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    Case and Technique Reviews: Calcified Lesions, Plaque Modification, and Atherectomy

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    Case and Technique Reviews: Calcified Lesions, Plaque Modification, and Atherectomy

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    Randa Tabbah
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    68 views62 pages

    Case and Technique Reviews: Calcified Lesions, Plaque Modification, and Atherectomy

    Uploaded by

    Randa Tabbah

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 62

    Case and Technique Reviews:

    Calcified Lesions, Plaque


    Modification, and Atherectomy
    Ajay J. Kirtane, MD, SM
    Center for Interventional Vascular Therapy
    Columbia University Medical Center /
    New York Presbyterian Hospital

    @ajaykirtane
    Disclosure Statement of Financial Interest

    • Ajay J. Kirtane
     Institutional grants to Columbia University
    and/or Cardiovascular Research Foundation
    from Medtronic, Boston Scientific, Abbott
    Vascular, Abiomed, CSI, CathWorks,
    Siemens, Philips, ReCor Medical
    The Underexpanded Stent: This is a Real Problem

    7F EBU 3.5 IVUS – Wouldn’t cross


    2.0 x 15 balloon: would not cross 1.25 x 6 followed by 1.5 mm balloon
    NC Quantum 3.0 x 15 @ 30 (x4 times) NC Euphora 3.0 x 15 @ 30 (x2 times)
    How/Why
    Did This Happen?
    Calcification on Angiography

    • Moderate:
    Seen only during
    cardiac motion,
    usually one side
    of vessel

    • Severe:
    Seen on still frame,
    usually both sides
    of vessel
    IVUS Detection of Calcium

    Because IVUS does not penetrate into calcium. . .


    1) It cannot measure thickness or mass, only arc and length
    2) We assume that superficial calcium is thicker than deep calcium
    Potkin et al. Circulation 2001;81:1575-85
    Lee et al. Am J Cardiol 2011;108:1547-51
    Unlike IVUS, OCT penetrates calcium and is able to
    assess calcium thickness and area/volume as well as
    arc. However, there is little data assessing the impact
    of OCT-measured calcium (arc, thickness, etc) on
    stent expansion.

    Stent expansion Calcium Arc <90° Calcium Arc >90°


    ANOVA p=0.02
    Calcium Area <1.58 mm2 77.9%* 73.6%
    *p=0.01
    Calcium Area >1.58 mm2 71.5% 69.3%*

    Yabushita et al. Circulation 2002;106:1640-5


    Yamada et al. TCT2013
    Frequency of “heavy” calcification in the
    SYNTAX trial: Randomized + Registry
    N=2,636 pts with LM or 3VD
    PCI (n=1,095) CABG (n=1,541)

    50.6% 54.2%

    Farooq et al. J Am Coll Cardiol 2013;61:282–94


    Implications of coronary calcification
    • Coronary calcification results in:
     Impaired stent delivery, decreased
    stent expansion, increased
    malapposition and stent asymmetry
     Increased procedural complications
    (edge dissections and perforations)
     Increased rates of stent thrombosis
    and restenosis
    MACE Study
    1- year Events Stratified by Calcium Severity
    30.0
    None/mild Moderate Severe
    p<0.001
    25.0 24.2

    20.0
    Event Rate (%)

    p<0.001
    15.0
    13.2
    p=0.003
    10.3
    10.0 8.5

    p=0.489 5.4
    5.0 4.1 4.3
    2.7
    1.6 1.5 1.6
    0
    0.0
    Cardiac Death MI TVR MACE

    Sharma et al. Catheter Cardiovasc Interv.;1-8 https://doi.org/10.1002/ccd.28099


    Lesion Preparation =
    Plaque modification + lumen expansion
    • Facilitates procedural success when
    treating calcified/complex lesions
     enables lesion access for balloons and
    especially stents
    • Plaque modification: changing lesion
    compliance
     minimizes vessel “trauma” (severe
    dissections)
     creates a larger MLD
    Why is Appropriate Lesion Preparation for
    Coronary Calcification Important?
    Lesion calcification:
    • May impair stent delivery or expansion
    • May abrade polymers off DES

    Stentablation
    Kobayashi et al.
    CCI
    2001;52:208-11
    Calcium Volume Index (CVI) Scoring System

    Fujino et al, Eurointervention 2018


    Calcium Fracture and Relation to Outcomes
    61 pts with heavily calcified lesions studied serially with OCT
    Fracture was seen in 48% (more frequently with CB or atherectomy)

    Fracture was associated with greater MSA and less restenosis/ID-TLR

    Kubo et al, JACC CV Imaging 2015


    Treatment of Calcified Lesions: Options
    NC balloons Cutting balloon Angiosculpt

    Laser Rotational atherectomy Orbital atherectomy


    Strategy for Approaching Calcified Lesions
    Angiographic
    Calcification?

    Mild Moderate Severe

    Calcification on Imaging?
    - +

    Mild, Mod/severe,
    Adventitial Luminal

    Non-atherectomy Atherectomy
    strategy Strategy
    Strategic Failure

    Adapted from Tomey et al, JACC CV Intv 2014


    Rotablator Rotational Atherectomy System

    guide wire
    FDA approved May 1993

    diamond coated burr


    1.25 mm - 2.5 mm
    drive shaft (0.25 mm increments)

    1.5mm 1.75mm
    1.25 mm 2.0mm
    sheath
    4.3 french O.D.
    DIAMONDBACK 360: Coronary
    Orbital Atherectomy System
    Device Features
    •Simple device setup
    On-handle speed control
    •Microsecond feedback •Low (80K) and High Speed (120K)
    to changes in loading
    •135cm usable length
    Power on/off switch
    •8 cm axial travel
    Electric motor
    powered
    Eccentric handle
    diamond coated
    crown

    6Fr Guide 0.012” Viper Wire


    Compatible

    ViperSlide® Lubricant
    •ViperSlide reduces friction during
    Saline Infusion Pump operation
    •Mounts directly on to an IV pole •20ml ViperSlide per liter of saline
    •Provides power
    •Delivers fluid
    •Includes saline sensor
    Coronary Intravascular Lithotripsy (IVL)

    Ali Z et al, JACC CV Imaging 2017


    Case Presentation
    • 73F with PAF on anticoagulation with unstable
    angina (some atypical features) that
    “stabilized” with medical therapy
    • Nuclear stress test: anteroseptal ischemia
    • No further recurrence of rest chest pain
    though has CCS III angina despite beta-
    blocker and CCB
    Left Coronary System
    How Would You Treat?

    • Atherectomy
    • Specialty Balloon
    • NC Balloon
    • Imaging

    Randomized in ECLIPSE
    ECLIPSE
    Evaluation of Treatment Strategies for Severe CaLcifIc Coronary
    Arteries: Orbital Atherectomy vs. Conventional Angioplasty Prior
    to Implantation of Drug Eluting StEnts

    ~2000 pts with severely calcified lesions; ~60 US sites


    Randomize
    Orbital Atherectomy Strategy 1:1 Conventional Angioplasty Strategy

    (1.25 mm Crown followed by non- (conventional and/or specialty


    compliant balloon optimization) balloons per operator discretion)

    2nd generation DES implantation 2nd generation DES implantation


    and optimization and optimization

    1° endpoints: 1) Post-PCI in-stent MSA (N~400 in imaging study)


    2) 1-year TVF (all patients)
    2° endpoint: Procedural Success (stent deployed w/RS<20% & no maj complications)
    Principal investigators: Ajay J. Kirtane, Philippe Généreux; Study chairman: Gregg W. Stone
    Sponsor: Cardiovascular Systems Inc.
    Final Angiogram
    7F EBU 3.5 GC
    Sion Blue GW
    (Workhorse GW
    would not cross)
    Turnpike LP advanced
    (Corsair would not
    cross)
    WHAT
    NEXT?
    Time for…
    Sion Blue GW
    removed
    Atherectomy wire
    advanced through
    microcatheter
    After atherectomy,
    wire exchanged for
    a Wiggle Wire
    Diagonal protected

    NC 3.0 x 15 mm
    @ 16 atm
    NC 3.5 x 15 @ 14 atm
    IVUS
    IVUS (post Atherectomy/POBA)
    Unable to advance
    stent to lesion
    WHAT
    NEXT?
    6F Guide Extension
    Final (after postdilation/IVUS)
    Case Presentation
    • 69 y.o. male with HTN, HLD, • Vitals: T 36.4, HR 75, BP: 139/82,
    CVA (25 years ago, residual R RR 18, SpO2 98% on RA.
    hemiparesis) • PE: No JVD, RRR, nml S1/S2, no
    murmur
    • CAD (with MI in the past) • CTA B/L
    • Worsening exertional angina, • +2 pulses b/l, no edema
    no rest symptoms Labs:
    WBC: 9.43 / Hb: 15.5 (MCV: 91.1) /
    • Medications: Hct: 44.9 / Plt: 203

     Aspirin, Clopidogrel, Atorvastatin 144 | 101 | 12


    --------------------< 113
    20, Furosemide 20 mg, Metoprolol 4.3 | 28 | 0.88
    succinate 100 mg, Baclofen,
    pro-BNP: 223, Coags: normal
    Phenytoin, Ranitidine
    Troponin mildly positive and stable
    Case Presentation

    • Echocardiogram:
     EF 20-25%
     Anterior/
    anteroseptal/apical
    akinesis (without
    thrombus)
     Remaining walls
    variably hypokinetic
    Diagnostic Catheterization
    RHC:
    RA 17/10 (10)
    RV 31/17
    PA 31/20 (25)
    PW 24/20 (19)

    PA sat 66%
    AO sat 94%

    CO 4.6
    CI 2.3

    AoP: 89/58/72
    Diagnostic Catheterization
    Diagnostic Catheterization
    What Next?
    What Next?
    Viability Study: no significant viability in the
    LAD distribution. All other walls are viable.
    Access and Setup
    6-7F slender Ao 105/77/88
    RRA
    RA 13/9 (8)
    Ultrasound- RV 33/13
    guided 5F RFA PA 33/16 (22)
    PW 12/9 (8)
    (swapped for
    14F Impella AO sat 96%
    sheath) PA sat 63%

    7F RFV CO 4.27
    CI 2.18
    Access and Setup

    JL3.5, angled glide wire, Impella CP


    Amplatz SS to advance guide 7F AL 0.75 SH guide
    PCI: Atherectomy
    PCI: Post-Atherectomy
    PCI: Thrombectomy
    PCI: 3.0 mm NC Predil, 4.5 mm DES
    Final result
    Finishing Up / Impella Explant

    Hemodynamics: Long multipurpose


    Ao 101/74/84 catheter placed in
    right iliac artery
    RHC: via RRA
    PA 44/13/30
    PCWP: mean 23 Perclose sutures
    tied
    PA sat 62%
    Light manual
    CO 3.71 pressure for track
    CI 1.89 ooze
    Conclusions
    • Coronary calcium is becoming more and more prevalent in
    the modern-day cath lab / CHIP era
    • Aging population
    • Comorbidities
    • “Downstream” presentations

    • Calcified lesions are among the highest-risk lesions we treat


    • Short-term pain/suffering + risk
    • Longer-term outcomes
    Conclusions
    • Imaging is a MUST
    • Diagnosis of calcium
    • Treatment algorithms (based upon length, arc, thickness)
    • After initial lesion preparation and prior to stent implantation
    • Stent optimization

    • The field of adjunctive therapies for calcific lesions is


    heating up with more and more data emerging soon…

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