Ziyad Ghazzal MD, FACC, FSCAI Professor of Medicine Deputy Vice President/Dean Associate Dean for Clinical Affairs American University of Beirut

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1 Ziyad Ghazzal MD, FACC, FSCAI Professor of Medicine Deputy Vice President/Dean Associate Dean for Clinical Affairs American University of Beirut Adjunct Professor Emory University School of Medicine

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3 Indication for revascularization Medical Rx vs. PCI vs. CABG Risks vs. benefits of PCI Truly informed consent Pre procedural planning Intra procedural approach Post procedure care

4 Chest discomfort related to ischemic myocardium? Symptoms Unstable? Myocardium at risk? Lesion Chronicity? Cost/benefit ratio

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7 PCI related lesion complications PCI related patient complications Stent thrombosis Restenosis

8 Cardiologists' beliefs about PCI reflect trial results, but patients' beliefs do not Almost three quarters of patients thought that without PCI, they would probably have MI within 5 years, and 88% believed that PCI would reduce risk for MI.

9 Clinical scores, Angiographic scores

10 Anatomic and clinical scoring tools

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13 Aorto ostial Bifurcating ostial Large branching vessel Tortuous segments Calcified segments Large thrombus burden Diffuse disease, heavily calcified Small vessels, diffuse disease Degenerated vein graft Chronic total occlusion In-stent restenosis AMI Multivessel lesions Bifurcating lesions Large myocardium at risk Tortuous and heavily calcified Left main disease

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15 Rates of Major Adverse Cardiac or Cerebrovascular Events among the Study Patients, According to Treatment Group and SYNTAX Score Category. Serruys PW et al. N Engl J Med 2009;360:

16 Diabetes Renal insufficiency Dialysis Anemia Peripheral vascular disease Severe cardiomyopathy Congestive heart failure Hypotension Infection Increased bleeding risk

17 Farooq V, et al. Heart 2013;0:1 12. doi: /heartjnl- 2013

18 SYNTAX score II Farooq V. et. al. Lancet 2013 Feb 23;381(9867):639 EIGHT PREDICTORS: i. Anatomical SYNTAX score ii. -Potential Age improvement in sxs iii. iv. When we study revascularization options, we weigh: -In-hospital procedural/surgical risks -Quality Creatinine clearance of life and clinical status -Long term risks & benefits Left ventricular EF v. Unprotected left main vi. vii. viii. Peripheral vascular disease Female sex COPD

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21 improved patient satisfaction, quicker, less anxiety, shorter hospital stay reduced use of resources, possibly lower cost simpler access site management concern regarding adequately blocking platelet adhesion with clopidogrel without pretreatment is now obviated by the availability of newer oral anti-platelets with faster onset

22 difficulties with informed consent for complex interventions involving alternative therapies limited relationship between operator and patient rapid decision-making under time pressure procedure room availability, length working day total physician and hospital reimbursement for Medicare patients is less for the diagnostic procedures when performed on the same day as the intervention (costs may be higher and reimbursement lower)

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24 J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L. 3, N O. 1 0,

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27 One or two stents?

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29 Randomized Trial of Simple Versus Complex Drug-Eluting Stenting for Bifurcation Lesions CIRCULATION 2010;121:1235

30 simple strategy main vessel stented, followed by optional kissing balloon dilatation/t-stent complex strategy both vessels systematically stented (culotte or crush techniques) with mandatory kissing balloon dilatation

31 simple strategy Primary end point=8.0% MI=3.6% In hospital MACE=2% complex strategy Primary end point=15.2% MI=11.2% In hospital MACE=8%

32 systematic 2-stent technique results in longer procedures, higher x-ray doses, more procedural complications higher rate of in-hospital and 9-month MACE there may be subtypes of coronary bifurcation that nonetheless merit a systematic 2-stent strategy

33 If the side branch is > 2.5 mm and has a significant ostial lesion, use double wire technique

34 A perfect result should always be obtained in the main vessel even if it is at the expense of an average result in the smaller side branch If a significant side branch is lost, consider stenting and final kissing balloon with more emphasis on the final result in the main branch

35 If the side branch is small (<2mm and supplies a small territory) do not try to save it at the expense of the main branch

36 If the two branches are large and tight, consider starting with a two-stent strategy

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38 836 CTOs in stable angina 582 (69.6%) procedures were successful. Stents were implanted in 97.0% of successful procedures (mean: 2.3 ± 0.1 stents per patient, 73% drug-eluting) All-cause mortality was 17.2% for ucto and 4.5% for scto at 5 years (p < ). The need for CABG was reduced following scto (3.1% vs. 22.1%; p < ). Multivariate analysis demonstrated that procedural success was independently predictive of mortality

39 1,791 patients who underwent PCI of 1,852 CTO at 3 centers in the United States, South Korea, and Italy between 1998 and 2007 Median follow-up was 2.9 years Procedural success in 1,226 (68%) patients 66% received drug-eluting stents Successful CTO PCI was an independent predictor of a lower cardiac mortality and reduced need for CABG

40 Higher success Short occlusion Tapered tip No side branch at entry point No evidence of calcification on fluoroscopy Short chronicity Lower success Long occlusion Blunt tip Calcified vessel Branch at entry Entry point at ostium Long chronicity Risks of CTO Procedural complications Radiation exposure Contrast volume Renal function

41 CrossBoss Stingray TORNUS GuideLiner CORSAIR FINECROSS PROGREAT

42 Avoid ad hoc PCI Consider new imaging techniques (3D cine angio or CT angio) Implement thorough pre procedure planning Provide full explanation of risks and benefits Refer complex CTOs to high volume CTO operators

43 Experienced staff Pre procedure planning Detailed inventory Seek help when needed

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