Download Practical approaches and novel technology to optimize left main

Practical approaches and novel
technology to optimize left main
procedure outcome
12th EBC meeting, October 14-15, 2016 Rotterdam
Session Objective
1. To learn about contemporary treatment strategies for
LMCA bifurcation lesions and to reflect on practical
cases;
• SB Access
– Reverse J, Venture catheter, Crusade catheter
• SB protection
– Jailed wire technique, jailed balloon, predilatation
• Stent techniques
– Provisonal T, crush, culottes, kissing, TAP, mini-crush,
DK-crush…
• Stent optimization
– Proximal optimization technique, final kissing
ballooning…
• Imaging, physiology
– IVUS, OCT, FFR
Courtesy of HC. Gwon
Session Objective
2. To learn from state-of-the-art imaging on stent
behavior in bifurcation
Provisional stenting
Culotte
The visible heart
DK Crush
Reconstruction from CT scan
Session Objective
3. To learn about usefulness of novel generation DES
dedicated to large vessel treatment
Platinum
Iridium Core
Cobalt Alloy
Outer
Core Wire Technology used to create
sinusoid-formed wire
Core Wire Technology enables:
• Increased deliverability
• Thinner struts with enhanced
radiopacity
• No compromise to structural
strength
Onyx xlv provisional LM bifurcation: final result
Selection of treatment for left
main: Current guidelines and
clinical aspects to be considered
G. Stankovic, MD, PhD
LEFT MAIN STENTING
• LMCA disease presents in 5-7% of
patients undergoing coronary
angiography1
• The left main is a critical vessel
supplying 75-100% of left
ventricular cardiac mass1
• Medical management alone results
in a high mortality rate, further
requiring revascularization2
Images from: Kapur P et al, Europen Congress of Radiology (ECR) 2012
1. Fajadet J, Chieffo A. Current management of left main coronary artery disease. European Heart Journal (2012) 33, 36–50.
2. Bittl JA, He Y, et al. Bayesian Methods Affirm the Use of Percutaneous Coronary Intervention to Improve Survival in Patients with Unprotected Left Main Coronary Artery Disease Circ. 2013;
127: 2177–2185.
6
EVOLUTION OF ESC GUIDELINES FOR LEFT MAIN PCI
PCI for distal LM: IIb
| 2010
Focus on lesion type and severity:
• PCI is always inferior to CABG
for LM lesions of all types
• PCI is NOT recommended for
MVD, SYNTAX score ≥33
PCI acceptance
| 2013
PCI has prominent role
| 2014
| 2016?
Focus on lesion type and patient
surgery risk:
Focus on lesion severity:
• PCI is recommended when it is 1
lesion in patient with high risk of
surgery
• PCI is NOT recommended for
MVD in low surgery risk patients
• PCI is recommended for simple lesion,
SYNTAX ≤22
• PCI should be considered for
intermediate lesions
• PCI is NOT recommended for complex
lesions, SYNTAX ≥33
7
60% OF LEFT MAIN PATIENTS ARE ELIGIBLE FOR PCI1,2
Multi-vessel disease comprises a high
proportion of low-intermediate
SYNTAX score patients3
Breakdown of left main patients by
SYNTAX score2
100%
90%
80%
SYNTAX ≤ 22
32%
SYNTAX > 32
40%
SYNTAX 23–32
28%
70%
60%
LM + 3VD
50%
LM + 2VD
40%
LM + 1VD
30%
LM Isolated
20%
10%
0
LOW SYNTAX
0 – 22
1.
2.
3.
INTERMEDIAT
E SYNTAX
HIGH SYNTAX
23 -32
>32
Windecker S, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal (2014) 35, 2541–2619
Morice MC, Serruys PW, et al. Outcomes in Patients With De Novo Left Main Disease Treated With Either Percutaneous Coronary Intervention Using Paclitaxel-Eluting Stents or Coronary
Artery Bypass Graft Treatment in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) Trial. 2010; 121:2645–2653.
Fajadet J, Chieffo A. Current management of left main coronary artery disease. European Heart Journal (2012) 33, 36–50.
LM PCI OUTCOMES IMPROVE WITH NEWER
TECHNOLOGY
PCI has gained acceptance
as a primary treatment
modality for left main
disease, especially for lowto-intermediate SYNTAX
lesions1
Outcomes in left main PCI continually
improved with improved stent platforms3
MACE
HR (95% CI)
p-Value
n
BMS
0.33 (0.23–0.47)
< 0.05
260
First-generation DES
0.53 (0.35–0.80)
< 0.05
394
Second-generation DES
1.01 (0.68–1.49)
NS
4704
CABG Better
PCI Better
1. Windecker S, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal (2014) 35, 2541–2619.
2. Morice MC, Serruys PW, et al. Outcomes in Patients With De Novo Left Main Disease Treated With Either Percutaneous Coronary Intervention Using Paclitaxel-Eluting Stents or Coronary
Artery Bypass Graft Treatment in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) Trial. 2010; 121:2645–2653.
3. Park SJ, Ahn JM, et al. Temporal Trends in Revascularization Strategy and Outcomes in Left Main Coronary Artery Stenosis: Data From the Asan Medical Center-Left Main Revascularization
Registry. Circ Cardiovasc Interv. 2015;8:e001846.
4. Includes n = 51 zotarolimus-eluting stent.
9
CHALLENGES OF LEFT MAIN PCI
•
Up to 80% of left main lesions involve the
bifurcation1
•
75% of left main diameters are 4.00–5.75
mm1
•
Aorto-ostial issues of disease within 3 mm of
the ostium can be fibrotic, calcified and rigid
•
The diameter of the LMA can range from 4.0
to 7.4 mm limiting device selection
– Large vessels tend to have large side branch
openings which provide significant blood flow
to the myocardium and may have involved
disease
Images from: Kapur P et al, Europen Congress of Radiology (ECR) 2012
Fajadet Eur Heart J 2012; 33: 36-50
1. Windecker S, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal (2014) 35, 2541–2619.
2. ShandJA, et al. A Prospective Intravascular Ultrasound Investigation of the Necessity for and Efficacy of Postdilation Beyond Nominal Diameter of 3 Current Generation DES Platforms for the Percutaneous Treatment of the Left Main Coronary Artery
Catheterization and Cardiovascular Interventions 84:351–358 (2014).
10
LEFT MAIN BIFURCATION RHEOLOGY
Left main bifurcation flow dynamics favor provisional stenting
Atherosclerotic lesions tend to form
in areas of low shear stress1
Atherosclerosis is accelerated
along the lateral wall of the left
main, close to the bifurcation3
Left main bifurcation physiology
is favorable towards provisional
stenting
In the left main bifurcation, wall
shear stress is typically low on the
lateral walls and high at the carina2
The carina is frequently free
of disease3
EBC consensus4:
Provisional stenting is the
preferred strategy in LMCA
bifurcation lesions5
1.
2.
3.
4.
5.
Ku. Arterioscl . 1985; 5(3): 293–302.
Soulis. Hippok. 2014; 18(1): 12–16.
Fajadet. Eur Heart J . 2012; 33: 36–50.
Lassen. EuroInterv. 2014; 10:545–60.
Per EBC consensus a two-stent technique is preferred in case of significant proximal LCX disease.
11
BIFURCATION TECHNIQUE SELECTION
• Stenting Technique selection1
–
–
–
–
–
Plaque distribution
Size of the main and the side branch
Severity and length of the side-branch lesion
Bifurcation angulation
Operator experience/expertise
• A single stent strategy whenever possible may help to reduce
major adverse cardiac events (MACE)2
• Among two-stent techniques, there seems to be no difference
between the treatment approaches2
1. Fajadet J, Chieffo A. Current management of left main coronary artery disease. European Heart Journal (2012) 33, 36–50.
2. Palmerini T, Marzocchi A, Tamburino C, et al. Impact of bifurcation technique on 2-year clinical outcomes in 773 patients with distal unprotected left main coronary artery stenosis treated with
drug-eluting stents. Circ Cardiovasc Interv 2008;1:185-92.
12
Take-home message
Provisional LMCA stenting technique: step-by-step
1. Both branches are wired starting with the most
difficult one
2. MB is stented (stent sized according to MB distal
reference) and SB wire is jailed
3. The stent is post-dilated using the Proximal
Optimization Technique (POT) to maximize stent
apposition
4. Stent is now well apposed proximally, while the SB is
partially covered by scaffolding
5. MB wire is pulled back and re-inserted through
the most distal strut of the SB opening scaffold
6. Jailed wire is removed and re-inserted in the distal
MB (with a formed loop at the distal end)
7. The Kissing Balloon inflation is done to optimize
side branch flow and access
8. Final result (if suboptimal, can then place additional
stents)
Louvard & lefèvre. Eurointervention 2011;7:160-163
Visible Heart® & Resolute Onyx™ DES
Visible Heart®
Resolute Onyx™
• Powerful imaging tool for • Improved deliverability
studying bifurcation stent
and conformability
behavior
based upon the flexible
• Visualization for studying
design: continuous
new bifurcation
sinusoidal technologies
techniques and
(CST);
complications
• Enhanced radiopacity
and thinner struts (Core
Wire)