Case 20: Complex Multivessel PCI in a High SYNTAX Score
Case Presentation
- A 74-year-old man presented with class II angina and stress MPI done as pre-op for renal transplant evaluation, revealed moderate multivessels ischemia (apical, inferior and infero-lateral).
- Coronary angiogram revealed calcified 3 V CAD and LVEF 55%. He was evaluated by CTS and had Heart team discussion; then declined CABG.
- Medical History: Controlled Hypertension, Hyperlipidemia, ESRD on HD, Diet controlled DM
- Medications : Aspirin, Atorvastatin, Metoprolol XL, Lisinopril, Amlodipine
- Angoigram revealed 3 V CAD: 80% long calcified mid RCA, 100% RCA-AV cont, subtotal calcified long segmental mid-distal LAD, 60% D1, 80% LCx-OM2, 80% LCx-LPL, LVEF 55% and Syntax score 33.
- Planned for high risk multivessel PCI with appropriate use of imaging, rotational atherectomy and Impella LV assist as deemed necessary.
Angiogram
Case Review and Planning
PCI Strategy
- Plan to do PCI to LAD
- With the presence of long calcified lesion in LAD, may require adequate lesion modification (i.e., Rotational atherectomy).
- Initial wire choice: Fielder/FineCross
- Second wire choice: Gaia series and MiracleBros
STEPS
- We first used Fielder (non-tapered polymer jacketed tip) with FineCross microcatheter. However Fielder didn’t cross the calcified lesion.
- Then we switched to Gaia 3 (tapered, hydrophilic coating, composite core with 1:1 torque) and able to navigate through the calcific LAD lesion.
- Exchanged to Rota wire via FineCross microcatheter.
- Rota ablation was performed with 1.5 Burr, followed by PTCA and two DES (3.5/38 and 3/18 mm) placement in mid and distal LAD.
Wiring Technique
Final Angiogram
The case can be reviewed at https://ccclivecases.org/complex-multivessel-pci-in-a-high-syntax-score-patient-october-2020
Learning Points
- Composite core technology, used in Gaia series, enables to perform an excellent 1:1 torque control, compared to a traditional one.
- Composite core consists of dual core and dual coil with multiple wire components to enhance durability and torque transmission.
- We used Gaia 3 wire in this case and able to perform very fine movement to negotiate the subtotal long calcific lesion while providing an additional support via a microcatheter.
