Letters to the Editor


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Letters to the Editor

  1. 1. Letters to the Editor Trifurcating Coronary Artery Disease: As we have previously proposed,3 LM trifurcation stenting needs to Expanding the Frontier of Interventional be reserved for patients who are at high risk of bypass surgery or Cardiology refuse surgery as a first treatment option. Trifurcating coronary disease involves unique coronary anatomy We read with interest the manuscript published by Furuichi et al1 that is challenging even to the most experienced operators. Our pre- in the April 2007 issue of the Journal of Invasive Cardiology. The viously published classification and treatment methodology2 needs authors presented their experience with drug-eluting stents (DES) in to be validated in larger registries before we can recommend the rou- trifurcation lesions in the coronary arteries, predominantly left main tine use of trifurcation stenting to the interventional community. trifurcation (13 out of 15 patients). The mean follow-up period was 19.0 ± 8.3 months. The authors reported a target lesion revascular- Nicolas Shammas, MD, MS, FACC, FASCI ization (TLR) rate of 20%, and a target vessel revascularization President and Research Director, (TVR) rate of 40%. There were no deaths, acute stent thrombosis or Midwest Cardiovascular Research Foundation Q-wave myocardial infarctions reported. The results overall appear Davenport, Iowa favorable for this complex group of patients. The authors described a nearly identical classification of trifurca- References tion disease to the Shammas classification2,3 presented at New Car- 1. Furuichi S, Sangiorgi GM, Palloshi A et al. Drug-eluting stent implanta- tion in coronary trifurcation lesions. J Invasive Cardiol 2007;19:157–162. diovascular Horizons, held in New Orleans in November of 2006,4 2. Shammas NW. Trifurcating coronary artery disease: A proposed classifica- and published earlier this year in the January and February issues of tion and treatment methodology. J Invasive Cardiol 2007;19:32–35. the Journal of Invasive Cardiology. Also, Shammas et al published the 3. Shammas NW, Dippel EJ, Avial A. et al. Long-term outcomes in treating first long-term follow-up report on DES in treating left main (LM) left main trifurcation coronary artery disease with the paclitaxel-eluting stent. J Invasive Cardiol 2007;19:77–82. trifurcation disease in the February 2007 issue of the Journal.3 In 4. Shammas NW, et al. Long term outcome in treating trifurcation coronary both the Shammas and Furuichi manuscripts, no definite relation- artery disease with the Taxus drug eluting stent. Presented at New Cardio- ship appears between the method of stenting and TLR or the type of vascular Horizons, New Orleans, Louisiana, November 2006. disease distribution and complications. In the Shammas manuscript, a forced logistic regression analysis in 20 consecutive patients with LM trifurcation disease showed that the method of treatment or the Reply to Letter to the Editor distribution of disease did not predict the combined endpoint of death, acute stent thrombosis and TLR. In the manuscript by We thank Dr. Shammas for the interest he has shown our Furuichi et al, restenosis also occurred almost equally with trifurca- manuscript. We are pleased to see that operators from highly qual- tion stenting using the “double-crush” and the “modified-V” tech- ified centers share our interest about this complex and rare proce- niques. It is possible that the small number of patients in both studies dure. 1,2 Unfortunately, along with the enthusiasm for such challenging procedures, we also share some concerns about poten- prevent a valid statistical conclusion about the relationship between tial risks in terms of stent thrombosis, the need for extended disease distribution as described earlier by Shammas, and similarly in antiplatelet therapy and the lack of data regarding long-term out- Furuichi et al, and the occurrence of adverse events. We propose the comes. These concerns are even more relevant due to the fact that development of a large multicenter registry for trifurcation coronary trifurcation lesions are frequently located in critical sites like the artery disease to determine how the published classification and treat- left main trunk or the anterior descending artery. Regrettably, it is ment methodology of trifurcation disease2 predict overall outcomes difficult to provide an unbiased judgment about the safety and and major adverse events during and following treatment. efficacy of this type of procedure since it is performed in an Finally, we believe that current data do not allow us to conclude extremely rare number of patients, as clearly witnessed by our that trifurcation stenting is a safe procedure, as is proposed by series of 15 cases collected over a 4-year period out of more 8,000 patients. Initial enthusiasm began immediately after the arrival of Furuichi et al.1 Trifurcation stenting is a complex procedure that drug-eluting stents, which many thought would allow operators to should only be performed by highly experienced operators. In our tackle any lesion and anatomy with multiple stent implantations. busy interventional catheterization laboratory of several thousand This enthusiasm has now evolved into a more mature vision of interventions yearly, we previously reported in 20 consecutive patients percutaneous therapies. The advantages of stent implantation in of LM trifurcation disease an overall adverse event rate of 29.4%. comparison to bypass surgery continue to face some shortcomings These included sudden death (5.3%), acute stent thrombosis (10%) present in each of the two approaches, and a clear winner has not and TLR (11.8%). In the Shammas manuscript, stent thrombosis yet been declared, at least for some complex and unique anatomi- could be attributed to delayed clopidogrel administration until shortly cal locations such as trifurcation lesions of the distal left main after the end of the procedure in the only 2 patients who developed coronary artery. Despite some potential problems occasionally seen with drug-eluting stent implantation such as late stent thrombosis. Stent thrombosis with DES has been reported, however, thrombosis and uncertainty regarding the need for double in approximately 4% of bifurcation stenting cases, and it is more like- antiplatelet therapy,3,4 we cannot deny that the results we are pre- ly to occur at a higher rate with trifurcation stenting. Again, larger senting are very encouraging and so far do not seem to deter from registries are needed to determine the true rate of stent thrombosis the careful utilization of drug-eluting stents in appropriate with trifurcation DES stenting and the overall safety of the procedure. patients with a suitable trifurcational anatomy. 284 The Journal of Invasive Cardiology
  2. 2. LETTERS A registry collecting all these cases from different qualified centers References would be more than welcome. We believe it could be a useful means 1. Shammas NW. Trifurcating coronary artery disease: A proposed classification and treatment methodology. J Invasive Cardiol 2007;19:32–35. to better recognize caveats and limitations of stenting these lesions 2. Shammas NW, Dippel EJ, Avial A. et al. Long-term outcomes in treating left main and finally to improve our approach to this specific field. trifurcation coronary artery disease with the paclitaxel-eluting stent. J Invasive Cardiol 2007;19:77–82. Antonio Colombo, MD, Shinichi Furuichi, MD 3. Stone GW, Moses JW, Ellis SG, et al. Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents. N Engl J Med 2007;356:998–1008. Flavio Airoldi, MD 4. Lagerqvist B, James SK, Stenestrand U, et al. Long-term outcomes with drug- Emo Centro Cuore Columbus, Milan, Italy eluting stents versus bare-metal stents in Sweden. N Engl J Med E-mail: info@emocolumbus.it 2007;356:1009–1019. The Pronto Catheter: Distal Embolization of Any the artery, underscores the need for a constant negative pressure to be maintained by the device until the entire thrombus has been extracted. Remaining Thrombus Fragments May Be a Risk Investigation into overcoming this risk, with emphasis on preventing of Creating and Then Removing Negative Pressure potential embolic complications by creating and then removing suc- tion, is warranted to improve the safety of this novel percutaneous In patients presenting with an acute coronary syndrome, intracoro- intracoronary thrombectomy system. Aspirating the guide catheter after nary thrombus removal is often required during percutaneous coronary removing the Pronto is a way to decrease the risk of embolization of intervention. The Pronto (Vascular Solutions, Inc., Minneapolis, Min- any distal thrombus fragments in our experience, and this could be nesota) catheter is a hydrophilically-coated dual-lumen catheter designed added to the deployment steps in the instructions. for the removal of fresh, soft emboli and thrombi from vessels in the arterial system. While the smaller-wire lumen accommodates the Ravi K. Mallavarapu, MD, Talley F. Culclasure, Jr, MD, FACC, guidewire, the larger extraction lumen allows for removal of thrombus Erskine A. James, MD, FACC by using the syringe through the extension line and stopcock. The Pron- Mercer University School of Medicine to uses simple vacuum suction and has been described as a quick and Department of Internal Medicine simple tool for the management of thrombus in the setting of acute Macon, Georgia myocardial infarction.1,2 Although certain precautions and warnings have E-mail: snehabeach@gmail.com been stated in the instructions for use, the importance of maintaining suction during the entire procedure is not mentioned. We believe that maintaining negative pressure once the extraction of thrombus has been References 1. Pershad A, Hoelzinger D, Patel S. Pronto catheter thrombectomy in started is of critical importance until the process is completed. The acute ST-segment myocardial infarction: A case series. J Invasive Car- instructions state that blood will enter the syringe until all the vacuum is diol 2006;18:E191–194. gone. The next step is to turn the stopcock to the “off” position. This 2. De Young MB, Kazziha S. Use of a thrombus extraction catheter has a two-fold effect: apart from closing the syringe from the vessel (Pronto) in the treatment of acute myocardial infarction after coronary lumen, this step also cancels the vacuum that had until then, extracted embolism post mitral valve replacement. J Invasive Cardiol the thrombus. With such loss of negative pressure, the remaining throm- 2006;18:E273–E275. bus in the vessel is free to embolize with no vacuum holding it. This is crucially important with large thrombi. We believe that this potential to cause distal embolization of any remaining fragments of thrombus in Vol. 19, No. 6, June 2007 285