The grey zone of coronary interventions: Degenerated saphenous vein grafts

Transcription

1 PCI: procedural complications August 26: 14:00 15:30 The grey zone of coronary interventions: Degenerated saphenous vein grafts Prof. Dr. M. Haude Städtische Kliniken Neuss Lukaskrankenhaus GmbH

2 Declaration of interest statement Presenter: Michael Haude Affiliation/Financial Relationship Grant/Research Support Consulting Fees/Honoraria Company OrbusNeich Biotronik Abbott Vascular Medtronic Volcano

3 Degenerated SVG - Pathobiology - Thin fibrous cap Foam cells Layered thrombus Typical SVG disease process: First month Intimal Hyperplasia 1-7 years build-up of atheroclerosis with superimposed thrombus >7-10 years Occlusion MJ Davies, Atlas of Coronary Artery Disease

4 Degenerated SVG - angiographic findings - focal diffuse

5 Major complication of SVG-PCI: Periinterventionelle Mikroembolisation - No-Reflow - - No - Reflow - Definition: TIMI flow 0 or I after PCI Frequency: % after elektiver PCI % after AMI-PCI % after SVG-PCI Abbo et al. Am J Cardiol

6 SVG-PCI - No-Reflow - Distal Embolization Thrombus Lipids Cholesterol Foam cells Macrophages Vasoactive substances Inflammation

7 Distal Embolization SVG-PCI - No-Reflow - Thrombus Lipids Cholesterol Foam cells Macrophages Vasoactive substances Inflammation Adapted from Hori M, et al., Am J Physiol. 1986;250:H

8 SVG-PCI - Size of embolized particles - Grube et al AJC 2002;89:

9 Release of soluable vasoactive factors during PCI of saphenous vein grafts 28 pts with PCI of 31 SVG lesions with PercuSurge GuardWire protection and analysis of the aspirate: Vasoconstrictive factors: Endothelin (+300%) Serotonin (+970%) Thrombotic factors: Tissue factors (+450%) Thrombin/antithrombin III complex (+240%) Prothrombin fragment F1+2 (+240%) Pro-inflammatory factors: scd40l (+123%) E-selectin (+25%) Salloum J et al.j Invasive Cardiol 2005;17:

10 Aspirate-Serotonin-Levels vs. Aspirate-induced Maximum Force of Contraction in Isolated Rat Mesenteric Arteries with (+ E) and without (- E) Endothelium with Endothelium without Endothelium r = p-value = r = p-value = Force of Contraction (% of KClEmax) Force of Contraction (% of KClEmax) Serotonin (nmol/l) Serotonin (nmol/l) Leineweber et al. J Am Coll Cardiol 2006; 47:

11 Release of TNF-α during Stent Implantation in Venous Bypass Grafts Böse et al. AJP 2007; 292:H

12 SVG-PCI - No-Reflow - Hong MK et al. Circulation 1999 and JACC

13 SVG-PCI - No-Reflow related CK-MB rise and outcome - Hong MK et al. Circulation 1999 and JACC

14 SVG-PCI How to avoid and treat no-reflow during SVG-PCI?

15 Verapamil for Prevention of Slow-No Reflow Phenomenon (VAPOR trial) 22 pts with SVG-PCI Slow- or No-Reflow TIMI Frame Count 10 pts with prior verapamil boluses in the SVG 12 pts without prior verapamil boluses in the SVG 0 33% 53.3 P= No difference in cardiac biomarker release following PCI Michaels AD et al. J Invasive Cardiol 2002;14:

16 Adenosine for Prevention and Treatment of Slow-No Reflow Phenomenon 143 pts with SVG-PCI 70 pts with prior adenosine boluses (24 microg) 73 pts without prior adenosine boluses Slow- or No-Reflow 14.2% n. s. 13.6% Sdringola S et al. Catheter Cardiovasc Interv 2000;51:

17 Adenosine for Prevention and Treatment of Slow-No Reflow Phenomenon 20 pts with Slow- or No-Reflow Reversal of Slow- or No-Reflow 11 pts 5 boluses (7.7 ± 2.6) 9 pts < 5 boluses (1.5 ± 1.2) 91% P= % Final TIMI flow 2.7±0.6 P= ±0.8 Conclusion: Adenosine does not prevent Slow-No reflow but it can effectively treat it during SVG PCI Sdringola S et al. Catheter Cardiovasc Interv 2000;51:

18 Sodium Nitroprusside and Nitroglycerine for Prevention and Treatment of Slow-No Reflow Phenomenon 62 pts with STEMI <12h Final TIMI III: microg NTG microg SNP Final TIMI 2: microg NTG microg SNP via Export cath. Youssef AA et al. Circ J 2006;70:

19 Sodium Nitroprusside or Nitroglycerine for Prevention and Treatment of Slow-No Reflow Phenomenon Post NTG Post SNP p Final TIMI III 87.1% 100% Corrected TIMI 19.5± ±7.6 < frame count Myocardial blush 2.1± ±0.4 < Youssef AA et al. Circ J 2006;70:

20 Adenosine + Sodium Nitroprusside for Prevention and Treatment of Slow-No Reflow Phenomenon 75 ACS pts with Slow- No-Reflow Slow- or No-Reflow 25 pts with prior saline boluses (12 microg) 25 pts with prior adenosine boluses (12 microg) 25 pts with prior adenosine boluses + SNP boluses (50microg) 70% 31% 4% Reversal by adenosine + SNP to: TIMI II: 16% TIMI III: 84% Parikh KHS et al. Can J Physiol Pharmacol 2007;85:

21 Intragraft Nicardipine for Prevention of No-Reflow during PCI of Saphenous Vein Grafts 68 pts with 83 elective SVG PCIs Prophylactic intragraft injection of nicardipine Results: Slow- or No-Reflow: 2.4% CPK >3 ULN: 1.5% CPK-MB >3 ULN: 4.4% MACE (death, MI, TVR): 4.4% Fischell TA et al. J Invasive Cardiol 2007;19:

22 30-days MACE Rate % GP IIb/IIIa Inhibitors in SVG-PCI Pooled analysis of 627 pts with SVG-PCI in 5 randomized intravenous GP IIb/IIIa inhibitors trials with pts: 3 with abciximab 2 with eptifibatide Roffi M et al. Circulation 2002;106:

23 30-days MACE Rate % GP IIb/IIIa Inhibitors in SVG-PCI Hazard Ratio & 95% CI for Death, MI or TVR Roffi M et al. Circulation 2002;106:

24 Mechanical Embolic Protection Devices Distal occlusion and aspiration devices Distal filter wires Proximal occlusion and aspiration devices

25 Distal balloon occlusion / aspiration - GuardWire

26 SVG-PCI - Distal balloon occlusion / aspiration devices - Advantages Easy to cross lesion More steerable and lower profile than filter-wires Compatible with devices Aspirate large and small particles Reliably trap debris Easy device retrieval Entraps soluble mediators Disadvantages Cannot use on distal lesions No antegrade flow 5-8% are intolerant Balloon-induced injury Not as steerable as PTCA wires Difficult to image during the procedure

27 Filter devices AngioGuard, Cordis Medtronic Protection Device Accunet, Guidant

28 SVG-PCI - Filter devices - Advantages Preserve antegrade flow Contrast imaging is possible throughout the procedure Simple to use Disadvantages May not capture all debris Difficult to evaluate retrieval of debris during the procedure Filters may clog Delivery catheters may cause embolization before filter deployment Retrieval sheath may snag on stents

29 Proximal protection device

30 SVG-PCI - Proximal protection devices - Advantages Protects myocardium during wire crossing Wire of choice (.014 ) Use contrast suspension for lesion visualization Large lumen catheter can aspirate large thrombus/embolic loads No landing zone required Disadvantages No antegrade flow Myocardial ischemia during procedure More complex to use than distal filters Can not use with ostial/proximal disease

31 Protected SVG-PCI - incidence of no-reflow - Baim DS et al. Circulation 2002;105: Stone GW et al. Circulation 2003;108:

32 Protected SVG-PCI - postinterventional CK-MB rise - Baim DS et al. Circulation 2002;105: Stone GW et al. Circulation 2003;108:

33 Protected SVG-PCI - 30-day MACE rate - Baim DS et al. Circulation 2002;105: Stone GW et al. Circulation 2003;108:

34 Protected SVG-PCI - 30-day MACE rate - PROXIMAL Trial: Distal Protection with filter devices in 81% Mauri L et al. J Am Coll Cardiol 2007;50:

35 Microcirculatory protection during SVG-PCI - Guidelines - ESC Guidelines 2005 distal protection systems IA (SAFER, FIRE) ACC/AHA Guidelines 2006 distal protection systems IB (SAFER, FIRE) ESC Guidelines 2010 distal protection systems IB (SAFER, FIRE) proximal protection system IIb B (PROXIMAL) Silber S, et al. Eur Heart J 2005;26(8): Smith SC Jr, et al. J Am Coll Cardiol 2006;47(1):e1-121 Wijns W, et al. Eur J Cardiothorac Surg Sep;38S1:S1-S52. Epub 2010 Sep 36 16

36 SVG-PCI Which stent to use?

37 SVG-PCI - PTFE covered BMS vs BMS - Turco MA, et al. Catheter Cardiovasc Interv 2006;68: Stone GW, et al. J Am Coll Cardiol Int 2011;4:300-9 Stancovic G, et al. Circulation 2003;108:

38 SVG-PCI - PET mesh stent MGUARD - 16 pts with SVG-PCI No angiographic complications No procedural complications No MACE at 30 days Maia F, et al. Catheter Cardiovasc Interv 2010;76:

39 SVG-PCI - DES vs BMS - Brilakis ES, et al. J Am Coll Cardiol 2009;53: Vermeersch P, et al. J Am Coll Cardiol Int 2006;48:

40 SVG-PCI - ISAR-CABG - Randomized trial in 610 pts with SVG stenoses DES (PES, 2 different SES): n=303 BMS: n=307 Test DES superiority Endpoints: MACE, death, MI, stroke, repeat revascularisation, stent thrombosis Follow-up: 1 year Mehili J, et al. Lancet 2011;378:

41 SVG-PCI - ISAR-CABG - Results at 1 year DES BMS HR (95% CI) Psuperiority MACE 15.0% 22.1% 0.64 ( ) 0.02 Death 5.1% 4.7% 1.08 ( ) 0.83 MI 4.1% 6.0% 0.66 ( ) 0.27 Stent thrombosis* 0.7% 0.7% 1.00 ( ) 0.99 TLR 6.8% 13.1% 0.49 ( ) 0.01 * Definite or probable Mehili J, et al. Lancet 2011;378:

42 SVG-PCI - DES implantation technique - IVUS-guided undersizing of DES in SVGs to reduce plaque prolapse Hong et al. Am J Cardiol 2010;105:

43 SVG-PCI - DES implantation technique - IVUS-guided undersizing of DES in SVGs to reduce plaque prolapse Hong et al. Am J Cardiol 2010;105:

44 30-days MACE Rate % SVG-PCI - Conclusions 1 - No-reflow is the major complication during SVG- PCI. Today, PCI of SVG lesions with mechanical distal or proximal protection is state-of-the-art. There are no convincing data available that adjunct pharmacotherapy before or during elective or ACS PCI of SVG lesions can prophylactically avoid slow- / no-reflow or reduce MACE. Intragraft adenosine + SNP probably can reverse slow- / no-reflow best

45 30-days MACE Rate % SVG-PCI - Conclusions 2 - PTFE covered BMS have failed to limit no-reflow during SVG-PCI. DES are recommended for SVG-PCI to limit restenosis and reintervention without safety concerns compared to BMS