01,Decwmber,2017 Complex PCI 2017 Case PresentationsⅡ

Which Is Better PCI or CABG for LMT Lesion and CTO of RCA Case?

- Decision from CT Information -

Masaaki Okutsu

Kawasaki Medical School General Medical Center

Okayama, Japan

Case

• 76y.o. Female

• Diagnosis) Effort angina and inferior OMI

• Risk factor) Hypertension, Dyslipidemia

• UCG) EF:50%, inferior:hypokinesis

• Renal function)

Cr: 0.73mg/dl, eGFR:58.4 ml/min/1.73m2, CCr:55ml/min

CAG

CAG

• SYNTAX scoreⅠ:48

• SYNTAX scoreⅡ

PCI:47.3

/ 4y mortality 26.1%

CABG:33.5

/ 4y mort 9.0%

• J-CTO score : 1

CAG

CT information

CT information

CT information

KCCT score : 2

CT information

CT information

CT information

CT information

Which Is Better PCI or CABG ?

• SYNTAX scoreⅠ:48

SYNTAX scoreⅡ

PCI:47.3 / 4y mortality 26.1%

CABG:33.5 / 4y mort 9.0%

• CTO of RCA

J-CTO score: 1 (intermediate)

KCCT score: 2 (intermediate)

• Bifurcation lesion

LMT: Medina (1,1,1)

LAD prox: Medina (1,1,1)

Which Is Better PCI or CABG ?

• PCI for RCA CTO seems not to be difficult antegradely. However, retrograde access is difficult.

• LMT bifurcation has diffuse plaque with calcification from LMT to LAD but quite focal stenosis at LCX ostium caused by ulceration.

• LMT bifurcation lesion has large referential diameter.

My strategy

• Treatment strategy is PCI.

• First target is RCA CTO. LMT to LAD is second.

• If PCI is failed in RCA CTO, treatment strategy should be changed to CABG.

First session

XT-A+Caravel Post balloon (2.5mm)

PCI for RCA

Ultimaster (2.25*33mm) Ultimaster (2.5*33mm)

PCI for RCA

KBT (2.0/2.25mm) Ultimaster (3.0*33mm)

PCI for RCA

Ultimaster (3.5*38mm)

PCI for RCA

Second session

PCI for LCA

Balloon (2.5mm) Balloon (3.0mm)

PCI for LCA

Resolute Integrity (3.5*15mm) Stent distal edge dissection

PCI for LCA

Ultimaster (2.5*15mm) KBT (2.5/3.5mm) + POT (5.0mm)

PCI for LCA

Ultimaster (2.5*15mm) KBT (2.5/3.5mm) + POT (5.0mm)

PCI for LCA

Balloon (2.0mm) Balloon (2.0mm)

PCI for LCA

Ultimaster (2.25*33mm) KBT (2.0/2.25mm) + POT (3.0mm)

PCI for LCA

Ultimaster (2.25*33mm) KBT (2.0/2.25mm) + POT (3.0mm)

PCI for LCA

PCI for LCA

IVUS

LMT:15.2mm2

LAD os:9.1mm2

LCX os:13.9mm2

Summary

• CT showed detail information of CTO and LMT bifurcation.

• RCA CTO lesion could be treated by antegrade approach only.

• LMT distal bifurcation lesion was treated with single stent and without severe stenosis of LCX ostium.

• This result seems to have not so bad prognosis.

Conclusion

• If SYNTAXⅠor Ⅱscore is high but each lesion is not so complex, PCI might be considerable option.

• CT is very helpful to make treatment strategy for CAD patient.