PCI For MVD: Complete vs Partial Revascularization

--Partial More Realistic in Most Patients

Yuejin Yang MD, PhD, FACC

Cardiovascular Institute and Fu-Wai

Hopital, CAMS & PUMC

CIT 2010, Mar.31-April.3,2010, Beijing, China

Indications for Revascularization• Myocardial ischemia due to chronic severe

coronary mechanical blockages (stable AP)• Acute myocardial ischemia due to acute

coronary severe mechanical stenosis (UA or NSTEMI)• AMI due to acute coronary thrombotic total blockages (STEMI)• The evidence of myocardial ischemia or

infarction• The evidence of coronary mechanical severe

stenosis even obstructions except for non-mechanical one

Why Revascularization?• Solve the coronary mechanical blockages

– Bypass a new conduit (CABG)– Open and scarfolding the blockage lesions (PCI: stenting)

• Not for the non-mechanical obstructions• Not for thrombotic stenosis except for total

obstructions (STEMI)• Medications for the non-mechanical and less

severe coronary obstructions– Anti-spasm– Anti-platelet and anti-coagulation– Stablizing the vulnerable plaque

Why Complete Revarscularization

• CABG era– Once bypass surgery, complete

Revars.

– No routine dual-antiplatelet therapy

– No statins

– No medications for stabilizing even

preventing from progression of

the atherosclerotic plaque lesions

Why Partial Revarscularization

• DES period– Routine dual anti-platelet regimen

– Routing statins

– Medical treatment can stabilize or

prevent from lesion progression

– Borderline lesions(50%-70%):

no need for stenting without evidence

of myocardial ischemia

PCI: Complete Revascularization?• No need in some pts with MVD

– No improving long term outcomes– Just prevent myocardial ischemia and

relieve ischemic symptoms

– In pts without symptoms and ischemic evidence– In disdal coronary lesions– In senior persons– In small vessels– In 1-V CTO lesion with abundant collateral

circulations

PCI: Complete Revascularization?

• Technically impossible in some Pts– 3-V diffused disease– Diffused lesions– Small vessel CTOs– Distal severe stenosis even CTOs– Non-dominant RCA stenosis– High risk lesions (severe calcifications )– In very old, weak and high risk pts– In AMI pts with another coronary CTOs

PCI: Complete Revascularization?

• No more benefits even harmful for the pts– More stents– Much more costs – Over treatment– High risks for stent thrombosis– High risks for stent restenosis and

revascularizations– Not criterion of PCI– No faithfulness between Drs and Pts– Waste limited medical sources

PCI: Partial Revascularization• More realistic in most pts with MVD• Stenting the ischemia related vessel• Ischemic symptoms alleviated even no more• PCI only for IRA in Pts with STEMI can save life• PCI only for proximal severe stenosis can

improving quality of life and outcomes• Cost much less• Save the huge amount of medical sources and

social expenses• Affordable for more pts and families

Mr. Wang MX M 46yrs 69880209-9-18Baseline CAA: LM: OK

LAD: unremarkable Mid-LCX: CTO, but small Mid-RCA: 100% occluded (2 stents

deployed) 3 days later STEMI occurred

CAA: mid-RCA stent totally occluded

Cases 1: No need PCI for Samll LCX CTO

Baseline CAA (09-18-09)

RCA: 2 DES deployed

LM-Bif. with Severe Calcification: Technically Impossible for complete revas.

• 杜贵荣 F 80 Yrs• ACS• LM bifurcation with severe calcification

lesion• CABG strong suggested and contraindicated • IABP inserted• Kissing stenting performed• Sequential high pressure and final kissing• High pressure pre- and post-dilatation(20

atm)• IVUS checked

Baseline CAA+LVG

IABP+TFI+Balloon Predilatation

Kissing Stenting with High Pressure Deployment and Post-dilatation

Final Optimal Results

Triple-VD with Diffused Lesions:Technically Impossible for Complete

Revas.

陈立忠 M 55yrs 682710

3-VD: 均弥漫病变

LAD 弥漫病变最重 90% （做）

LCX 弥漫病变最重 90% （做）

Nondominant RCA 弥漫病变最重 90% （未做）

Baseline CAA

LAD Stenting

Dominant LCX Stenting

Cases 3 Mr. Yang XP M 62 yrs 456039

09-8-26

STEMI (IPW)×4 hrs

2001 Mid-LCX BMS×1

2004 follow-up CAA: normal

2006 Ischemic symptom-driven

Second BMS (driver) in Prox-LCX

Statin discontinued for 2 yrs due to side effects

Severe chest pain for 4 hrs

STEMI: No More Benefit of STEMI: No More Benefit of

Complete RevascularizationComplete Revascularization

Baseline CAA: LCX(IRA) definite ST occlusion

OCT Exam first, then Ballooning

was done

Conclusions • PCI of complete revascularization in multi-

vessel disease is not needed, technically impossible, no benefit and even harmful to the patients.

• On the other hand, partial revascularization of PCI is cost effective, technically feasible, and also can improve quality of life and outcomes

• Partial revascularization in PCI is more realistic in most patients with multi-vessel disease

• It can save huge amount of money even though revascularization rate might be 10% higher in partial vs complete revascularization.

Welcome Attend China Heart Conference (IHF2010) ：

2nd international TR Coronary Therapeutics (TRCT)

Chaired byYue-Jin Yang MD. PhD. FACC

Co-Chaired byDr. Saito

Dr. kiemeneijiNCC, 2010/08/13-15, Beijing, China

Thank you very much !