angioplastía del tci: el papel de la imagen intracoronariaangioplastía del tci: el papel de la...
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Angioplastía del TCI: El Papel de la Imagen Intracoronaria
Mauricio G. Cohen, MD, FACC
Associate Professor of Medicine,
Director Cardiac Cath Lab
@DrMauricioCohen
#RadialFirst
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Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or
affiliation with the organization(s) listed below.
Affiliation/Financial Relationship Company
Grant/Research Support
Consulting Fees/Honoraria Abiomed / Terumo Medical / Medtronic /
Merit Medical / The Medicines Company
Major Stock Shareholder/Equity Accumed
Royalty Income None
Ownership/Founder None
Intellectual Property Rights None
Other Financial Benefit None
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Circ Cardiovasc Interv. 2016;9:e003700
Major Adverse Cardiac Events
7 RCTs
3192 patients
IVUS associated with larger post-PCI MLD,
and greater reduction in the diameter stenosis
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Circ Cardiovasc Interv. 2016;9:e003700
Cardiovascular Mortality
Myocardial Infarction
TLR
Stent Thrombosis 0.49 (0.24–0.99) 0.04
0.60 (0.43–0.84) 0.003
0.52 (0.26–1.02) 0.06
0.46 (0.21–1.00) 0.05
OR (95% CI) p value
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ADAPT DES: How IVUS changed the procedure?
38
23 22
13
7 8
0
10
20
30
40
50
Larger stentor balloon
Higherinflationpressure
Longer stent Incompleteexpansion
Incompleteapposition
Additionalstent
Pati
en
ts, %
Post Dilation
Operator changed the PCI strategy in 74% (2484/3349) of patients
IVUS used:
• before PCI only 7%
• after PCI only 30%
• before and after PCI 63%
Witzenbichler B et al.
Circulation 2014;129:463-470
“All-comers” study of 8,583 patients to determine the frequency,
timing, and correlates of stent thrombosis and adverse clinical
events after DES. IVUS utilized in 3349 patients (39%)
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Definite/P
robable
ST
(%
)
Time in Months
3361 3260 3182 3065 1791
5221 5019 4886 4713 2279
Number at risk:
IVUS Used
IVUS Not Used
P = 0.004
HR: 0.47 [95% CI: 0.28, 0.80]
0.55%
1.16%
0
1
2
0 6 12 18 24
IVUS Used
No IVUS Used
Witzenbichler B et al. Circulation. 2014;129:463-470
Relationship Between IVUS Use and Definite/Probable Stent
Thrombosis Within 2 Years
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Case Presentation
• 74 yo woman, DM, HTN, DLP, CKD III, Obesity (BMI 44)
2008: BKA of the left / right iliac stent
2015: Lateral wall MI – PCI of LCx
• Current presentation: NSTEMI
• Diffuse 2 mm down sloping ST segment depression
• Troponin 0.3, GFR 33 (Cr 1.44), Hb 12.5, Plts 144
• Small R radial artery, 2.5-3 mm L radial artery
• STS PROM 4.042%
• CT surgery said NO
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Diagnostic
Cath
Syntax Score 29
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Left Main Disease – Rules
• Heart Team discussion - Guidelines
• Stenting strategy
Location: ostium, shaft and/or bifurcation
Understanding of bifurcation stenting techniques
• Imaging is critical: IVUS or OCT
• Focus on access safety
Transradial access with slender 7-in-6
Transfemoral for support
• Pelvis CT to assess iliofemoral vessel size
• Ultrasound guided access with micropuncture
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Recommendations for LM Revascularization
Levine G, et al. J Am Coll Cardiol. 2011;58:44-122
Windecker S, et al. Eur Heart J. 2014;35:2541-619
United States Europe
PCI CABGLow
SxScore 0-22 IIa B I B
Intermediate
SxScore 23-32 IIb B I B
High
SxScore >32 III B I B
PCI CABGLow
SxScore 0-22 I B I B
Intermediate
SxScore 23-32 IIa B I B
High
SxScore >32 III B I B
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8,1
10,8
15
8,3
12,7 12,4
0
2
4
6
8
10
12
14
16
SS 0-22 SS 23-32 SS >33
PCI CABG
Head SJ et al. Lancet 2018; 391: 939–48
Left Main Disease
All Cause Mortality11 Trials 1·02 (0·77–1·34)
P= 0·91
1·20 (0·94–1·51)
P= 0·14
1·52 (1·15–2·02)
P=0·0029
Mortality According to
Syntax Score
Pinteraction
0·21
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Relative Risk Reduction with PCI
vs. CABG in the EXCEL TrialProcedure
Early Peri-procedure
Stone GW et al. N Engl J Med 2016;375:2223-2235
-50%
-38%
-58%
-75%
-86% -87%-100%
-90%
-80%
-70%
-60%
-50%
-40%
-30%
-20%
-10%
0%
Str
oke
MI
Ble
ed
ing
Rena
l fa
ilure
Pro
lon
ged
intu
bation
Arr
hyth
mia
s
**
*
*
**
*P<0.05
Short Term Outcomes
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Pre-stent deployment assessment of lesion
characteristics, calcification, and size for LM
Disease feature Studied cutoff
Plaque characterization Thin cap fibroadenoma, fibrotic,
lipid-rich, or calcified
Minimal luminal area (MLA) < 6 mm2
Lesion calcification requiring
atherectomy
> 270°
Landing zone evaluation Ideally, < 50% stenosis and without
lipid-rich plaque.
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IVUS to Guide the LM Intervention
de la Torre Hernandez J et al. JACC CV Int 2014;7:244–54
Pooled analysis of 4 registries in Spain – 2 propensity-matched
groups of 1010 pts (505 x 2) with and without IVUS
IVUS No IVUS P
Overall, n 505 505
MACE (Death, MI, TLR) 14.4 22.2 0.006
- Death 7.4 13.0 0.01
- Cardiac 3.3 6.0 0.07
- MI 4.5 6.5 0.4
- TLR 7.7 6.3 0.7
Stent thrombosis (def/prob) 0.6 2.2 0.04
Subgroup with distal lsns, n 221 226
Cardiac death, MI, TLR 11.0 19.0 0.03
Distal lsns + 2 stents, n 63 62
Cardiac death, MI, TLR 16.7 41.0 0.02
MACEAdj HR (95%CI) =
0.70 (0.52–0.99)
P = 0.04
Days
Surv
ival (%
)
IVUS
No IVUS
100
90
80
70
60
0 200 400 600 800 1000 1200
Slide Courtesy: Gregg Stone
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EXCEL Trial: IVUS-Guided PCI
in 690/935 pts (74%)
Pre and Post-Stenting
Post-Stenting Only
Pre-Stenting Only
43.2%
39.1%
16.4%
Maehara A. TCT 2016
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EXCEL: Change in LM stenting by IVUS
YESNO
51.7%
N=357
48.3%
N=333
• Used larger balloon: 30% (107)
• Post-dilated: 29% (102)
• Used higher pressure: 17% (62)
• Treated stent under-expansion: 16% (57)
• Led to provisional 1 stent strategy rather
than planned 2 stents: 11% (41)
• Led to planned 2 stent strategy rather
than provisional 1 stent: 9% (33)
Maehara A. TCT 2016
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*IDR: ischemia driven revascularization
IVUS MSA tertiles (range)Low: 4.4-
8.7 (n=172)
Inter: 8.8-
10.9 (n=169)
High:
11.0-17.8
(n=163)
P
L vs I
P
L vs H
Death/MI/stroke 19.4% (32) 16.1% (26) 9.6% (15) 0.45 0.01
Death/MI/stroke/IDR* 26.6% (44) 23.8% (39) 18.3% (29) 0.66 0.08
All cause death 13.8% (22) 10.0% (16) 5.2% (8) 0.34 0.01
Cardiovascular death 7.4% (12) 4.8% (8) 4.0% (6) 0.39 0.16
MI 10.5% (17) 8.2% (13) 3.7% (6) 0.49 0.02
Stroke 1.8% (3) 1.2% (2) 2.1% (3) 0.66 0.98
Stent thrombosis (D/P) 3.1% (5) 1.2% (2) 0.0% (0) 0.26 0.03
Left main IDR 12.0% (19) 8.3% (13) 8.8% (14) 0.30 0.41
Non-TV IDR 1.9% (3) 3.3% (5) 1.3% (2) 0.48 0.65
3-Year Outcomes by LM Minimal Stent Area
Maehara A. TCT 2016
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Conclusions of EXCEL IVUS Substudy
• In the EXCEL trial, 73% of PCI cases were performed
using IVUS guidance. In the half of IVUS guidance cases,
the procedure was changed by the IVUS findings.
• After treatment with CoCr-EES, a small final MSA of the
left main coronary artery measured by IVUS was strongly
associated with death, MI and stent thrombosis during
long-term follow-up.
Maehara A. TCT 2016
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• 11.4% with ISR at 9 months
• 33.8% with underexpansion of one segment
• Angiographic ISR 24.1% with underexpansion
vs. 5.4% without underexpansion.
• Although acute malapposition was observed in
28 pts, malapposition was not related to MACE
at follow-up.
LAD
ostium
LCX ostiumPOC
Proximal
LM 8mm2
Criteria for Underexpansion
Kang et al. Circulation Cardiovasc Interv. 2011;4:562-9
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MACE98.1%
90.2%
Months after Initial Procedure
Eve
nt F
ree
Su
rviv
al R
ate
(%
)
P<0.001
100
Log-rank test
Underexpansion (+)
Underexpansion (-)
No. at risk
Underexpansion (+)
Underexpansion (-)
133
260
131
260
126
255
121
246
75
129
90
80
70
60
50
40
0 6 12 18 24
TLR
98.5%
90.9%
Months after Initial Procedure
Eve
nt F
ree
Su
rviv
al R
ate
(%
)
P=0.001
100
Log-rank test
Underexpansion (+)
Underexpansion (-)
No. at risk
Underexpansion (+)
Underexpansion (-)
133
260
131
260
126
255
121
246
75
129
90
80
70
60
50
40
0 6 12 18 24
MACE-free and TLR-free Survival
Kang et al. Circulation Cardiovasc Interv. 2011;4:562-9
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• Strut protrusion into the aorta was seen in 68%, with a
protrusion length of 3.4±1.7mm
• Incomplete stent ostial coverage seen in 23%, with uncovered
ostial length of 2.3±1.3mm and residual plaque burden of
38±12%
• Acute malapposition seen 18.8%
• Only 1.2% of LMCA developed ostial restenosis; and not
related to strut protrusion or ostial coverage or acute
malapposition
Kang et al. Am J Cardiol 2013;111:1401-7
n=199 (Left main)
When treating an ostial or proximal lesion with a DES, the
decision of whether to protrude the proximal end of the stent or
leave the ostium uncovered does not appear to be critical
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Algorithm for LM Bifurcation PCI
Rab T, et al. JACC Interv 2017;10:849–65
• Provisional stenting of side branch (usually LCx)
• Culotte: narrow angle, similar vessel diameters of
LAD and LCX
• DK Crush: narrow or wide angle, dissimilar vessel
diameters.
• DK crush better than Culotte, provisional
• TAP: wide angle, dissimilar vessel diameters
• T-stent: wide angle
• V-stent: Y bifurcation – Unstable patients
• Simultaneous kissing stents: patient unable to
tolerate ischemia
• Tryton Stent: Non DES
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Chen, S-L et al. J Am Coll Cardiol 2017;70:2605–17
Kandzari D et al. Circ Cardiovasc Interv. 2018;11:e007007
DK Crush VDouble Kissing and Double Crush Versus Provisional T Stenting Technique
Stenting Technique N=529
Provisional stent 65.2%
Sidebranch balloon 70.7%
Sidebranch stent 22.1%
Planned 2-stent 34.8%
T-stent 51.1%
Culotte 23.3%
EXCEL Trial
14,4 21,20
5
10
15
20
25
MACE 3 yrs
Provisional 2-Stent
HR 0.51, 95%CI 0.32, 0.82, adjusted P<0.005
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Kandzari DE et al. Circ Cardiovasc Interv. 2018;11:e007007
77
Number at risk:
73 72 69 67 67 64264 246 242 238 233 227 218105 90 88 86 85 83 8278 70 69 64 61 60 55
14.3%
19.2%
13.8%
23.3%
0
5
10
15
20
25
30
Time (Months)
0 6 12 18 24 30 36
Provisional 1-stent and 2 SBs with DS ≥50%
Planned 2-stents and 2 SBs with DS ≥50%
Provisional 1-stent and 0-1 SB with DS ≥50%
Planned 2-stents and 0-1 SB with DS ≥50%
De
ath
, s
tro
ke
or
MI (%
)
HR [95% CI =
0.56 [0.32, 0.99]
P = 0.04
HR [95% CI =
0.71 [0.34, 1.48]
P = 0.36
Provisional 1-Stent vs. Planned 2-Stents
For LM Distal Bifurcation Disease (n=529)
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Almost all bifurcation lesions, including the
distal LM bifurcation, can be safely treated by
radial artery access using a 6 Fr guiding catheter.
EuroIntervention 2016;12:38-46
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Lesion Preparation: 1.5 Rota Burr
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IVUS post Rotational Atherectomy
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LAD stenting with short main branch
protrusionResolute
2.75 x 30 mm
LAD
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LAD stent
balloon crush
NC 3.5 x 12 mm
LCx
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Side (LAD) Branch wire recrossing
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First kissing
balloon inflation
• NC 3.5 x 12 mm - LCx
• NC 2.5 x 15 mm - LAD
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Side branch wire is removed
Main branch (LCx) stenting
across the Side Branch
Resolute 3.5 x38 mm
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POT
Proximal
optimization
technique
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Second side branch
wire recrossing
through the main
branch stent and the
crushed SB stent
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Second kissing
balloon inflation
• NC 3.5 x 12 mm - LCx
• NC 2.5 x 15 mm - LAD
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Re-POT
Re–proximal
optimization
techniqueNC 4.0 x 12 mm
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IVUS
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Final Result
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Access and Hemostasis #ldTRA
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Ahn et al. BMC Cardiovascular Disorders (2016) 16:49
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Unprotected LM PCI
• Heart Team endorsement
• Use your best stent, endorsed by data
• Always imaging
• Knowledge of devices and bifurcation techniques
Provisional stenting is preferred DKCRUSH
• Access:
Consider radial slender techniques. Usually 7-in-6
Femoral access for support Ultrasound & Micropuncture& Preclose