calcified coronary lesion difficulties and challenges
Download
Skip this Video
Download Presentation
Calcified Coronary Lesion: Difficulties and Challenges

Loading in 2 Seconds...

play fullscreen
1 / 51

Calcified Coronary Lesion: Difficulties and Challenges - PowerPoint PPT Presentation


  • 113 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Calcified Coronary Lesion: Difficulties and Challenges' - glynn


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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

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

slide29

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%

slide33
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

slide34

PCI for RCA

GC: JR 4.0, GW: Pilot 50

Predilation BC: Sprinter 1.5 x 15mm and 2.0 x20mm

slide35

Final result-RCA

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

slide36

PCI for LM

1 week later

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

slide38

PCI for LM-Predilation

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

slide39

PCI for LM-1st Stent Implantation

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

slide40

PCI for LM-2nd Stent Migration

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

slide41

PCI for LM-Retrieving Stent

Migrated stent was retrieved successfully assisted with Sprinter 1.5x15mm

slide43

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

slide44

PCI for LM-Postdilation

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

slide45

PCI for LM-1stFinal Kissing

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

and Sprinter 3.0x12mm (LCX)

slide46

2nd IVUS test

LAD ostia stent expansion unacceptable

slide47

PCI for LM-Re-postdilatation

Re-postdilatation with Avita HP 3.5x15mm

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

slide48

PCI for LM-2stFinal Kissing

2nd final kissing

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

ad