Is it common to have multiple catheterizations close together to reach difficult lesions for stent placement?

Multiple Catheterizations for Difficult Coronary Lesions

Multiple catheterizations close together are sometimes necessary to reach and treat difficult coronary lesions for stent placement, particularly in complex anatomical situations such as bifurcations, ostial lesions, and left main coronary artery disease. 1

Situations Requiring Multiple Catheterizations

Complex Lesion Types

• Bifurcation lesions: When treating bifurcation lesions (occurring in 60-90% of left main cases), multiple catheterizations may be needed, especially when employing a two-stent strategy 1
• Ostial lesions: Precise placement of stents at aorto-ostial locations often requires specialized techniques and sometimes multiple attempts 2
• Left main coronary artery (LMCA) disease: Treatment of LMCA lesions, particularly distal bifurcation lesions, frequently requires complex approaches that may necessitate multiple catheterizations 1
• Chronic total occlusions: These challenging lesions may require multiple attempts and specialized equipment 1

Technical Challenges

• Stent delivery failure: In approximately 3-4% of cases, stents fail to deploy properly, requiring additional catheterization attempts with different stent types or approaches 3
• Difficult vessel anatomy: Tortuous vessels, severe calcification, or angulated segments may prevent successful stent delivery on first attempt 3
• Need for multiple stents: Long dissections or extensive disease may require either a single long stent or multiple overlapping stents, potentially requiring additional catheterization procedures 4

Early Postoperative Catheterization

Contrary to historical beliefs that interventions should be avoided in the early postoperative period, recent evidence suggests that:

• Diagnostic and interventional catheterization can be performed safely in the early postoperative period 1
• Angioplasty, stent implantation, and device occlusion can be performed safely within 6 weeks after surgery 1
• These early interventions may improve survival to discharge for patients requiring mechanical cardiopulmonary support 1

Special Considerations for Multiple Catheterizations

Physiological Assessment

When multiple lesions are present, physiological assessment using fractional flow reserve (FFR) can help determine which lesions require intervention:

• In vessels with multiple stenoses, a pressure pullback recording can identify regions with significant pressure gradients 1
• This approach allows treatment of the stenosis with the largest gradient first, followed by reassessment of remaining stenoses 1

Imaging Guidance

Intravascular ultrasound (IVUS) is particularly valuable when multiple catheterizations are needed:

• IVUS is reasonable for assessment of angiographically indeterminate left main CAD 1
• IVUS guidance is advocated in most cases for stent optimization, especially in complex situations like LMCA bifurcations 1

Stenting Strategies for Complex Lesions

For bifurcation lesions:

• Provisional side-branch stenting should be the initial approach when the side branch is not large and has only mild/moderate focal disease at the ostium 1
• Elective double stenting is reasonable with complex bifurcation morphology involving a large side branch where risk of side-branch occlusion is high 1

Risks and Complications

Multiple catheterizations may increase risks of:

• Contrast-induced nephropathy
• Vascular access complications
• Radiation exposure for both patient and operator 4
• Stent deployment failure (3.3% of cases) 3
• Peripheral stent embolization (0.3% of cases) 3

Optimizing Outcomes with Multiple Catheterizations

To improve outcomes when multiple catheterizations are needed:

• Employ a multidisciplinary team approach including interventional cardiologists, cardiac surgeons, and cardiac anesthesiologists 1
• Use specialized equipment like the Ostial Pro positioning system for aorto-ostial lesions 2
• Consider longer dual antiplatelet therapy (DAPT) duration (≥1 year) for complex interventions, particularly with 2-stent strategies 5
• Minimize contrast volume and radiation exposure by careful planning 4

Conclusion

While single catheterization procedures are preferred when possible, multiple catheterizations are sometimes necessary and appropriate for treating complex coronary lesions. The decision to perform multiple procedures should be based on lesion complexity, technical challenges encountered, and the potential benefit to the patient's morbidity and mortality outcomes.