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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

Calcified Coronary Lesion:Difficulties and Challenges

Zhou Yu Jie MD, PhD, FACC, FSCAI, FHRS

Beijing An Zhen Hospital, Capital Medical University, Beijing, China



Marker for cad and increased mortality
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)


Coronary artery calcium cac in the multi ethnic study
Coronary Artery Calcium (CAC) in the Multi-Ethnic Study

CAC are associated with CHD events

Coylewright et al. Atherosclerosis.2011


Risk factors the mesa study
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


Inverse relationship between bmi and cac
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


Elevated bsa is a predictor of cac not bmi
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


Mechanism of cac
Mechanism of CAC

Vascular calcification is an active ,regulated process

BMP-Smadsignaling

BMP-Wnt signaling


Major theories of vascular calcification
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


No effective medicine treatment
No effective medicine treatment

  • Evidence from meta-analyses

Statin and LDL-C

Statin and calcification

Coylewright et al. Atherosclerosis.2011


Statins promote cac vadt trail
Statins promote CAC (VADT trail)

Saremi et al. Diabetes Care.2012;2390-2



Strategy of pci in cac
Strategy of PCI in CAC

  • Balloon angioplasty

  • Cutting balloon

  • Rotablator

  • Stent

  • Post dilation

  • Laser


Strategy for balloon angioplasty
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


Cutting balloon for calcified lesion
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


Rotablator for calcified lesion
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


Rotational atherectomy ra
Rotational Atherectomy(RA)

RandomizedROTAXUS Trial Outcome

JACC Cardiovasc Interv 2013 Jan;6(1):10-9


Randomized rotaxus trial outcome
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


Analysis of the uk central cardiac audit database
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


Rotational atherectomy for lm in octogenarians
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


Rotablator for failed angioplasty
Rotablator for failed angioplasty

  • An 84 year man

  • Previous failed angioplasty due to balloon rupture

  • CAG showing severe CCL

21


Pci for lad rotablator
PCI for LAD- Rotablator

22


Stent deployment

23

Stent deployment


Rotational atherectomy and ivus
Rotational Atherectomy and IVUS

Pre

Pre

Post RA

1.75 mm

burr

b

a

Post 1.75 mm burr RA


Des for calcified lesion
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


Post dilation for calified lesion
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



Clinical presentation

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


Laboratory tests II), presented with unstable episodes in last 2 weeks (CCS III)

  • 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%


Electrocardiogram II), presented with unstable episodes in last 2 weeks (CCS III)


Coronary Angiography II), presented with unstable episodes in last 2 weeks (CCS III)


Coronary Angiography II), presented with unstable episodes in last 2 weeks (CCS III)


T II), presented with unstable episodes in last 2 weeks (CCS III)he 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


PCI for RCA II), presented with unstable episodes in last 2 weeks (CCS III)

GC: JR 4.0, GW: Pilot 50

Predilation BC: Sprinter 1.5 x 15mm and 2.0 x20mm


Final result II), presented with unstable episodes in last 2 weeks (CCS III)-RCA

DES implantation: Firebird2 2.75x33mm for d-RCA and Partner 3.0x36mm for p-RCA


PCI for LM II), presented with unstable episodes in last 2 weeks (CCS III)

1 week later

GC: EBU 3.5, GW: BMW (to LAD) and Runthrough NS (to LCX)


Pre-PCI IVUS II), presented with unstable episodes in last 2 weeks (CCS III)


PCI for LM II), presented with unstable episodes in last 2 weeks (CCS III)-Predilation

Predilation BC: Sprinter 2.5 x 15mm, 12-20atm


PCI for LM II), presented with unstable episodes in last 2 weeks (CCS III)-1st Stent Implantation

DES implantation : Firebird2 2.75x23mm for m-LAD (12atm)


PCI for LM II), presented with unstable episodes in last 2 weeks (CCS III)-2nd Stent Migration

LM/p-LAD Stent Migration (Cypher 3.5x33mm), exchange to 8F sheath


PCI for LM II), presented with unstable episodes in last 2 weeks (CCS III)-Retrieving Stent

Migrated stent was retrieved successfully assisted with Sprinter 1.5x15mm


Migrated stent II), presented with unstable episodes in last 2 weeks (CCS III)


PCI for LM II), presented with unstable episodes in last 2 weeks (CCS III) -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


PCI for LM II), presented with unstable episodes in last 2 weeks (CCS III)-Postdilation

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


PCI for LM II), presented with unstable episodes in last 2 weeks (CCS III)-1stFinal Kissing

1st final kissing with Avita HP 3.5x15mm (LAD)

and Sprinter 3.0x12mm (LCX)


2 II), presented with unstable episodes in last 2 weeks (CCS III)nd IVUS test

LAD ostia stent expansion unacceptable


PCI for LM II), presented with unstable episodes in last 2 weeks (CCS III)-Re-postdilatation

Re-postdilatation with Avita HP 3.5x15mm

(18-24atm for LM/p-LAD stent)


PCI for LM II), presented with unstable episodes in last 2 weeks (CCS III)-2stFinal Kissing

2nd final kissing

Avita HP3.5x15mm (LAD) and Sprinter3.0x12mm (LCX)


Final result II), presented with unstable episodes in last 2 weeks (CCS III)


Final IVUS test II), presented with unstable episodes in last 2 weeks (CCS III)-acceptable


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