VsevolodM ironovm D,P hd. R ussiancardiology R esearchcenter

Transcription

1 VsevolodM ironovm D,P hd R ussiancardiology R esearchcenter

2 R ationaleforadjuvanttechniques AftertheS YN T AX study,tw odifferentissuesininterventional cardiology havebeenm adeclear: Incom plex angiographicsituations w em ustbevery careful( Heartteam approach ) butw ecanm asterthem T hiscould beoneofthereasonsw hy interventionalists arepushinghardertothelim itsincom plex cases Increasedriskofcom plications 2

3 R ationaleforadjuvanttechniques Com plex coronary anatom y: - L ongand calcified lesions - S everetortuosity - Anglesm orethan90 - N oguidecathetersupport(duetocom plicatedostium engagem entorproblem sofaccesssite) - CT O s Increasedriskofcom plications 3

4 R ationaleforadjuvanttechniquesinr ussia - N ew P CIcenters(w ideningofthenet) - N um berofp CIsincreasing(~ ayear) - M orecom plex procedures - M ore difficult patients(age,frailty,com orbidities,cabg in m ed history) Increasedriskofcom plications 4

5 R ationaleforadjuvanttechniques W eneedsupport,tofinishtheprocedure 5

6 W hatcanw edotoincreasesupportincases w ithcom plex anatom y? - L ongsheathsand sheathlessguides - Extrasupportguidingcatheters - Extrasupportcoronary w ires - Buddy w iretechnique - Anchoringtechnique - M otherand child catheters - Etc oralofthem S ofthydrophilicw iredeep T echnique - Deepw irepenetration 6

7 W hatcanw edotoincreasesupportincases w ithcom plex anatom y? S ofthydrophilicw iredeep T echnique ordeep w irepenetration 4 m ainquestions: 1.W hy? 2.W hat? 3.How? 4.W hen? 7

8 W hy? - Easy touse - N oneedfor additionaldevices - Canbeperform ed ad hoc - R eproducible - Greatsupport 8

9 T elescopicdevices Guidezilla -5Fguideextensioncatheteris intended tobeused inconjunctionw ith guidecatheterstoaccessdiscreteregions ofthecoronary and/orperipheralvasculature, and tofacilitateplacem entofinterventional devices.l ength 25 cm

10 T elescopicdevices P ros& Cons P ros: Cons: - Greatsupport - R iskofdissections - S am eguidew ire - Failtocross - Fast - Can tbeused invessels< - R eproducible - Canbeused inacs 2, 5m m - M ustbeperform ed by experienced operator - P rice - N ochancetousebvs

11 W hat? - Allsofthydrophilic w irescanbeused - Inselectivecasesnon hydrophilicw irescan beused asw ell - Canbeused in com binationw ith otherdevices 11

12 How? T ip: T ipofthew ire W iregoesthroughvessel-vessel orvessel-cavity anastom osisin diastole How topenetrate:fastrotation w ithsm allpurposivem ovem ent N B!Don tpushthew ire high riskofperforation! 12

13 How? Глубо ко е п ро в ед ение ко ро нарно го п ро в од ника

14 W hen? - Guidingcatheteris unstableintheostium - Balloonorstentfailto cross - Especially incasesof coronary dissections afterdilatation,w henits im possibletofind true lum enw iththebuddy w ire 14

15 W hen? P ros& Cons P ros: Cons: - Bestsupport - Can tbeperform ed inacs - S am eguidew ire - Arrhythm ias - Fast - M ustbeperform ed by - S afe experienced operator - R eproducible - S tillcanusetelescopic devicesorothertechnics forsubstantialsupport - P rice 15

16 Aim ofthestudy T o evaluate efficacy and safety ofdifferent adjuvant techniques (such asdeep w ire penetration,telescopic devices,rotational atherectom y)inpatientsw ithcom plex coronary anatom y.and to stratify the decision m aking processin patientsw ith tortuous, calcified and longlesions 16

17 Inclusioncriteria 1. L ong lesions>70% (m ore than 20 m m ),severe tortuosity, calcified plaquesorproxim alca++ in distally diseased artery, CT O 2. P atientsw ith angina or silent ischem ia and docum ented ischem ia 3. P atientsw hoareeligibleforcoronary stenting 4. And w hen CABG isnot an option (High risk patientsw ith com orbiditiesorpatientsaftercabg,w hen re-cabg can tbe done) 17

18 Exclusioncriteria 1. History ofbleedingdiathesisorcoagulopathy 2. S T -elevationacutem yocardialinfarctionrequiringprim ary stenting(incaseofdeepw irepenetration) 3. Contraindicationtoaspirin,clopidogrelorothercom m ercial antiplateletagent 4. R eferencevesselsizelessthan2.5 m m by visualestim ation (incaseoftelescopicdevices) 5. N on-cardiacco-m orbid conditionsarepresentw ithlim ited lifeexpectancy orthatm ay resultinprotocolnon-com pliance 18

19 Angiographiccharacteristics LM L AD/DB L CX /M B R CA CT O P riorcabg S YN T AX score M ultipletechniques used inonecase Deepw ire penetration (n=388) , 1 T elescopic devices (n=51) , 4 R otational atherectom y (n=53) ,

20 P roceduresuccessincom plex coronary anatom y P roceduresuccess(incl.ct O s) InCT O s W ith Conventional adjuvant P CI(2010techniques 2013) (after2014) 85 % 97% 74 % 86, 7% M eancontrastm ediavolum e 210±140 m l 120±90 m l Fluoroscopy tim e 35±21 m in 20±18m in N um berofw iresused 3, 2 1, 8

21 Com plications P CI(n=461) W ireperforation 3 (0, 7% ) Cardiactam ponade 0 Collateralinjury 3 (0, 7% ) In-hospitaldeath 0 In-hospitalM I 2 (0, 4% ) S ignificantrestenosisafterrotablation@ 1y fu (n=53) 1 (1, 8% )

22 461 Patients with complex coronary anatomy ( total n=2100 PCIs in ) A nte-, retrograd e C TO rec analization N o C TO B alloon d ilatation Balloonfailedtopass Deepw irepenetration (n=388) Balloonfailedtodilate T elescopicdevices (n=51) R otational atherectom y (n=53) S tentpositioning attem pt T elescopicdevices (ifpossible) P roceduralsuccess Deepw irepenetration 22

23 70 yofem alepatient, S tableangina3-4 class,l onghistory ofhypertension, BP upto200/120 m m Hg L ongand tortuouslesionsinr CA and L Cx

24 R esult

25 Deepw irepenetration

26 R esult

27 67 yofem alepatient, S tableanginaclass3, L onghistory ofhypertension L Cx CT O

28 Deepw irepenetration

29 Deepw irepenetration

30 R esult

31 T akehom em essage Inpatientsw ithlongand calcified lesionsw henballoonfailsto crossor dilate use of rotational atherectom y issafe and associated w ith higherproceduralsuccessrate,the restenosis rateat1y fu islow U se of deep w ire penetration technique and telescopic devicesissafe and allow sto im prove support during balloon orstentdeliveringand positioning Adjuvant techniquesim prove successrate ofp CIsin com plex coronary anatom y cases,at the sam e tim e reducing the fluorotim eand contrastm ediavolum e