PCI σε Ασθενείς με Ιστορικό Αορτοστεφανιαίας Παράκαμψης
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- Allyson Pauline Pope
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1 ΠΑΝΕΛΛΗΝΙΑ ΣΕΜΙΝΑΡΙΑ ΟΜΑΔΩΝ ΕΡΓΑΣΙΑΣ Φεβρουαρίου 2018 Θεσσαλονίκη ΟΜΑΔΑ ΑΙΜΟΔΥΝΑΜΙΚΗΣ & ΕΠΕΜΒΑΤΙΚΗΣ ΚΑΡΔΙΟΛΟΓΙΑΣ PCI σε Ασθενείς με Ιστορικό Αορτοστεφανιαίας Παράκαμψης Αχιλλέας Ζαχαρούλης Επιμελητής Α ΕΣΥ Β Πανεπιστημιακή Καρδιολογική Κλινική ΠΓΝΑ ΑΤΤΙΚΟΝ
2 Life after CABG Karacsonyi et al. Circulation Intv 2017; in press
3 Native disease progression ANGINA AFTER CABG Bypass graft failure Arterial *Proximal subclavian disease SVG Chen et al, JACC 1996
4 100 PCI target vessel in prior CABG pts NCDR: /2009 Prior CABG: 17.5% (300,902 of 1,721,460) Native SVG Arterial Arterial + SVG 80 68,0 76,5 66,1 p < % 60 53,7 44, ,0 20,4 31,4 0 5,0 2,9 2,3 0,7 0,2 0,2 1,9 0,2 0-1 yrs 1-5 yrs 5-10 yrs >10 yrs Time from CABG Brilakis et al, JACC Intv 2011
5 SVG PCI challenges ACUTE DISTAL EMBOLIZATION Embolic Protection CHRONIC IN-STENT RESTENOSIS DES vs. BMS Progression of intermediate lesions
6 CK-MB rise after successful SVG PCI without EPD (n=1056) 60 53,0 Normal CK-MB 1-5x CK-MB >5x CK-MB 40 % 32,0 P< ,0 P< ,7 4,8 6,5 0 Prevalence 1 Year Mortality Hong et al. Circulation 1999;100;
7 No Reflow Phenomenon Pathology Larger surface area cm 2 Typical LAD cm 2 Particulate from a SVG Case
8 Prevention of no-reflow in SVGs Vasodilators GP IIb/IIIa inhibitors PTFE Covered stents Undersized stents Low pressure stent deployment Laser Thrombectomy EMBOLIC PROTECTION DEVICES
9 Embolic protection Devices
10 Embolic Protection Reduces No-Reflow SAFER Trial p= ,2% 8,3% Unprotected GuardWire System FIRE Trial p=ns 2,6% 3,6% FilterWire EX System 0% 5% 10% GuardWire is a trademark of PercuSurge, Inc. Baim DS, et.al., Circulation. 2002;105:
11 SAFER: Primary Endpoint 30 Day Outcomes 42% relative reduction in MACE Baim DS, et al Circulation 2002;105:
12 DPD and SVG PCI: Long Term Outcomes Cathet Cardiovasc Interv 2015
13 Embolic protection devices during SVG stenting
14 Embolic Protection Devices available in the US for SVG interventions in 2017 Device Manufacturer Approval date Guardwire Medtronic 6/2001 Filterwire Boston Scientific 6/2003 Spider ev3 6/2006 Proxis St Jude 7/2007
15
16 Intragraft Vasodilators for SVG PCI Adenosine (24 mcg) Sdringola et al. Catheter Cardiovasc Interv 2000;51:394-9 Nitroprusside ( mcg) Zoghbi et al. J Invasive Cardiol 2009;21:34-9 Verapamil (200 mcg) Michaels et al. J Invasive Cardiol 2002;14: Nicardipine ( mcg) Fischell et al. J Invasive Cardiol 2007;19:58-62
17 Stent selection to prevent distal embolization
18 Μικρότερα Stent (match native vessel) για Μεγαλύτερα SVGs Μεγάλο stent σε μεγάλο μόσχευμα Μικρό stent σε μεγάλο μόσχευμα Αθηρωματικό υλικό προπίπτει μέσω του stent στον αυλό Το αθηρωματικό υλικό παραμένει πίσω από τα strut του stent
19 Επιλογή stent με λόγο διαμέτρου προς το μόσχευμα <0,7 μείωνει την πρόπτωση υλικού
20 Επιλογή μικρότερου stent παρά το malapposition έχει καλά αποτελέσματα
21 DES vs BMS for SVG PCI
22 N Comparison Allocation process F.U. (months) Protection Devices (%) DAPT duration (months) BMS DES BMS DES RRISC 75 BMS vs SES random SOS 80 BMS vs PES random BASKET LATE 47 BMS vs DES random 18 NA NA 6 6 Ge et al 150 BMS vs DES historical Hoffman et al 120 BMS vs PES historical Lee et al 223 BMS vs DES contemporary NA NA Chu et al 105 BMS vs SES historical >6 >6 Whorle et al 39 BMS vs PES historical Ellis et al 350 BMS vs SES historical NA NA Okabe et al 482 BMS vs DES contemporary Vignali et al 360 BMS vs DES contemporary 14 NA NA 1 6 Minutello et al 109 BMS vs SES historical Gioia et al 225 BMS vs DES contemporary Assali et al 111 BMS vs DES Historical >6 Applegate et al 148 BMS vs DES Propensity sco >3 Bansal et al 109 BMS vs DES Contemporary NA NA Ramana et al 311 BMS vs SES contemporary 34 NA NA 3 3 van Twisk et al 250 BMs vs DES contemporary >3 Total patients: 3294 Median Follow up: 18 months
23 Death
24 Death and MI
25 TVR
26 Native Vessel vs. SVG PCI in post CABG patients
27 Post CABG treatment J Am Coll Cardiol Intv 2016;9:884 93
28 Native vs. SVG PCI: Long term outcomes J Am Coll Cardiol Intv 2016;9:884 93
29 Retrograde CTO through SVG
30 ΕΥΧΑΡΙΣΤΩ ΠΟΛΥ
31 Lack of benefit from GP IIb/IIIa inhibitors in SVG PCI 605 pts: 389 treated with GP IIb/IIIa 116 control Roffi et al. Circulation 2002;106:3063-7
32 Outcomes of 1363 patients undergoing CTO PCI, classified according to whether they had undergone CABG
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