Atherectomy, Intravascular Imaging, Patient Management, Protected PCI

TCT 2022: Contemporary Techniques for Optimal Outcomes in High-risk PCI


“What does contemporary PCI look like?” Kate Kearney, MD, FSCAI, asks in the opening of her Sunday symposium at TCT 2022. She identifies best practices such as imaging and atherectomy and asks, “How can we take these best practices and make them actually present in our cath lab on a routine basis?” She emphasizes how innovation, experience and best practices have reduced bleeding over time. “We have seen in our own programs that as we implement best practices for large-bore femoral access, we’re getting better at that.” 

To highlight what it looks like to implement contemporary techniques for optimal outcomes in high-risk PCI, Dr. Kearney describes the steps she took in treating an 82-year-old woman with dyspnea and NSTEMI after recent aortic rupture and repair. She explains how this case required consideration of the complex nature of the case and the high-risk nature of the patient. 

In her first step, “getting a lay of the land,” Dr. Kearney found that the patient had a favorable RHC and favorable anatomy for placing hemodynamic support. Her next step was to quickly treat the RCA and move on to the left side. “Cases like these are important, because we have to think about ‘what’s the next lily pad I can jump to,’” she says. 

Unfortunately, after placing the stent on the right and turning her attention to the left side, Dr. Kearney’s treatment plan encountered challenges when the team could not advance the microcatheter down the left circumflex or the LAD. “In these cases, it’s not just the tools, but it’s the other techniques we have,” she notes, as she describes the team’s problem solving that eventually led to an acceptable result.

While it was a long and frustrating case, the team still followed the best practice of performing post-procedural imaging. Dr. Kearney emphasizes, “The way we honor the patient is to leave them with the best potential long-term outcome as possible.”

Dr. Kearney concludes by explaining that the way forward with contemporary techniques for optimal outcomes involves data, training and growth. She acknowledges the challenges, yet necessity, of enrolling complicated patients in clinical trials. “If we look at these high-quality registries,” she states, “that actually gives us a very solid framework of how to make these shared decisions with patients.” She highlights the importance of being able to learn from colleagues to improve your own practice and the importance of an “iterative growth mindset” that keeps adapting and implementing new technology and data into cases on the table.

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