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Javier Escaned: 3 Low contrast complex and CTO PCI
- 1. Ultra-low contrast in complex and CTO PCI cases Javier Escaned MD PhD Hospital Clinico San Carlos Madrid / Spain
- 2. EuroPCR.com Potential conflicts of interest Speaker's name : Javier Escaned I have the following potential conflict of interest to declare: Advisory board member: Abbott, Philips Speaker at educational events: Abbott, Abiomed, Boston Scientific, Medis, Philips
- 3. EuroPCR.com Ultralow contrast PCI: an emerging aspect of complex PCI
- 4. EuroPCR.com • Selecting PCI candidates • Identifying flow-limiting lesions • Planning the intervention • Choosing devices • Deciding when an adequate PCI result has been achieved • Establishing the cause of PCI failure The central role of angiography in the PCI culture
- 5. EuroPCR.com • Selecting PCI candidates • Identifying flow-limiting lesions • Planning the intervention • Choosing devices • Deciding when an adequate PCI result has been achieved • Establishing the cause of PCI failure 45 years later we have more and better tools than angiography CTCA IVUS iFR / FFR DCR
- 6. EuroPCR.com An example of the value of ULC: renal patients undergoing PCI AKI leading to loss of residual renal function Suboptimal quality of revascularisation → residual ischemia / stent failure Bleeding and ischaemic events linked to PCI
- 7. EuroPCR.com Benefit in CKD patients: beyond avoidance of acute kidney injury High High Low CKD Ca2+ managed with plaque preparation and IVUS guidance → better long-term outcomes Contrast-induced nephropathy is avoided Improved PCI results decrease dependence on antiplatelet treatment
- 8. EuroPCR.com • Very severe LV dysfunction • Very severe contrast allergy • Severe thyroid dysfunction • Anticipated long procedures (MVD, CTO) • Iatrogenic coronary dissections • Spontaneous coronary dissection • CTO treated with CART / ADR Clinical contexts in which ULC PCI is useful • Chronic kidney disease • Prior AKI • Renal transplant • Concomitant contrast-based tests (CTCA) • Shock / Out-of-hospital cardiac arrest • Emergency PCI with unknown eGFR • Patient frailty
- 9. EuroPCR.com ULC to improve safety and quality of PCI in multiple scenarios High High Low
- 10. • How can I know where the artery is? (ostium) • How could I possibly navigate wires without seeing the vessel? • Where is the lesion I have to treat? • How do I know I am treating / stenting the right site? • How do I know I have obtained a good result? • How can I rule that there are complications? • What is the final result of the intervention? Challenges of performing PCI without vessel opacification ??? ???
- 11. Stepwise approach to ultra-low contrast PCI
- 12. Pre-existing angiogram ULC PCI procedure Identifying PCI targets and reference landmarks
- 13. Stepwise approach to ultra-low contrast PCI
- 14. Pre-existing diagnostic angiogram serving as roadmap for contrast-free wiring
- 15. Coronary anatomy and roadmapping
- 16. 3.5 - 4.0 mm Wire-based IVUS and physiology coregistration - Planning-
- 17. 2.6 - 3.0 mm 3.5 - 4.0 mm Wire-based IVUS and physiology coregistration - Guidance -
- 18. Lesion coverage, stent expansión/apposition, dissections Functional result Wire-based IVUS and physiology coregistration - Evaluation of results and optimisation -
- 19. EuroPCR.com Ultralow contrast skills/tools as part of state-of-the-art PCI Setting the indication and predicting PCI effectiveness Performing high-quality revascularisation ULCPCI
- 20. EuroPCR.com Dedicated chapter on ULC PCI in the PCR-EAPCI Textbook Use of ultra-low contrast techniques in percutaneous coronary interventions Alejandro Travieso MD, Breda Hennessey MD, Asad Shabbir MD, Adrian Jerónimo, Nieves Gonzalo MD PhD, Javier Escaned MD PhD
- 21. Thank you for your attention OPTIMAL CTO 2019 London, June 5-6 2019