Contemporary Management of Complex Higher-Risk and Indicated Patients: Perspectives from China
Complex higher-risk and indicated patients (CHIPs) represent a challenging population in the field of interventional cardiology. These patients, characterized by severe coronary artery disease (CAD) requiring revascularization, face increased procedural risks. Since the term CHIP was introduced in 2016, it has garnered significant attention, sparking intense discussions on optimal treatment strategies. This article delves into the contemporary management of CHIPs, focusing on risk assessment, revascularization techniques, and innovative approaches from a Chinese perspective.
A comprehensive risk assessment is the cornerstone of managing CHIPs. This involves evaluating clinical presentation, functional tests, and anatomic characteristics to determine the suitability of revascularization. Percutaneous coronary intervention (PCI) emerges as a beneficial option, particularly for patients deemed inoperable or at higher surgical risk. Achieving complete revascularization through PCI is crucial, necessitating well-trained interventionalists with both technical and cognitive skills.
Bifurcation lesions present a unique challenge in PCI. The European Bifurcation Club advocates for main-vessel (MV) stenting with a proximal optimization technique and provisional side-branch (SB) stenting as the preferred approach. However, when a two-stent strategy is required, selecting and executing the appropriate technique becomes technically demanding. The DK-CRUSH strategy, proposed by Prof. Shao-Liang Chen, stands out as an evidence-driven option, demonstrating superiority over provisional stenting in the DKCRUSH-V randomized trial. This strategy ensures reliable final kissing inflation, reducing target lesion failure at a 1-year follow-up.
Prof. Yu-Jie Zhou introduced the active transfer of plaque (ATP) technique, which involves transferring plaque from the SB to the MV by pre-dilating a balloon in the SB and then fixing the plaque by releasing the stent in the MV. The ATP trial, which enrolled 284 patients with unprotected distal left main bifurcation lesions, showed no significant difference in target lesion revascularization between the ATP technique and provisional stenting groups. However, the ATP technique significantly reduced the risk of side branch compromise and SB stent implantation.
Chronic total occlusion (CTO) PCI has seen advancements in techniques and strategies, though these are not fully aligned with clinical practice. The Chinese CTO Club proposed a distinct strategy emphasizing dual coronary injection, careful assessment of CTO angiographic parameters, and the rational use of antegrade, retrograde, and antegrade dissection re-entry techniques. Intra-vascular ultrasound (IVUS)-guided PCI is also recommended. Future studies are needed to identify patients who would benefit most from CTO PCI compared to guideline-directed medical therapy (GDMT).
In-stent restenosis (ISR) is increasingly prevalent, with second-generation drug-eluting stents (DES) and drug-coated balloons (DCBs) recommended by current guidelines. However, implanting a new DES in recurrent and refractory ISR is concerning, while the “leave nothing behind” concept using DCBs is gaining traction. Lesion preparation before DCB treatment is essential, sometimes requiring aggressive pre-treatment with excimer laser coronary atherectomy (ELCA) or rotational atherectomy (RA), especially in cases of severe stent under-expansion due to heavy calcification. The photomechanical role of ELCA, combined with contrast injection, aids in plaque modification, though it remains a high-risk procedure.
Intra-coronary imaging is indispensable for managing ISR, providing mechanistic insights and guiding treatments. Optical coherence tomography offers detailed information on calcium distribution and thickness, indicating the need for enhanced lesion preparation before stent implantation. RA is widely used for sufficient calcium ablation, while orbital atherectomy may be favored for eccentric calcium. ELCA can create a channel for rotawire passing in heavily calcified lesions. Coronary intra-vascular lithotripsy (IVL) has shown promise in modifying heavily calcified plaques, with a 95% clinical success rate and a 95% rate of patients not experiencing major adverse cardiac events after 30 days of treatment.
Complex interventions do not always equate to higher-risk interventions. Procedural risk stems from complex coronary anatomy, patient comorbidities, and adverse hemodynamics. Cardiogenic shock complicating acute myocardial infarction carries a high in-hospital mortality rate of 65%. Prof. Zhou proposed the “PIE-2R” model, an integrated emergency rescue approach involving pacing management, circulatory support (IABP/Impella, and VA ECMO), respiration management, and revascularization. The success of this model relies on a multidisciplinary heart team for risk evaluation, timely and complete revascularization, and dedicated peri-procedural management.
Despite advancements in characterizing and risk-stratifying CHIPs, these patients are least likely to undergo revascularization, even with less invasive percutaneous approaches. This reluctance stems from a lack of expertise and confusion over revascularization indications, often leading to overestimation of procedural risks and underestimation of potential benefits. To address this, a dedicated, case-based curriculum for training interventionalists is essential. This curriculum should focus on evaluating and identifying candidates, treating them safely and skillfully, and understanding the rationale and goals of revascularization.
Additional studies are needed to demonstrate the short and long-term clinical benefits of revascularization compared to GDMT and the benefits of PCI compared to coronary artery bypass grafting. A more accurate risk model would help identify and treat the proper subset of patients, ensuring interventionalists are satisfied with the safety and effectiveness of PCI for CHIPs. This approach can achieve a true “higher risk, higher reward” paradigm, benefiting high-risk patients considerably.
In conclusion, the management of CHIPs requires a multifaceted approach, encompassing comprehensive risk assessment, advanced revascularization techniques, and innovative strategies. The perspectives from China highlight the importance of well-trained interventionalists, intra-coronary imaging, and multidisciplinary collaboration in optimizing outcomes for these complex patients. Continued research and dedicated training programs are essential to refine treatment strategies and improve the prognosis of CHIPs.
doi.org/10.1097/CM9.0000000000000280
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