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Calcified Coronary Lesion: Difficulties and Challenges

Calcified Coronary Lesion: Difficulties and Challenges. Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing, China. Sweet dream or nightmare ？. Marker for CAD and increased mortality. 4,609 asymptomatic individuals

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Calcified Coronary Lesion: Difficulties and Challenges

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  1. Calcified Coronary Lesion:Difficulties and Challenges Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS Beijing An Zhen Hospital, Capital Medical University, Beijing, China

  2. Sweet dream or nightmare？

  3. Marker for CAD and increased mortality • 4,609 asymptomatic individuals • Follow-up 3.1 years • 4,425 Suspected CAD patients • Follow-up 3 years JACC: CARDIOVASCULAR IMAGING. 2010 Dec;3(12). JACC: CARDIOVASCULAR IMAGING. 2012 Oct;5(10)

  4. Coronary Artery Calcium (CAC) in the Multi-Ethnic Study CAC are associated with CHD events Coylewright et al. Atherosclerosis.2011

  5. Risk Factors（The MESA study） • Race and gender • Age • BMI • Smoking • Family history of heart attack • Hyperlipidemia Intimal calcification • Hypertension Intimal calcification • Diabetes Medial calcification • CKD Medial calcification • Rheumatic diseases Circulation. 2007;115:2722-2730

  6. Inverse relationship between BMI and CAC Atherosclerosis. 2012 March ; 221(1): 176–182. Method： • 9,993 patients undergoing PCI • The degree of index lesion calcification (ILC) based on angiography

  7. Elevated BSA is a predictor of CAC, not BMI Method：3172 consecutive patients underwent CAC scores Coron Artery Dis 2012 Mar;23(2):113-7

  8. Mechanism of CAC Vascular calcification is an active ,regulated process BMP-Smadsignaling BMP-Wnt signaling

  9. Major Theories of Vascular Calcification DISTURBED Ca/Pi BALANCE Hyperphosphatemia Hypercalcemia DISTURBED Ca/Pi BALANCE Hyperphosphatemia Hypercalcemia DISTURBED Ca/Pi BALANCE Hyperphosphatemia Hypercalcemia DISTURBED Ca/Pi BALANCE Hyperphosphatemia Hypercalcemia DISTURBED Ca/Pi BALANCE Hyperphosphatemia Hypercalcemia DISTURBED Ca/Pi BALANCE Hyperphosphatemia Hypercalcemia INDUCING FACTORS Pi Lipids Inflammatory cytokines Others INDUCING FACTORS Pi Lipids Inflammatory cytokines Others INDUCING FACTORS Pi Lipids Inflammatory cytokines Others INDUCING FACTORS Pi Lipids Inflammatory cytokines Others INDUCING FACTORS Pi Lipids Inflammatory cytokines Others INDUCING FACTORS Pi Lipids Inflammatory cytokines Others LOSS OF INHIBITION Pyrophosphate MGP OPN Fetuin/alpha2-HS glycoprotein Others Ca x Pi INDUCTION OF BONE FORMATION Vascular bone and cartilage-like cells INDUCTION OF BONE FORMATION Vascular bone and cartilage-like cells INDUCTION OF BONE FORMATION Vascular bone and cartilage-like cells Vascular calcification INDUCTION OF BONE FORMATION Vascular bone and cartilage-like cells INDUCTION OF BONE FORMATION Vascular bone and cartilage-like cells CIRCULATING NUCLEATIONAL COMPLEXES CIRCULATING NUCLEATIONAL COMPLEXES CIRCULATING NUCLEATIONAL COMPLEXES Matrix Vesicles Matrix Vesicles Matrix Vesicles Matrix Vesicles Matrix Vesicles Apoptotic bodies Apoptotic bodies Apoptotic bodies Apoptotic bodies Apoptotic bodies Bisphosphonates OPG Bisphosphonates OPG Bisphosphonates OPG Bisphosphonates OPG Bone Remodeling Bone Remodeling CELL DEATH CELL DEATH CELL DEATH CELL DEATH

  10. No effective medicine treatment • Evidence from meta-analyses Statin and LDL-C Statin and calcification Coylewright et al. Atherosclerosis.2011

  11. Statins promote CAC (VADT trail) Saremi et al. Diabetes Care.2012;2390-2

  12. Stent thrombosis 12

  13. Strategy of PCI in CAC • Balloon angioplasty • Cutting balloon • Rotablator • Stent • Post dilation • Laser

  14. Strategy for balloon angioplasty • Small size balloon prefered • Pressure of BC from 8 atm, slowly increase • The up limit of pressure may be 16 atm • Flow restricting dissection or perforation be concerned 14

  15. Cutting balloon for calcified lesion • Indication for cutting balloon: Lesion relatively short (<20mm) Concentric lesions • Heavily calcified lesion not appropriate, but sometimes brought supprise 15

  16. Rotablator for calcified lesion • Effective device for calcified lesion • Differential tissue cutting ----selectively hard lesion, no soft tissue • Optimal burr size---60%-70% of reference vessel diameter • Prevent no flow & slow flow ----nitroprusside, adenosine , etc • Upper limit of rotablator: just enough for revascularization 16

  17. Rotational Atherectomy(RA) RandomizedROTAXUS Trial Outcome JACC Cardiovasc Interv 2013 Jan;6(1):10-9

  18. Randomized ROTAXUS Trial Outcome CONCLUSIONS： • RA does not increase the efficacy of DES in calcified lesions • Using RA did not reduce late lumen loss of DES at 9 months • RA remains the default strategy for complex calcified lesions Death MI TVR MACE JACC Cardiovasc Interv 2013 Jan

  19. Analysis of the UK central cardiac audit database Method： • 221,669 PCI procedures • 2152 patients (0.97%)：RA (RA+) • Remainder conventional PCI： (RA-) CONCLUSIONS： • RA was undertaken in patients with higher pre-procedural risk. • Medium term survival was worse among patients undergoing RA. • Procedural success and complication rates seem acceptable in this context. RA remains clinically useful for patients with calcified coronary lesions. Int J Cardiol. 2014 Jan 1;170(3):381-7

  20. Rotational atherectomy for LM  in octogenarians • 42 patients ≥80 years had undergone stenting for calcified LMCA disease • Procedural successis good (92.3% vs. 96.6%) • RA appeared to be a safe and effective strategy for the treatment of LMCA disease in octogenarians who were refused for surgery Int J Cardiol 2013 Apr;26(2):173-82

  21. Rotablator for failed angioplasty • An 84 year man • Previous failed angioplasty due to balloon rupture • CAG showing severe CCL 21

  22. PCI for LAD- Rotablator 22

  23. 23 Stent deployment

  24. Rotational Atherectomy and IVUS Pre Pre Post RA 1.75 mm burr b a Post 1.75 mm burr RA

  25. DES for calcified lesion • DES use was associated with a significantly lower risk in repeat revascularization (HR = 0.57; 95% CI 0.40–0.82; P = 0.002) compared to BMS group in CCL • TAXUS-IV sub study : 9-month angiographic follow-up, DES significantly reduced the amount of late loss compared with the BMS (0.26 +/- 0.56 vs 0.51 +/- 0.48 mm, p = 0.015) in the calcific lesions 25 Sripal Bangalore, CCI 77:22–28 (2011) Moussa I, Am J Cardiol. 2005 Nov 1;96(9):1242-7

  26. Post dilation for calified lesion • Post dialation last straw for calified lesion • Non compliant, high pressure balloon first choice • Be careful coronary perforation or serious dissection 26

  27. Postdilation in severe CCL 27

  28. Progressive deterioration of chest pain for 3 years (CCS II), presented with unstable episodes in last 2 weeks (CCS III) With a history of HBP, prior inferior and anterior myocardial infarction 2 1 Clinical presentation Male, 84-year-old Diagnosis: UAP Prior MI Hypertension 3

  29. Laboratory tests • TnI levels of 0.01 ng/mL (normal range, <0.05 ng/mL), Cre 76umol/L, ALT 23U/L, AST 34U/L • A 2-dimensional echocardiogram demonstrated decreased left ventricular function, with an ejection fraction of 41%

  30. Electrocardiogram

  31. Coronary Angiography

  32. Coronary Angiography

  33. The patient refused the surgical solution and medical conservative therapy After discussion the decision was made to perform sequential PCI: RCA CTO first, then unprotected LM lesions Treatment strategy

  34. PCI for RCA GC: JR 4.0, GW: Pilot 50 Predilation BC: Sprinter 1.5 x 15mm and 2.0 x20mm

  35. Final result-RCA DES implantation: Firebird2 2.75x33mm for d-RCA and Partner 3.0x36mm for p-RCA

  36. PCI for LM 1 week later GC: EBU 3.5, GW: BMW (to LAD) and Runthrough NS (to LCX)

  37. Pre-PCI IVUS

  38. PCI for LM-Predilation Predilation BC: Sprinter 2.5 x 15mm, 12-20atm

  39. PCI for LM-1st Stent Implantation DES implantation : Firebird2 2.75x23mm for m-LAD (12atm)

  40. PCI for LM-2nd Stent Migration LM/p-LAD Stent Migration (Cypher 3.5x33mm), exchange to 8F sheath

  41. PCI for LM-Retrieving Stent Migrated stent was retrieved successfully assisted with Sprinter 1.5x15mm

  42. Migrated stent

  43. PCI for LM -Continue with Mini-Crush Continue with 7F EBU 3.5; Mini-Crush technique was used Firebird2 3.5x33mm for LM/p-LAD and Firebird2 3.0x18mm for LCX

  44. PCI for LM-Postdilation Postdilatation with Avita HP 3.5x15mm (14-20atm for LM/p-LAD stent)

  45. PCI for LM-1stFinal Kissing 1st final kissing with Avita HP 3.5x15mm (LAD) and Sprinter 3.0x12mm (LCX)

  46. 2nd IVUS test LAD ostia stent expansion unacceptable

  47. PCI for LM-Re-postdilatation Re-postdilatation with Avita HP 3.5x15mm (18-24atm for LM/p-LAD stent)

  48. PCI for LM-2stFinal Kissing 2nd final kissing Avita HP3.5x15mm (LAD) and Sprinter3.0x12mm (LCX)

  49. Final result

  50. Final IVUS test-acceptable

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