the lesion measured >45mm. Lesion was taken to go for rotational atherectomy and to prepare the vessel before stenting due to high calcium burden. A rotablator wire (Boston Scientific, USA) was placed in the distal LAD and the guiding catheter (7F) was
Figure 2: IVUS performed for LAD and large burden of concentric calcium seen
advanced (Fig. 3A). Burr of 1.5mm was advanced on the
After pre-dilatation a BioMimeTM – Sirolimus Eluting
guidewire (Fig. 3B) and rotated at a speed of 160,000
Coronary Stent System, 2.75 X 48mm (Meril Life
rpm due to high degree of vessel tortousity. An
Sciences, India) was choosen to treat the long lesion to
angiogram (Fig. 3C) was taken after the rotational
avoid the stent overlapping. 2.75mm diameter was
atherectomy. A good result was seen by the 1.5mm
selected considering the distal LAD diameter. Excellent
burr so higher burr was not needed and directly
trackability and deliveribility was seen with the
balloon pre-dilatation was taken up. Trapping balloon
BioMime – Sirolimus Eluting Coronary Stent System
was advanced and a guide wire was placed to
(Fig. 3F & 3G). Angiogram of the side branch was taken
safeguard the diagonal. The lesion was predilated with
and found to be in good condition, hence the guide
2.5mm balloon at 16 ATM (Fig. 3D & 3E).
wire was pulled back from the side branch.
Issue 2, October 2013
VASCULAR VOYAGE
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A
B
C
D
E
F
G
H
Figure 3: Peri-procedure A) Guide wire placement in the long LAD lesion. B) Rotational Atherectomy with 1.5 burr. C) Post rotablation result. D)&E) Pre-dilatation of LAD lesion with 2.5 mm balloon at 16 atm pressure. F) BioMime 2.75X48 mm DES placement. G) BioMime 2.75X48 mm DES Expansion. H) Post dilatation of LAD lesion with 3.25 mm NC Quantum Apex balloon at 20 atm pressure.
TM
3.25mm NC Quantum Apex PTCA Dilatation Catheter
The final angiogram of LAD ensured the good flow in
(Boston Scientific, USA) was choosen to post dilate (at
the vessel (Fig. 5).
20 ATM) proximal part of LAD to make the stent tapering for optimum scaffolding and conformibility to tapering LAD vessel (Fig. 3H). A post-dilatation IVUS (Fig. 4) was performed and an excellent conformibility with no malapposed struts observed. A
B
Figure 5: Post Procedure A) & B) Final result after LAD stenting
After treating the LAD, iFR of RCA (Fig. 6) was undertaken with a 6F guide catheter and the iFR value was found to be 0.97. To have a final confirmation, 100µg of adenosine was administered to see the effect. Good pressure drop and rise was observed Figure 4: IVUS image after stenting
which was convincing and hence, decision was taken to treat the RCA medically and assess how the patient does in terms of LAD.
Issue 2, October 2013
VASCULAR VOYAGE
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Figure 6: iFR of RCA with a 6F guide catheter and the iFR value was found to be 0.97. Expert Panel Discussion The expert panel agreed that it is very important to prepare the vessel well in case of severely calcified long diffused lesions before pre-dilatation to avoid the problem of dissection and it is advisable to use
Ø Link:
http://www.pcronline.com/EuroPCR/EuroPCR-
2013/Complex-cardiovascular-interventions-and-newtechniques-Master-LIVE-demonstrations-by-Farrel-HelligMartyn-Thomas-Simon-Redwood-and-expert-paneldiscussion
rotational atherectomy before pre-dilatation. Also there was an agreement to use long stents in order to avoid the problem of overlapping. Dr. Upendra Kaul
Meril welcomes original contributions with an objective to disburse scientific information pertaining to "How I Treat...”
brought out a plan of forthcoming launch of a tapered TM
coronary stent know as BioMime Morph – Sirolimus Eluting Coronary Stent System that matches the diameter differentials from proximal to distal in long diffused lesions which will prove ideal in such situations. While discussing whether to stent the proximal part of the LAD and if IVUS is an accurate imaging tool to predict adequate result, Dr. MarieClaude Morice mentioned “when we see IVUS we see disease everywhere, what is more important is to have a lumen and we should understand where to stop. In this case IVUS images demonstrated no malposition of stent struts and an adequate lumen is found with a good stent expansion, which is convincing”. At the end
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
LM disease Bifurcation lesions CTOs Complex & Multi-vessel disease ACS – Primary PCI SVGs Renal Artery Disease Carotid Artery Stenting SFA Disease Tibio-Peroneal Disease
Please send in your articles in a word format with font size 12 not more than 8 pages along with your brief CV & Photograph to
[email protected]
Dr. Philip MacCarthy thanked the expert panel, audience and Dr. Farrel Hellig for his wonderful demonstration in the treatment of long calcified lesion using optimal stent system, PCI techniques an imaging tools. Reference Ø EuroPCR 2013/24-05-13/09:00
am - 13:00 pm Complex
cardiovascular interventions and new techniques - Master LIVE demonstrations by Farrel Hellig, Martyn Thomas & Simon Redwood and expert panel discussion.
Issue 2, October 2013
VASCULAR VOYAGE
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TM
BioMime
beyond 2 years
Excellent side branch access
0.29% Fo rshorte ning
3%
Rec o
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Now in e labl avai & 2.25 0
Ø2.0
l 44
&
mm
& 48
Available in 87 sizesDiameters (mm) : 2.00, 2.25, 2.50, 2.75, 3.00, 3.50, 4.00, 4.50 Lengths (mm) : 8, 13, 16, 19, 24, 29, 32, 37, 40, 44, 48 1.
S. Dani et al. EuroIntervention 2013;9:493-500
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