Sandeep Parekh

Livasa Hospital

Title: Is routine use of intravascular imaging warranted for all procedures?

Biography

Sandeep Parekh is a leading interventional cardiologist and Principal Consultant – Cardiology at Livasa Hospital, Mohali. A JIPMER graduate with a DrNB in Cardiology, he has held senior roles at CARE Hospitals and Max Super Speciality Hospital.

He is a Fellow of the European Society of Cardiology (ESC) and the Society for Cardiovascular Angiography and Interventions (SCAI), and a recipient of the Sri Krishna Memorial Gold Medal.

Parekh is known for his work on vasovagal syncope, systemic disease-related cardiac complications, and heart failure management. An active academic and mentor, he has authored multiple peer-reviewed publications and regularly presents at national and international forums.

Abstract

Background: Intravascular imaging (IVI), although used specifically in complex PCI, has limited penetration in real-world clinical practice in a majority of centers in India where its additional use escalates the cost of treatment. With the huge burden of cardiovascular disease, necessitating large volume of procedures, the interventionist has to judiciously decide the right case for imaging.

Case Summary: My case is a 49 years old female, diabetic and hypertensive since 6 years, who presented with ST elevation myocardial infarction of anterior wall with a window period of 30 minutes. Coronary angiography revealed significant stenosis in proximal left anterior descending artery (LAD) with grade 3 thrombus. In view of precarious hemodynamics, it was decided to expeditiously open the infarct related artery under ionotropic support which was achieved with good TIMI 3 flow and no complications. She was discharged on 3rd day of hospitalization. She was compliant with her medications and kept regular follow up on outpatient basis.However, after 8 months of the index procedure, she presented with postprandial retrosternal chest pain with elevated troponin levels. She was taken up for coronary angiography which showed focal instent restenosis in proximal LAD stent.IVI revealed a grossly under expanded stent due to underlying superficial calcium extending beyond 270°. The calcified plaque was modified with an adequately sized cutting balloon and after achieving adequate expansion, drug coated balloon angioplasty was done to prevent future neoatherosclerosis.

Conclusion: This case highlights how angiographic assessment of the underlying plaque morphology and final stent expansion can be misleading, especially in an acute coronary syndrome with fragile hemodynamics where the priority is to promptly establish flow. Although the use of IVI in every acute myocardial infarction is debatable, instent restenosis remains a very strong indication for its use to evaluate the underlying cause and modify plaque accordingly.