PCI for Left Anterior Descending Artery Ostial Stenosis

Transcription

1 PCI for Left Anterior Descending Artery Ostial Stenosis

2 Why do you hesitate PCI for LAD ostial stenosis?

3 LAD Ostial Lesion Limitations of PCI High elastic recoil Involvement of the distal left main coronary artery Concern for major side branch occlusion

4 Is it sate to stent in LAD ostium? Yes we believe it.

5 LAD Ostial Lesion Stenting.. Stenting with precise location may be a safe and feasible technique with an acceptable clinical outcome. Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

6 LAD Ostial Lesion Stenting.. Subjects : 111 patients, 111 Lesions Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

7 In-Hosptial Outcomes Procedure success Death Stent thrombosis NonQ-MI Emergency CABG 108 (97.5%) 0 (0%) 0 (0%) 4 (3.6%) 1 (0.9%) Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

8 QCA Data Ref. diameter(mm) Pre-MLD(mm) Post-MLD(mm) Acute gain(mm) Late loss(mm) 3.5 ± ± ± ± ± 1.0 Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

9 Angiographic Restenosis 26.1 % Involvement of LCX ostium (n=6, 5.4%) Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

10 Only Predictor for Restenosis Stenting at LAD Ostial Lesions Final MLD after Stenting Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

11 Long-term Outcome Cumulative Percentage Survival TLR free survival Follow-up duration (months) Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

12 Minimal Luminal Diameter mm Pre-PCI Post-PCI 6 months F/U LAD Ostium LCx Ostium Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

13 Patterns of Restenosis In-stent restenosis (n=18) Focal type(n=10) Diffuse type(n=8) Involvement of LCX ostium(n=6) Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

14 Which Stent is better? LAD Ostial Lesion High radial force Good visibility Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

15 Coil vs Tube Stent Restenosis Rate (%) *P< * 67 * Tube (PS) (n=22) Coil (Tantalum) (n=25) PTCA (n=31) Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

16 Is side branch occlusion disastrous as expected? Yes, but we have a tips.

17 LCX Occlusion during PCI LCX ostial compromise after stenting may be related with clinical recurrence. (20% of restenosis cases) However.. Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

18 Changes of LCX Ostial Diameter after Stenting LCX Ostial Diameter(mm) Baseline After Stenting Follow-up Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

19 Factors associated with the LCX ostial diameter change Variables Stent jail(>50%) LAD-LCX angle( 80 ) LCX ostial diameter Debulking procedure r value p value Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

20 Only Factors Associated with the LCX Ostial Diameter Change The presence of stent coverage of the LCX ostium>50% Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

21 For the Optimal Positioning of the Stents Superzooming technique(x 8) RAO caudal or LAD caudal view Stents with visible markers Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

22 Current Past Strategy recommended Strategy Precise placement Proximal strut of stent extended into the distal LM Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

23 Conclusions Stenting of ostial LAD stenosis may be a safe and feasible technique with an acceptable clinical outcome. Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

24 Can debulking be a useful adjunct to stenting?

25 LAD Ostial Lesion Debulking.. Aggressive debulking might reduce the residual plaque burden and subsequently the restenosis. However, it has limitation to prevent elastic recoil.

26 LAD Ostial Lesion Debulking and Stenting Synergistic effect may be expected to combine removal of plaque and inhibition of elastic recoil.

27 Debulking and Stenting Minimal lumen diameter mm Reference vessel : 3.2 ± 0.5 mm Pre Post Follow-up Bramucci E, et al, Am J Med. 90: , 2002

28 Debulking and Stenting Restenosis rate : 13.2% Bramucci E, et al, Am J Med. 90: , 2002

29 Randomized Comparison of Debulking Followed by Stenting Versus Stenting Alone for LAD Ostial Stenosis Seung-Jung Park, MD, PhD, FACC Cardiovascular Center, Asan Medical Center University of Ulsan, Seoul, Korea SJ Park, et al, J Am Coll Cardiol (In press)

30 Purpose Since March 2000 Prospective Randomized Comparison Study of DCA Followed by Stenting and Stenting Alone for LAD Ostial Stenosis SJ Park, et al, J Am Coll Cardiol (In press)

31 Inclusions Ostial stenosis : > 50% diameter Stenosis arising within 3 mm of the LAD orifice All patients were either symptomatic or ischemic by non-invasive testing De novo lesion SJ Park, et al, J Am Coll Cardiol (In press)

32 Procedures Various types of stents were used Prospective randomized trial Directional Coronary Atherectomy with Atherocath GTO system SJ Park, et al, J Am Coll Cardiol (In press)

33 Methods Angiographic Analysis IVUS Analysis SJ Park, et al, J Am Coll Cardiol (In press)

34 Follow-up Clinical follow-up was performed by making out patients clinic and telephone interview each 3 month and follow-up coronary angiography was taken at 6 months later. SJ Park, et al, J Am Coll Cardiol (In press)

35 Antithrombotic Regimen Aspirin 200 mg QD indefinitely, Ticlopidine 250 mg BID or Clopidogrel 75 mg QD for 1 month SJ Park, et al, J Am Coll Cardiol (In press)

36 LAD Ostial Stenting (n=86) DCA prior to Stent (n=44) Stent Alone (n=42) SJ Park, et al, J Am Coll Cardiol (In press)

37 Baseline Clinical Findings Age (years) D + S (n=44) 59 ± 7 S (n=42) 57 ± 9 P Men / women 36 / 8 33 / Unstable angina (%) 33 (75%) 28 (67%) LV EF (%) 65 ± 8 61 ± Multivessel ( 2) 5 (11%) 7 (17%) SJ Park, et al, J Am Coll Cardiol (In press)

38 Risk Factors Current smoker D + S (n=44) 18 (41%) S (n=42) 23 (55%) P Diabetes mellitus 7 (16%) 9 (21%) Hypercholesterolmia (> 200 mg/dl) Systemic HTN 12 (27%) 12 (27%) 14 (33%) 15 (36%) Previous MI 2 (5%) 2 (5%) SJ Park, et al, J Am Coll Cardiol (In press)

39 Angiographic Findings Type B2, C D + S (n=44) 23 (52%) S (n=42) 13 (31%) P Lesion length (mm) 11.9 ± ± Stent length (mm) 15.0 ± ± Ball to Art ratio 1.1 ± ± Max inf press (atm) 12.8 ± ± SJ Park, et al, J Am Coll Cardiol (In press)

40 Angiographic Findings Reference size (mm) D + S (n=44) 3.6 ± 0.5 S (n=42) 3.6 ± 0.6 P MLD (mm) Baseline 1.1 ± ± Final 4.0 ± ± 0.5 < Follow-up 2.3 ± ± SJ Park, et al, J Am Coll Cardiol (In press)

41 Diameter Stenosis (%) Baseline D + S (n=44) 68.6 ± 10.4 S (n=42) 71.9 ± 14.2 P Final ± ± 12.2 < Follow-up 37.3 ± ± SJ Park, et al, J Am Coll Cardiol (In press)

42 Role of Debulking Minimal lumen diameter mm 4 P<0.001 Debulking + Stent Stent only P= P= Pre Post Follow-up SJ Park, et al, J Am Coll Cardiol (In press)

43 Cumulative Percentage of patients (%) 100 Pre-intervention Follow-up Post-intervention Cumulative percentage of patients DCA and Stent Stent alone DCA and stenting Stenting alone Minimal Luminal Diameter (mm) Minimal lumninal diameter (mm) SJ Park, et al, J Am Coll Cardiol (In press)

44 Role of Debulking Change of lumen diameter mm 3 P=0.007 Debulking + Stent Stent only P= Acute gain Late loss SJ Park, et al, J Am Coll Cardiol (In press)

45 Role of Debulking Restenosis rate (%) P= / 32 (28%) 11 / 30 (37%) 0 Debulking + Stent Stent only SJ Park, et al, J Am Coll Cardiol (In press)

46 Conclusions Debulking procedure with stenting gained greater luminal area, but it did not lead to lower restenosis rate due to the tendency of higher late loss. SJ Park, et al, J Am Coll Cardiol (In press)

47 IVUS analysis Serial (pre-intervention, post-dca, post-intervention) IVUS evaluation : 67 (78%) patients SJ Park, et al, J Am Coll Cardiol (In press)

48 IVUS Findings Reference segment EEM CSA (mm 2 ) Pre-intervention Post-DCA Post-intervention Lumen CSA (mm 2 ) D + S (n=35) 15.0 ± ± ± 2.8 S (n=32) 14.9 ± ± 3.6 P Pre-intervention 9.5 ± ± Post-DCA 10.0 ± 2.4 Post-intervention 10.3 ± ± SJ Park, et al, J Am Coll Cardiol (In press)

49 IVUS Findings Lesion segment EEM CSA (mm 2 ) Pre-intervention Post-DCA Post-intervention Lumen CSA (mm 2 ) Pre-intervention Post-DCA Post-intervention D + S (n=35) 14.2 ± ± ± ± ± ± 1.5 S (n=32) 13.7 ± ± ± ± 2.4 P SJ Park, et al, J Am Coll Cardiol (In press)

50 Role of Debulking Reduction of plaque burden % 100 P=0.632 Debulking + Stent Stent only P= Preintervention Post-DCA Postintervention SJ Park, et al, J Am Coll Cardiol (In press)

51 Effect of Residual Plaque Restenosis rate % Debulking + Stent P=0.081 Stent only 13/41 (32%) /7 (0%) 8/20 (40%) 5/21 0/7 0/2 (24%) (0%) (0%) 40 > 40 Residual Plaque burden (%) SJ Park, et al, J Am Coll Cardiol (In press)

52 Role of Debulking Restenosis rate according to remodeling (%) 70 P= /6 (67%) P=0.929 Debulking + Stent Stent only /7 (0%) Positive remodeling 5/19 (26%) 4/16 (25%) Non-Positive remodeling SJ Park, et al, J Am Coll Cardiol (In press)

53 Suggestions The device limitation for substantial reduction of plaque burden might explain in part the lack of restenosis-reducing effect of DCA prior to stenting. More effective debulking with new debulking device might be needed to improve angiographic result. Debulking might be beneficial in lesions with positive remodeling. Park SJ, et al, Cathet Cardiovasc Intervent. 49: , 2000

54 Determinants of Angiographic Restenosis QCA and IVUS predictors associated with angiograhic restenosis SJ Park, et al, J Am Coll Cardiol (In press)

55 Angiographic Findings Restenosis (n=20) No restenosis (n=42) P Lesion length (mm) 11.6 ± ± Reference size (mm) 3.7 ± ± MLD (mm) Baseline 1.2 ± ± Final 3.5 ± ± SJ Park, et al, J Am Coll Cardiol (In press)

56 IVUS Findings Reference Segment EEM CSA (mm 2 ) Restenosis (n=20) No restenosis (n=42) P Pre-intervention 13.5 ± ± Post-intervention 13.9 ± ± Lumen CSA (mm 2 ) Pre-intervention 8.8 ± ± Post-intervention 9.2 ± ± SJ Park, et al, J Am Coll Cardiol (In press)

57 IVUS Findings Lesion Segment EEM CSA (mm 2 ) Restenosis (n=20) No restenosis (n=42) P Pre-intervention 12.8 ± ± Post-intervention 17.1 ± ± Lumen CSA (mm 2 ) Pre-intervention 1.9 ± ± Post-intervention 8.4 ± ± SJ Park, et al, J Am Coll Cardiol (In press)

58 Association with Plaque Burden and Restenosis (%)100 P=0.061 Restenosis No restenosis P= Pre-intervention Post-intervention SJ Park, et al, J Am Coll Cardiol (In press)

59 Predictor of Restenosis -Multivariate Analysis- Stent CSA after procedure Odds ratio ; % CI ; P = SJ Park, et al, J Am Coll Cardiol (In press)

60 Stent CSA after Procedure Restenosis rate (%) /18 (44%) P= < 9 > 9 Cross sectional area 5/30 (17%) (mm 2 ) SJ Park, et al, J Am Coll Cardiol (In press)

61 Clinical Follow-up (n=86) Mean Duration : months TLR 10 (12%) DCA + Stenting 5 (11%) Stenting alone 5 (12%) Death 0 Q MI 0 SJ Park, et al, J Am Coll Cardiol (In press)

62 Conclusions We consistently suggest that the final stent area is the most important determinant for prediction of restenosis. The final stent area 9 mm 2 might be a good guideline of optimal PCI for LAD ostial stenosis. SJ Park, et al, J Am Coll Cardiol (In press)

63 Two Representatives of Future Revascularization Surgeon s View : I like MIDCAB. Interventionist s View : I believe DES.

64 % MIDCAB vs. Stent 6 months follow-up MIDCAB (n=108) P= Stent (n=108) P= P= Death 2 3 P=0.68 AMI 5 8 TLR 15 Combined Diegeler A, et al, N Engl J Med 2002;347:561

65 MIDCAB vs. Stent 200 days FU of death, MI, stroke, and TLR Event free survival (%) P=0.21 MIDCAB Stent days Drenth DJ, et al, J Thorac Cardiovasc Surg 2002;124:130

66 Sirolimus Eluting Stent SIRIUS Late loss (mm) In-stent In-segment Restenosis (%) In-stent In-segment TLR (%) MACE (%) Sirolimus (n=234) Control (n=228) P value <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 TCT, Oct 2002

67 SIRIUS - TLR Events Sirolimus Control P-value # events prevented per 1,000 patients Overall Male Female Diabetes No Diabetes LAD Non-LAD Small Vessel (<2.75) Large Vessel Short Lesion Long Lesion (>13.5) Overlap No Overlap Hazards Ratio 95% CI Sirolimus better

68 In the Future. LAD Ostial Lesion Randomized comparison studies about the efficacy of DES, debulking, and MIDCAB are being expected.