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1. Left Main and Multivessel PCI
Arasi Maran MD, FSCAI, FACC
Associate Professor of Medicine
Director of Coronary CTO Program
Medical University of South Carolina
Ralph H Johnson VA Medical Center
Charleston SC
2. Within the past 12 months, I or my spouse/partner have had a
financial interest/arrangement or affiliation with the organization(s)
listed below.
Affiliation/Financial Relationship Company
Consulting Fees/Honoraria Boston Scientific, Teleflex,
Medtronic, Shockwave
Disclosure Statement of Financial Interest
Faculty disclosure information can be found on the app
3. Case 1
• 77yr old with ESRD, Chest Pain during HD
• NSTEMI with normal EF, mild AS
• LHC – Severe ostial Left main
• CT Surgery – 25% mortality with ESRD
• Came back to the cath lab
14. Conclusions for Case 1
• Intravascular imaging is key to plan for a complex case
• Not technically complex, but hemodynamics can get tricky
• Wolverine is a great tool for managing superficial calcium,
ostial disease
• Trust intravascular imaging and Hemodynamics
15. Case II
49 yr old WM with
H/O Recurrent
Necrotizing
Pancreatitis
Disconnected
Pancreas with
Pancreatic stent
in place
H/O Alcohol
abuse
Chronic Kidney
disease
NSTEMI
presentation
3 V disease
CT Surgery
Turndown
21. Discussion
Distal Left Main
Long LAD lesion
Long Cx Lesion
Calcium
Low EF
High risk of bleeding
Short DAPT
• MCS
• Atherectomy choice
• Access
• Stent strategy
22. My Plan
RHC
MCS based on
numbers
IVUS
SWL if balloon
delivers
If not
atherectomy
Double Stent
Strategy for Left
Main Bifurcation
36. Case III
• 91yr old with 87yr old wife to clinic to discuss PCI options
• Worsening dyspnea on exertion and LE edema
• PMH: Atrial fibrillation, Asthma, Tobacco abuse
• Echo and Coronary Calcium score -1655---LHC
• Meds: Aspirin , Atorvastatin, Lopressor 25 mg BID, Warfarin,
Inhalers
39. Echo
EF of 72%
Severe biatrial
enlargement
AVA -1.1sq cm
Mean gradient
of 14. mm of
Hg
Max pg - 27
Peak velocity
of 2.61m/s
Moderate TR,
RVSP – 36 mm
of Hg
40.
41.
42.
43. Factors To Consider
• Poor visualization of the bifurcation
• Need for atherectomy in the setting of HR of 45 BPM
• Moderate AS
• Normal EF
• Frailty
61. Take Home Points
• Iliac tortuosity can be a major issue with single access via
Impella sheath
• Intravascular imaging
• Shockwave Lithotripsy can be used to modify plaque at
bifurcation points
• Occlusion balloon technique is extremely useful to wire vessel
take off at difficult angles
• Sometimes – walk away with the simplest strategy
62. Cautionary Tale
• 59yr old
• Indian male
• Works in our hospital
• Typical Angina
• Stress Test – Anterior ischemia
• Normal EF
• Known Elevated Ca Score
65. Final Take Home Points – Left Main/Multivessel
PCI
• Failing to Planning = Planning to fail
• Review – Alone, With another partner, Find another partner
• Make Plan A
• Then make plan B and then Plan C
• Figure out your back up person
• Do not forget your documentation – risk benefit ratio, alternate
treatment options
66. It is Okay
• Despite your best efforts,
outcome was devastating if
• You did it for the right
reason
• You have done due
diligence
• You learn from what you
missed.
