FELLOWS’ CORNER
“The two things that have
revolutionized CTO PCI are the
Corsair microcatheter, and the
Stingray re-entry balloon.”
—William Lombardi, MD
needs and how we can improve to manage an ever
increasingly complex patient population.
So where are the gaps in technology and
training right now?
There are three barriers to growth: 1) calcium,
2) anatomic ambiguity, and 3) our professional
culture.
We still struggle with calcium. Rotational and
orbital atherectomy are under-utilized in my opinion. Interventionalists usually shy away from these
devices due to high complication rates, increased
procedure times, and lack of proficiency. This becomes a self-fulfilling prophecy: as operators train
less and do less, they subsequently develop more
fear of the procedure.
The second challenge that we struggle with is
anatomic ambiguity. What I mean by that is that
the more confident we are of where we’re going
and where we need to go, the less uncomfortable
we are during the procedure. But [in CTO interventions] we have no real-time imaging that could
help us outline the vessel or inform the operator
of exactly where the vessel architecture is as we
cross the occluded segment. That becomes much
more pronounced as we do post-bypass CTOs as
they are longer, more calcified, and have multiple
collateral sources so it is harder to see the course
of the entire vessel.
The third barrier is our professional culture in
interventional cardiology. Because of its broadened
growth and no real minimum standard for interventionalists, the care variability across the profession is the widest it has ever been. Because of the
challenges of post-graduate training, medical-legal
concerns, and political and economic issues, there
is less desire for interventionalists to evolve to do
more complicated procedures. What people like
Gruentzig, Hartzler, and even the early pioneers of
STEMI—Bill O’Neil and Cindy Grimes—achieved,
potentially could not be done in our current
medical staff, medical-legal environment because
people are so quick to put others down who are
trying to evolve and move our space forward,
rather than collaborate and work together. We all
36 CardioSource WorldNews: Interventions
sit somewhere on the bell-shaped curve. At the
very left-hand side of the curve are the innovators,
next come the early adopters, then there are the
mid-adopters, then the late adopters, and then the
naysayers. We have to work on setting up newer
constructs to allow those who want to to find a
way forward. So interventionalists have to make a
choice: Do you want to be a doer or do you want
to find excuses?
How has technology revolutionized the field of
CTO PCI?
The two things that have revolutionized CTO PCI
are the Corsair microcatheter and the Stingray reentry balloon.
Going retrograde prior to the Corsair microcatheter was doable but significantly challenging;
now with the development of the Corsair, it has
helped make retrograde CTO PCI possible for any
interventionalist.
The second giant leap forward was the anterograde reentry techniques facilitated by the
Stingray re-entry balloon because that gave us a
solution when we could not go retrograde or in
simpler cases where the wire was past the distal
cap but subintimal. This is a much easier solution
than parallel wire and hope and poke, and the numerous other strategies we utilized historically. Because of those technologies, the hybrid algorithm
could be developed to give people a simpler and
more consistent construct with which to manage
CTO PCI.
If you were going to give advice to FITs
interested in CTO PCI, what would that be?
There are a couple pieces of advice I would
give them. First, if you are not currently at an
institution that does CTOs, you have to get out
into the world and find a place that does so you
can learn more about it. Second, you have to
push your attendings and ask them why they are
not doing CTO PCI? Why are they behind other
institutions? Third, don’t become siloed. You have
to get out of our comfort zone and realize there
may be other ways to treat coronaries that what
your institution is teaching you. You need to go to
meetings where they are talking about complete
revascularization and addressing the challenges
rat her than making excuses and running away
from the challenges. Finally, don’t think that once
you are done with your fellowship, you’re done.
On a personal note I will tell you, I am not as
good of an interventionalist as I need to be. Every
day I go to work, I try to figure out how can I get
better at my craft? I’m blessed because I get to
work with a lot of really smart people and I get
to go around the world and do cases—it keeps
me out of my silo and forces me to continually
improve. ■
Sandeep Kumar Krishnan, MD is an interventional
cardiology Fellow-in-Training at the University of Washington
Medical Center in Seattle, WA. In addition to interventional
cardiology, he is also interested in healthcare policy and
serves as the FIT member on the American College of
Cardiology’s Health Affairs Committee.
For more interviews, profiles, news and resources for
FITs, visit ACC.org/FIT.
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September/October 2016