The 2010 Live Symposium of Complex Coronary and Vascular Cases

With a special focus on calcified, bifurcation and total occlusion lesions

Samin K. Sharma, MD, Director, and Annapoorna S. Kini, MD, Associate Director, of the Cardiac Catheterization Laboratory at Mount Sinai Hospital, lead the way in this annual course, where the focus is teaching both physicians and staff clinical and practical information. The Live Symposium was held June 16-19, 2010, at Mount Sinai Hospital in New York City. A Nurse/Technologist Symposium took place Wednesday, June 16th. The annual Live Cases Symposium has been teaching interventionalists, fellows and cath lab professionals with a balance of live cases and lectures for 13 years. New to the conference this year was a return of the peripheral vascular track (both live cases and lectures), and narrowed focus on moderately complex cases in order to emphasize tips and tricks. Coronary Track The conference opened with Dr. Sharma’s lecture, “Top 10 Advances of Interventional Cardiology 2009.” His list included: 10) Clopidogrel resistance/proton pump inhibitor studies; 9) The BARI 2D and FREEDOM trials, establishing the role of aggressive medical therapy in mildly symptomatic diabetic patients; 8) Bifurcation lesion trials PRECISE, CACTUS and Nordic Bifurcation III, concluding that “a complex strategy (done correctly) of two stents may be required)”; 7) Early intervention (within 24 hours) in non-ST-elevation myocardial infarction (STEMI) patients was shown to be better than “watch and wait”; 6) Successful percutaneous aortic valve trials, with the PARTNER (US) trial results to be presented at the September 2010 TCT meeting; 5) The HORIZONS-AMI trial, showing drug-eluting stents (DES) have a role in acute MI if the patient takes their medications; 4) The 5-year follow up of the DEFER trial and the 2-year follow up of the FAME trial, which showed long-term benefit from the use of fractional flow reserve (FFR); 3) DES comparison trials, showing advantages for Xience (Abbott Vascular, Redwood City, CA) as well as Endeavor (Medtronic, Minneapolis, MN) (in stent thrombosis only), with Genous (OrbusNeich, Wanchai, Hong Kong) stent trials ongoing; 2) Ticagrelor, with a 2% lower death, MI and stroke rate, lower stent thrombosis, and no increase in bleeding as compared to clopidogrel; 1) Trials showed percutaneous coronary intervention (PCI) has good outcomes in unprotected left main (LM) stenting in isolated LM disease. However, coronary artery bypass graft surgery (CABG) remains superior for complex, advanced LM disease. After Dr. Sharma’s opening lecture, Valentin Fuster, MD, PhD, Director of Mount Sinai Heart, in a pre-recorded video message, discussed some of this thoughts about performing complex interventions today. • Fellows training must improve to include education in hemodynamics, physiology and pathophysiology. • For those looking for a black-and-white answer to the question of multi-vessel disease, surgery or intervention, the answer is “neither.” “We must be open to complexity,” Dr. Fuster noted. • Coronary artery disease (CAD) cannot be considered in isolation. It can affect the lower extremities, and may affect the microvasculature of the brain and cause problems in cognitive function. CAD should be seen as a systemic disease. • The future is in the promotion of health and prevention of disease. “From every point of view, “ Dr. Fuster said, “including economics, we need to deal with the disease as it comes to us today, but also must try to prevent future disease and correct risk factors.” Prediman K. Shah, MD, Director of the Division of Cardiology and the Atherosclerosis Research Center at Cedars-Sinai Medical Center in Los Angeles, spoke about his work on atherosclerosis, sharing what recent research has shown about the progression from “a normal artery received at birth” to a diseased one: 1) If a lipid doesn’t stick to the arterial wall, there is not much atherosclerosis. 2) Lipid levels can be high, but without “pro-inflammatory priming,” activated by genes, there will be no atherosclerosis. Hyperlipidemia plus a subsequent inflammatory activation brings about atherosclerosis. 3) Plaque angiogenesis also contributes to plaque formation and destabilization. 4) Macrophages are not created equal, but have a “tremendous heterogeneity” in their effects. Live Cases The live case series (24 live cases were presented) began with Dr. Sharma, Dr. Kini and several well-known, experienced interventionalists participating, either directly in the case or commenting as a panelist. Cases focused on moderately complex patients with multi-vessel disease, bifurcation lesions, and chronic total occlusions. While there was a strong focus on the patient and obtaining a good outcome, all involved made sure to explain their actions and/or emphasize tips and tricks, some of which are shared below: • 40% of stents will not be fully expanded with a 3 to 5-second inflation; data shows that 15-20 seconds is superior. For hard, calcified lesions, Dr. Sharma said, he often will inflate for one minute or more, if the patient can tolerate it. • When you see a great deal of calcium, start with a Rotablator, not balloons, to save time. Dr. Kini emphasized that in cases with visible calcium in the lesion on fluoroscopy, go with Rotablator even without pre-procedure intravascular ultrasound (IVUS). • The Kinetix wire (Boston Scientific) is recommended for angulated lesions. • The Venture catheter (St. Jude Medical, Minnetonka, MN) is recommended for helping to get through the side branch of a stent. The wire will not break up or prolapse with this catheter, according to Dr. Sharma. • IVUS artifacts are common in tortuous arterial segments. • Panelist Augusto Pichard, MD, Director of the Cardiac Cath Lab at Washington Hospital Center in Washington, D.C., spoke about his preference for spot stenting versus a “full metal jacket” of several long stents. Dr. Pichard has been doing spot stenting for the past 3 years. The downside, he said, is that it requires more work in the form of IVUS and FFR use, but the RAVEL (clinical trial) era, of ‘stent normal to normal,’ in his thoughts, is over. • During the case of a patient with 3-vessel CAD requiring a complex PCI with multiple left anterior descending artery (LAD) and diagonal lesions, Dr. Sharma was asked by a panelist, “How do you approach these complex patients — do you have a strategy or do you have a more dynamic approach?” Dr. Sharma responded that he worked by strategy, and felt that staged interventions (5-8 weeks) were safer in these patients. • Impella left ventricular assist device (LVAD) (Abiomed, Danvers, MA) use at Mount Sinai is at about 2 per month, while intra-aortic balloon pump (IABP) use is at about 30-35 per month (roughly 450 PCIs occur in the cath lab each month). Additional highlights of the live case symposium series included: • A successful live transcatheter aortic valve implantation (TAVI) of a CoreValve at the International Heart Center Rehin-Guhr, Essen, Germany, by Eberhard Grube, MD, and Pedro Moreno, MD, in a 91-year-old female with a severe aortic stenosis. • Several cases with the LipiScan (InfraReDx, Inc., Burlington, MA), near-infrared (NIR) spectroscopy catheter, a device for the prospective identification of vulnerable plaque. • Use of optical coherence tomography (OCT, LightLab Imaging, Inc.; acquired by St. Jude Medical, Inc.) to accurately delineate plaque composition, and stent expansion and endothelization, was used in three cases. Chronic Total Occlusions Takahiko Suzuki, MD, Director of the Toyohashi Heart Center in Toyohashi, Japan, participated in some of the live cases and also presented on chronic total occlusion (CTO) recanalization. He noted that success in opening CTOs is heavily dependent on the skills and technique of the individual operator. Problems today include: 1) A low success rate; 2) A high rate of restenosis/reocclusion; 3) A high risk of complications. Still, the continuous innovation of techniques and wires, he said, is improving rates of success. Microcatheters have improved, with the best being the Finecross (Terumo Medical, Somerset, NJ), in Dr. Suzuki’s opinion, with the Asahi Corsair (Asahi Intecc Co Ltd., Aichi, Japan) also a good option. Wire techniques changed quickly after CTO revascularization began in 2000, moving from the use of single wires to the parallel wire technique, then adding the use of IVUS guidance, and finally, in 2005, moving to the retrograde approach, a “revolutionary” approach to CTOs. Dr. Suzuki said that the retrograde approach with the CART technique (basically, creating a subintimal dissection with limited extension only at the site of the CTO) is “guaranteed, if the wire goes through the collateral channel.” Old, tortuous CTOs are “no problem” with the CART technique, noted Dr. Suzuki, who, in 2009, had a 96% success rate at the Toyohashi Hospital. Arguing for a more conservative approach to CTO revascularization was K.K. Haridas, MD, DM, DNB, Director of Cardiology at the Amrita Institute of Medical Sciences, in Kerala, India. Dr. Haridas emphasized the technical and procedural challenges inherent in crossing CTOs. One of the problems is the lack of skilled operators, said Dr. Haridas, noting that the retrograde approach must be taught in clinical practice. There is also still uncertainty regarding which patients will benefit, he said, pointing out the risk to the collaterals and of complications. In addition, “many IVUS trials have shown that 15-40% of the time, we are subintimal without recognizing it,” said Dr. Haridas. Vascular Track The Live Cases Symposium’s vascular track, directed by Prakash Krishnan, MD, Director, Endovascular Intervention and Assistant Professor of Medicine at Mount Sinai, offered live cases and presentations available in a separate auditorium, but also available for viewing (with headsets) in the coronary track auditorium. Co-director J. Michael Bacharach, MD, FSCAI, Section Head, Vascular Medicine and Peripheral Vascular Intervention, North Central Heart Institute, in Sioux Falls, SD, began by commenting on “basic realities” of peripheral arterial disease (PAD) today. It is not well-recognized by patients or physicians, he said, and there is no effective medical therapy. Our goals should be to identify the impact of PAD and appreciate its risks, promote awareness, characterize the care team, and generate a national PAD task force. Joshua A. Beckman, MD, Director, Cardiovascular Medicine Program at Brigham and Women’s Hospital, Boston, MA, discussed three elements of PAD diagnosis and treatment: 1) Should we screen for PAD? Fully one-half of PAD-afflicted patients are asymptomatic, and only 1 out of 10 patients presents with classic symptoms. Critical limb ischemia presents in 1-2% of the PAD population. 2) Common diagnostic methods in PAD “Is a pulse exam enough to exclude PAD?” asked Dr. Beckman. “No. In the right population, it’s worth a single ankle-brachial index (ABI) screen.” In patients with an iliac stenosis, he noted, ABI does not work as well, and measurement of a post-exercise ABI may help. An ABI > 1.30 indicates vascular calcification, making an ABI uninterpretable. Why won’t more physicians use an ABI? Most physicians cite the time factor, said Dr. Beckman. He suggested that if a handheld Doppler can’t be used, try automated blood pressure cuffs (a 2006 Hypertension study showed good sensitivity and specificity with this method, Dr. Beckman said). 3) Beware the diabetic patient with PAD Twenty to thirty-three percent of diabetics have PAD, Dr. Beckman said. PAD presence in diabetics is an independent predictor of bad outcomes, and leg complications are actually an unusual complication when compared to the far more common CAD. Dr. Beckman concluded that we should screen for PAD in patients who are asymptomatic and meet the PARTNERS trial criteria (> 70 years old or 50-69 with diabetes and/or smoking). Jeffrey Olin, DO, Director of Vascular Medicine at Mount Sinai Medical Center, discussed the difficulties of deciding which patients to treat with renal intervention. He concluded that the pending CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial might answer questions about who and when to treat renal stenosis, because, currently, “We don’t know how to treat these patients. Some get better, some stabilize, and some worsen after stenting.” Additional vascular track highlights included multiple live cases, as well as presentations from: • Craig M. Walker, MD, Cardiovascular Institute of the South, Houma, LA, on acute limb ischemia; • Endarterectomy versus carotid stent: an analysis of the data with Mark Wholey, MD, an interventional radiologist at UPMC Shadyside, Pittsburgh, PA. • Peter Faries, MD, Chief of Vascular Surgery at Mount Sinai Hospital, performed a successful live carotid stent case emphasizing on the safest tips and tricks to prevent complications; • Selecting appropriate patients for carotid revascularization with J. Michael Bacharach, MD; • What to do when complications arise in carotid patients (neuro rescue) with Adnan H. Siddiqui, MD, PhD, Assistant Professor Neurosurgery & Radiology, State University of New York — University at Buffalo, Buffalo, NY; • An aortic abdominal aneurysm series with Bruce H. Gray, DO, Greenville Memorial Hospital, Greenville, SC and Richard Green, MD, Director of Vascular Surgery at Lenox Hill Hospital, New York, NY; • Michael Marin, MD, Chair of Surgery at Mount Sinai Hospital, discussed the role of AAA stent grafts during a live aneurysm case relayed from the OR. • A complications/”my worst nightmare” symposium with Mark Davies, MD, PhD, MBA, Vice-Chair and Professor of Surgery at Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, TX. Course directors Dr. Sharma and Dr. Kini wish to thank all attendees and presenters for a successful 2010 symposium, and look forward to the 2011 Live Symposium of Complex Coronary & Vascular Cases. For more information, please visit https://www.cccsymposium.org, as well as https://www.ccclivecases.org to watch a monthly, live seminar highlighting in-depth procedural techniques for managing complex coronary cases. The next live case takes place Tuesday, Oct 19, 2010, at 8am EST.

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