SCAI unveils guidance for complex PCI
At its virtual Scientific Sessions, the Society for Cardiovascular Angiography and Interventions released a statement on optimal PCI practices in patients with complex CAD.
“The anatomic and clinical complexity of the patients arriving to our cath labs has been on the rise for some time,” Robert F. Riley, MD, MS, FACC, FAHA, FSCAI, research and medical director of the complex coronary therapeutics program at The Christ Hospital Heart Health System, said during a presentation. “While we use terms like ‘complex coronary artery disease’ and ‘high-risk PCI’ a lot, we have not formally defined them up to this point ... and we don’t have a document that addresses best practices for PCI in this expanding patient group.”
Offering such guidance is important because CMS is now reimbursing for certain PCI procedures performed at ASCs, Riley said.
The document, simultaneously published in Catheterization and Cardiovascular Interventions, is also intended to serve as a companion to SCAI’s new statement on the appropriate patient populations for PCI at ASCs, he said.
“Together, we really hope these documents can provide guidance on the appropriate setting for where to perform PCI across the spectrum of clinical and anatomic complexity,” Riley said.
Part of the document is devoted to preprocedural assessment of coronary anatomic complexity and high-risk clinical features.
The SYNTAX and Society of Thoracic Surgeons scoring systems for patients with multivessel CAD should be used, and a heart team approach is helpful to make appropriate revascularization decisions in complex patients, Riley said during the presentation.
Special attention should be paid to patients who have a high SYNTAX or STS score but are ineligible for CABG, he said.
These patients “have an increased risk of mortality and major adverse events that’s out of proportion to the risk that’s assessed by our traditional PCI stratification tools,” he said. “We also have a section on acute coronary syndromes where we reemphasize that invasive strategies are important for patients presenting with acute myocardial infarctions ... and we also emphasize the important role for complete revascularizations, particularly in the setting of STEMI.”
The document also references algorithms to guide use of mechanical circulatory support in patients with impaired left ventricular function and/or cardiogenic shock, he said.
Optimal interventional treatment
The document also addresses the optimal interventional treatment for complex CAD.
Transradial access is increasingly being utilized for complex interventions, but transfemoral access is a reasonable alternative when performed by experienced operators using the right tools, Riley said.
Dual antiplatelet therapy after complex PCI should last 6 to 12 months in most cases, but the TWILIGHT-COMPLEX study indicates it is reasonable to switch to ticagrelor (Brilinta, AstraZeneca) monotherapy after 3 months in many patients, he said.
Use of intravascular physiology assessments and imaging have been shown to improve hard outcomes in complex CAD and should be used, Riley said.
The document also introduces a new algorithm for treatment of calcified lesions. “It starts with lesions you can see with significant calcium,” he said. “You’ve potentially identified it using angiography, balloons that won’t expand or ideally via intravascular imaging when you’ve prepared for PCI. Criteria including arc, length and thickness of calcium are going to push you toward atherectomy vs. lithoplasty. Then it’s a matter of getting full expansion with a noncompliant or cutting/scoring balloon” before proceeding with stenting and image-guided optimization.
Once the complex PCI patient group is defined, “we can contextualize them in terms of where we are going to do their PCI,” Riley said. “Stable coronary disease patients without complexity can be done in either ASCs or hospital-based settings. On the other end of the spectrum are patients with cardiogenic shock and arrest. Those clearly have to be done in a hospital-based setting. Then there is the complex patient group in between. We prefer that these patients be done in a hospital-based setting for so many reasons: being able to stay overnight if needed, being able to manage any complications, etc. We did not want to be dogmatic and say they simply cannot be done in ASCs, but the hospital is certainly preferred.”