calcified coronary lesion: difficulties and challenges zhou yu jie md, phd, facc, fscai, fhrs...

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

JACC: CARDIOVASCULAR IMAGING. 2010 Dec;3(12). JACC: CARDIOVASCULAR IMAGING. 2012 Oct;5(10)

4,425 Suspected CAD patientsFollow-up 3 years

4,609 asymptomatic individuals Follow-up 3.1 years

Coronary Artery Calcium (CAC) in the Multi-Ethnic Study

Coylewright et al. Atherosclerosis.2011

CAC are associated with CHD events

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

Atherosclerosis. 2012 March ; 221(1): 176–182.

Method ：9,993 patients undergoing PCIThe degree of index lesion calcification (ILC) based on angiography

Elevated BSA is a predictor of CAC, not BMI

Coron Artery Dis 2012 Mar;23(2):113-7

Method ： 3172 consecutive patients underwent CAC scores

Mechanism of CAC

Vascular calcification is an active ,regulated process

BMP-Wnt signalingBMP-Smad signaling

Major Theories of Vascular Calcification

Vascular calcification

Apoptotic bodies

CELL DEATH

LOSS OF INHIBITIONPyrophosphateMGPOPNFetuin/alpha2-HS glycoproteinOthers

Matrix Vesicles

DISTURBED Ca/Pi BALANCEHyperphosphatemiaHypercalcemia

INDUCTION OF BONE FORMATIONVascular bone and cartilage-like cells

INDUCING FACTORSPiLipidsInflammatory cytokinesOthers

BisphosphonatesOPG

Bone Remodeling

CIRCULATING NUCLEATIONAL COMPLEXES

Ca x Pi

DISTURBED Ca/Pi BALANCEHyperphosphatemiaHypercalcemia

INDUCING FACTORSPiLipidsInflammatory cytokinesOthers

Apoptotic bodies

Matrix Vesicles

INDUCTION OF BONE FORMATIONVascular bone and cartilage-like cells

DISTURBED Ca/Pi BALANCEHyperphosphatemiaHypercalcemia

INDUCING FACTORSPiLipidsInflammatory cytokinesOthers

CELL DEATH

BisphosphonatesOPG

Apoptotic bodies

Matrix Vesicles

INDUCTION OF BONE FORMATIONVascular bone and cartilage-like cells

DISTURBED Ca/Pi BALANCEHyperphosphatemiaHypercalcemia

INDUCING FACTORSPiLipidsInflammatory cytokinesOthers

CIRCULATING NUCLEATIONAL COMPLEXES

CELL DEATH

BisphosphonatesOPG

Apoptotic bodies

Matrix Vesicles

INDUCTION OF BONE FORMATIONVascular bone and cartilage-like cells

DISTURBED Ca/Pi BALANCEHyperphosphatemiaHypercalcemia

INDUCING FACTORSPiLipidsInflammatory cytokinesOthers

Bone Remodeling

CIRCULATING NUCLEATIONAL COMPLEXES

CELL DEATH

BisphosphonatesOPG

Apoptotic bodies

Matrix Vesicles

INDUCTION OF BONE FORMATIONVascular bone and cartilage-like cells

DISTURBED Ca/Pi BALANCEHyperphosphatemiaHypercalcemia

INDUCING FACTORSPiLipidsInflammatory cytokinesOthers

No effective medicine treatment

• Evidence from meta-analysesStatin and LDL-C

Statin and calcification

Coylewright et al. Atherosclerosis.2011

Statins promote CAC (VADT trail)

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

Stent thrombosis12

Strategy of PCI in CAC

Balloon angioplastyCutting balloonRotablatorStentPost dilationLaser

Strategy for balloon angioplasty

Small size balloon preferedPressure of BC from 8 atm, slowly increase The up limit of pressure may be 16 atmFlow restricting dissection or perforation be

concerned

14

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

Effective device for calcified lesionDifferential tissue cutting ----selectively hard lesion, no soft tissueOptimal burr size---60%-70% of reference vessel

diameter Prevent no flow & slow flow ----nitroprusside, adenosine , etcUpper limit of rotablator: just enough for

revascularization

16

Rotational Atherectomy(RA)

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

Randomized ROTAXUS Trial Outcome

Randomized ROTAXUS Trial Outcome

Death MI

TVR MACE

JACC Cardiovasc Interv 2013 Jan

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

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 42 patients ≥80 years had undergone stenting for calcified LMCA

disease Procedural success is 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 • An 84 year man• Previous failed angioplasty due to balloon rupture• CAG showing severe CCL21

PCI for LADPCI for LAD- - Rotablator 22

Stent deployment23

Rotational Atherectomy and IVUS

a

b

Pre

Post RA1.75 mm

burr

Post 1.75 mm burr RA

Pre

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 dialation last straw for calified lesion Non compliant, high pressure balloon first

choiceBe careful coronary perforation or serious

dissection

26

Postdilation in severe CCL27

Clinical presentationClinical presentation

33

Diagnosis: UAP Diagnosis: UAP

Prior MIPrior MI

HypertensionHypertension

11Progressive deterioration of chest pain for 3 Progressive deterioration of chest pain for 3

years (CCS II), presented with unstable years (CCS II), presented with unstable

episodes in last 2 weeks (CCS III)episodes in last 2 weeks (CCS III)

22With a history of HBP, prior inferior and With a history of HBP, prior inferior and

anterior myocardial infarctionanterior myocardial infarction

Male, 84-year-oldMale, 84-year-old

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%

Laboratory tests

Electrocardiogram

Coronary Angiography

Coronary Angiography

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

PCI for RCA

GC: JR 4.0, GW: Pilot 50Predilation BC: Sprinter 1.5 x 15mm and 2.0 x20mm

Final result-RCA

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

PCI for LMPCI for LM1 week later

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

Pre-PCI IVUSPre-PCI IVUS

PCI for LMPCI for LM-Predilation-Predilation

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

PCI for LMPCI for LM--11stst Stent Implantation Stent Implantation

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

PCI for LMPCI for LM-2-2ndnd Stent Stent MigrationMigration

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

PCI for LMPCI for LM-Retrieving Stent-Retrieving Stent

Migrated stent was retrieved successfully assisted with Sprinter 1.5x15mm

Migrated stent

PCI for LMPCI for LM -Continue with Mini-Crush -Continue with Mini-Crush

Continue with 7F EBU 3.5; Mini-Crush technique was usedFirebird2 3.5x33mm for LM/p-LAD and Firebird2 3.0x18mm for LCX

PCI for LMPCI for LM-Postdilation-Postdilation

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

PCI for LMPCI for LM--1st Final Final KissingKissing

1st final kissing with Avita HP 3.5x15mm (LAD) and Sprinter 3.0x12mm (LCX)

2nd IVUS test LAD ostia stent expansion unacceptable

PCI for LMPCI for LM--Re-postdilatation

Re-postdilatation with Avita HP 3.5x15mm (18-24atm for LM/p-LAD stent)

PCI for LMPCI for LM--2st Final KissingFinal Kissing

2nd final kissingAvita HP3.5x15mm (LAD) and Sprinter3.0x12mm (LCX)

Final result

Final IVUS test-acceptable