Access & Closure, Clinical Research & Data, Intravascular Imaging, Safety & Efficacy, Protected PCI

Best Practices for Treating High-Risk PCI Patients


Jason Wollmuth, MD, FACC, highlights what operators need to do to get patients through complex high-risk PCI procedures and obtain the best procedural and long-term outcomes. Dr. Wollmuth is the director of complex coronary interventions at Providence Heart Institute in Portland, Oregon. He gave this presentation virtually at the CAMP at TCT event held before the 2021 Transcatheter Cardiovascular Therapeutics (TCT) conference.

Dr. Wollmuth focuses his presentation on two of the skills he believes interventional cardiologists need to master to excel in high-risk Protected PCI: large-bore access and intravascular imaging.

Large-bore access. Dr. Wollmuth discusses the current practice of using fluoroscopic and ultrasound guidance for vascular access, emphasizing that a good stick—using micropuncture and ultrasound guidance as well as low stick angle to minimize lift on the vessel and sheaths—is key to success for groin management.

Intravascular imaging. “The other thing that makes a huge difference in outcomes in these patients is hemodynamic assessment with coronary physiology and intracoronary imaging.” Dr. Wollmuth reviews data from several trials, including FAME 1 and FAME 2, in which fractional flow reserve (FFR) guided PCI outcomes were superior to angiography. “You can see,” he explains, “angiography leads to significant over- and under-treatment of potentially significant or nonsignificant lesions.”

He also reviews results from the DEFINE PCI study in which patients underwent blind instant wave-free ratio (iFR) measurements after PCI. Results revealed that 24% of patients had abnormal resting index after a successful angiographically-guided PCI. This, he states, “shows that we may need to combine hemodynamic assessment with intracoronary imaging to make sure that we’re treating the lesion appropriately.” He also reviews data demonstrating that intravascular imaging improves PCI outcomes, cutting stent failure in half.

Summarizing all this data, Dr. Wollmuth concludes that using modern PCI tools, such as iFR and intravascular ultrasound (IVUS), “it’s possible that multivessel PCI can be comparable to surgical revascularization.” He then reviews SYNTAX I and SYNTAX II, explaining that significantly higher IVUS usage post stent implantation in SYNTAX II PCI led to further optimization of stented lesions in 30.2% of patients. “So, by doing a better job with our PCI, we’re able to mimic the outcomes seen in patients undergoing bypass surgery.”

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