Αγγειοπλαστική σε Nόσο Στελέχους: Που βρισκόμαστε. Βάιος Τζίφος Δ/ντής Τμήματος Επεμβατικής Καρδιολογίας Τομέας Καρδιάς Ερρίκος Ντυνάν Hospital Center

Transcription

1 Αγγειοπλαστική σε Nόσο Στελέχους: Που βρισκόμαστε. Βάιος Τζίφος Δ/ντής Τμήματος Επεμβατικής Καρδιολογίας Τομέας Καρδιάς Ερρίκος Ντυνάν Hospital Center

2 Δεν έχω οικονομική σχέση με φαρμακευτική εταιρία.

3 2014 ESC/EACTS Guidelines on Myocardial Revascularization

4 2014 ACC/AHA SIHD Guidelines: ULMCA Revascularization for Survival

5 PCI CABG 5 YEAR FU of the SYNTAX trial (LM SUBGROUP)

6 PCI CABG 5 YEAR FU of the SYNTAX trial (LM SUBGROUP)

7 PCI CABG 5 YEAR FU of the SYNTAX trial (LM SUBGROUP)

8 PCI CABG 5 YEAR FU of the SYNTAX trial (LM 3VD SUBGROUP)

9 Rate of Repeat Revascularization to 5 years

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15 Incomplete Revascularization after LM PCI is Associated with Worse Cardiac Survival Italian CUSTOMIZE Registry of 400 pts undergoing LM PCI Residual SYNTAX score 0> is a marker of Incomplete Revascularization Capodano et al. Cardiovascular Interventions 2012

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17 Valentini et al, JACC 2012;14:

18 Use of IVUS during LM Stenting is Associated with Trend Towards Decrease Mortality

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20 According to Dr. Park and colleagues, possible explanations for the PCI trends are: Introduction of DES Development and widespread use of secondgeneration DES Progressive increase in the use of IVUS during PCI Simplification of stenting techniques Optimization of antiplatelet and adjuvant pharmacological treatment The lack of decline in clinical events in the CABG group is harder to explain. Therefore, these findings should be considered as hypothesis generating and should be confirmed in a large randomized controlled study

21 5-Year Outcomes of the PRECOMBAT Study Stenting Versus CABG for Left Main Stenosis: Kaplan-Meier Cumulative Event Curves of the Primary Endpoint and the Major Secondary Endpoint at the 5-Year Follow-Up The cumulative incidence of major adverse cardiac or cerebrovascular events (the composite of death from any cause, myocardial infarction, stroke, or ischemia-driven target vessel revascularization). J Am Coll Cardiol. 65;20:2198, May 2015

22 5-Year Outcomes of the PRECOMBAT Study Stenting Versus CABG for Left Main Stenosis: Kaplan-Meier Cumulative Event Curves of the Primary Endpoint and the Major Secondary Endpoint at the 5-Year Follow-Up The composite of death of any cause, myocardial infarction, or stroke. CABG = coronary artery bypass graft; PCI = percutaneous coronary intervention J Am Coll Cardiol. 65;20:2198, May 2015

23 The Button Bentall Procedure

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28 The Cabrol Procedure

29 Male 62 yo HTN Smoker Dyslipidemic UA Cabrol > 10Years RCA=100% EF = 35%

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32 43 y.o. male Heavy smoker Dyslipidemic Positive family history for CAD Presented with unstable angina # Case 3

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37 Planed Procedure: Complete revascularization with staged procedure. For the Left System double mini crash technique with 6F EBU 3.5 guiding catheter. 3 Asahi soft wires (LAD, OM1-2), Balloon 2.5/14mm in OM1

38 Post Balloon OM1 dissection OM1 stenting (Cypher Select Plus 2.5/13mm).

39 OM2 stenting (Cypher Select Plus 3.0/18mm). Post stenting result in OM1 OM2

40 Ostial LAD and distal LM stenting (Cypher Select Plus 3.5/18mm). Post stenting result in LAD and distal LM

41 Mid - Ostial LM stenting (Cypher Select Plus 3.5/13mm). Post stenting result

42 Final kissing balloon OM1-OM2 Mercury 2.5/14mm + 2.5/20mm Final kissing balloon Cx - LAD Mercury 2.5/14mm + Sprinter 3.5/15mm

43 Perfect overlap between the 2 stents in the mid portion of the LM trunk

44 IVUS POST

45 LM post dilatation (Sprinter 4.0/20mm, 24Atm) Final Result

46 Final Result

47 Next day LM stent dislocation Gap Between the 2 stents

48 LM stent dislocation and migration at the ostium and the aorta

49 The dislodged stent is crossed with wire and balloon (Sprinter 2.5/15mm)

50 The dislodged stent is trapped between the balloon and the tip of the guiding catheter Retrieval of the hole system

51 New stent implantation at the LM (Endeavor 4.0/18mm 24Atm) Stent post dilatation (Maverick 4.5/15mm 28Atm)

52 Final Result

53 RCA - Final Result

54 8 -Years FU

55 8 -Years FU

56 Conclusion LM PCI is not a taboo and has a Class 1 indication in the European Guidelines. Multivessel disease and CTOs are the limiting factors and not LM it self. Location of LM lesion is not a problem anymore. Contemporary and future trials will challenge surgery as the default strategy.

57 Ευχαριστώ πολύ για την προσοχή σας