Sunao Nakamura M.D,Ph.D.

Transcription

1 Drug Eluting Stent Implantation For Unprotected Left ain Coronary Arteries New Tokyo Circulation Research Group New Tokyo Hospital Sunao Nakamura.D,Ph.D.

2 Drug-Eluting Stent for Left ain Coronary Artery 1. Park SJ, Kim YH, Lee BK, et al. Sirolimus-eluting stent implantation for unprotected left main coronary artery stenosis. Comparison with bare metal stent implantation. J Am Coll Cardiol 25;45: Jose Suarez de Lezo, Alfonso edina, anuel Pan, et al. Rapamycin-eluting stents for the treatment of unprotected left main coronary disease. Am Heart 24;148: arco Valgimigli, Carlos A.G. van ieghem, Andrew T.L. Ong, et al. Short- and Long-Term Clinical Outcome After Drug-Eluting Stent Implantation for the Percutaneous Treatment of Left ain Coronary Artery Disease. Circulation. 25;111: Alaide Chieffo, Goran Stankovic, Erminio Bonizzoni, et al. Early and id-term Results of Drug-Eluting Stent Implantation in Unprotected Left ain. Circulation 25;111: arco Valgimigli, Patrizia alagutti, Jiro Aoki, et al. Sirolimus-Eluting Versus Paclitaxel-Eluting Stent Implantation for the Percutaneous Treatment of Left ain Coronary Artery Disease. J Am Coll Cardiol 26;47: atthew J. Price, Ecaterina Cristea, Neil Sawhney, et al. Serial Angiographic Follow-up of Sirolimus-Eluting Stents for Unprotected Left ain Coronary Artery Revascularization. J Am Coll Cardiol 26;47:871-7

3 Drug-Eluting Stent for Left ain Coronary Artery 1. S Nakamura, et al. Initial clinical experience of Sirolimus-eluting stent for treatment of left main coronary artery disease. JSC S Nakamura, et al. Durable clinical benefit following Sirolimus-eluting stent deployment on the outcome of patients with unprotected left main coronary arteries. TCT 24, ACC S Nakamura, et al. Comparison of efficacy and safety between Sirolimus-eluting stent and Paclitaxel-eluting stent in unprotected left main coronary. ACC 25, ESC 25

4 -ulticenter Registry in Asia- New Tokyo Hospital Damansara Heart Center Konyang University Hospital Husada Hospital Chest Disease Institute Siriaj Hospital Saint Louis Hospital King Chulalongkorn emorial Hospital Far Eastern Hospital Sunao Nakamura.D., Ph.D. (Japan) Tamil Selvan uthusamy.d. (alaysia) Jang-Ho Bae.D. (Korea) Yeo Hans Cahyadi.D. (Indonesia) Sudaratana Transapasawasdikul.D.(Thailand) Damras Tresukosol.D. (Thailand) Boonsert Chatlaong.D. (Thailand) Wasan Udayachalerm.D. (Thailand) Chao Loun Lai.D. (Taiwan)

5 Study Patients : LT Patients n=89 : Asian ulticenter LT Registry Patients n=118 Patients n=211 Cypher: Asian ulticenter LT Registry Patients n=193 Patients n=288 > 3 years > 2 years > 2 years > 1 year > 1 year ar Feb Feb Feb Feb BS: Japanese ulticenter Registry Patients n=88 > 3 years Patients n=12 > 2 years

6 Can We Improve Clinical Outcome of LT PCI? In hospital outcome Can reduce restenosis? Long term durability? Cypher and registry Other DES?

7 In-Hospital Outcome Cypher vs 2years BS (n=12) Cypher (n=193) (n=118) p Angiographic success (%) NS Clinical success (%) NS ACE (n) Death QI Urgent CABG Urgent PCI inor complication (%) Vascular hematoma (SAT) (SAT) No SAT NS NS NS NS NS

8 3 DAYS: ACE DES in LT (%) NO SAT Park Valgimigli Chieffo Price Nakamura

9 Can We Improve Clinical Outcome of LT PCI? In hospital outcome Can reduce restenosis? Long term durability? Cypher and registry Other DES?

10 Can We Improve Clinical Outcome of LT PCI? In hospital outcome Can reduce restenosis? Long term durability? Cypher and registry Other DES?

11 Restenosis Rate DES in LT (%) Park Valgimigli Chieffo Price Nakamura

12 Angiographic Follow-Up Cypher vs 2years BS 12 mo (n=12) BS 24 mo (n=12) Cypher 12 mo (n=193) Cypher 24 mo (n=193) 12 mo (n=118) 24 mo (n=118) p Clinical f/u (n) 12/12 12/12 193/ / / /118 NS Angiographic f/u (n) 1/12 94/12 17/ /193 11/118 82/118 NS Ref. diameter (mm:mean) NS LD (mm:mean) Late loss (mm:mean) Loss index (%:mean) Restenosis rate (%) TLR (%)

13 Restenosis Patients!! (%) 15 1 BS Cypher Ostium id shaft

14 TLR Patients: 4.7% Cypher Age Gender Lesion location Stenting strategy Location of restenosis No.1 78 F Stenting across LCX No.2 54 Culotte No.3 69 Culotte No.4 77 Culotte No.5 68 Culotte No.6 77 odified T No.7 82 Crushing Distal stent edge No.8 62 Crushing LAD ostium No.9 65 F Crushing

15 TLR Patients: 7.6% Age Gender Lesion location Stenting strategy Stent Location of restenosis Timing of restenosis No.1 69 Culotte 6 mo No.2 77 Culotte 6 mo No.3 7 Culotte LAD ostium 4 mo No.4 73 Crush 7 mo No.5 73 Crush 6 mo No.6 78 F Stenting across LCX 6 mo No.7 82 Kissing stent Distal stent edge 4 mo No.8 68 Culotte 6 mo No.9 54 Stenting across LCX LT - LAD diffuse 5 mo

16 Can We Perform LT PCI in ALL Cases? Severely calcified cases lesion CTO ISR Low EF: Improve LV contraction?

17 Stenting Procedure of bifurcation lesion in LT Park Single Kissing Crush Others Valgimigli Single Crush Kissing T-stent Culotte Chieffo Single Crush T-stent Culotte V-stent Price Single Kissing Crush Others Nakamura Single Crush T-stent Culotte 5 1 (%)

18 Case 7 :LT bifurcation lesion Cypher Pre LT bifurcation lesion Culotte stenting Post LT1 Distal LCX ostial ISR Restenosis LCX ost. Follow-up

19 If we really want double stenting. ini-crushing Stenting Technique (1) 1st step ain Artery Side branch Double wiring to the both branch and kissing ballooning 2nd step Advance the two stents in the bifurcation lesion simultaneously and dilated of stent in side branch only

20 ini-crushing Stenting Technique (2) 3rd step Remove the stent balloon and wire from the side branch and Deploy the stent in the main vessels 4th step Recross the wire through the stent strut in the main vessel to the side branch 5th step Kissing ballooning to the both vessels

21 Follow-Up Results 12mo Single stenting Culotte stenting n=79 n=46 Cypher odified T-stenting Crushing stenting n=42 n=24 Angiographic follow-up (%) Angiographic restenosis (n) Both LT - LAD LT - LCX In-hospital ACE 12-month total ACE (n) Death I CABG TLR

22 Can We Improve Clinical Outcome of LT PCI? In hospital outcome Can reduce restenosis? Long term durability? Cypher and registry Other DES?

23 Can We Perform LT PCI in ALL Cases? Severely calcified cases lesion CTO ISR Low EF: Improve LV contraction?

24 Can We Perform LT PCI in ALL Cases? Severely calcified cases lesion CTO ISR Low EF: Improve LV contraction?

25 Can We Perform LT PCI in ALL Cases? Severely calcified cases lesion CTO ISR Low EF: Improve LV contraction? Low EF: Improve LV contraction?

26 Conclusions 1. Treatment of unprotected left main trunk coronary artery disease with Cypher Sirolimus-eluting stent and Paclitaxel-eluting stent are safe and feasible. 2. Implantation of Cypher Sirolimus-eluting stent and Paclitaxel-eluting stent result in a larger LD at follow-up and dramatically decrease the restenosis rate and target lesion revascularization compared with implantation of bare metal stent. 3. Implantation of Cypher Sirolimus-eluting stent and Paclitaxel-eluting stent with modified T-stenting with mini-crush stenting technique and single stenting technique seems to be able to decrease the restenosis rare at follow-up compared with other stenting techniques. 4. These clinical benefits with Cypher Sirolimus-eluting stent and Paclitaxel-eluting stent are durable at least 2 years.