Lefevre T - Left main PCI

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Left main pci via transradial approach: How to keep things simple.

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Lefevre T - Left main PCI

  1. 1. Left Main PCI Via TRA How to Keep Things Simple Thierry Lefèvre, Massy, France
  2. 2. % TR PCI TRA for PCI in France/Europe/USA France Europe USA
  3. 3. % TR PCI TRA for PCI in France/Europe/USA France Europe USA
  4. 4. % TR PCI TRA for PCI in France/Europe/USA France Europe USA
  5. 5. % TR PCI TRA for PCI in France/Europe/USA France Europe USA
  6. 6. Why TRA ? Price to ü Early ambulation Pay ü Patient confort ü Very low access site complication ü Less transfusion Learning curve ü Shorter hospital stay Guide size limitation ü Less staff workload ü Lower cost ü Less death ?
  7. 7. Learning Phase Consensus document on the radial approach in PCI. EuroIntervention, publish-ahead-of-print January 2013
  8. 8. Why LM PCI ? ü Results at least as good as surgery in patients with Syntax score < 32. ü Even better for ostial, mid shaft LM, when distal LM can be treated with one stent. ü Results have improved since Syntax with better experience, strategy, new generation DES and leaving less residual syntax score.
  9. 9. Why LM PCI via TRA ? After the Learning Phase üSame results as TFA üWith all the advantages of TRA
  10. 10. The French LM Taxus Registry: TRA vs TFA Main Clinical Characteristics Radial Patients (n) Age (years) Diabetes (%) Hypertension (%) Hypercholesterolemia (%) Smoker (%) Previous MI (%) Unstable angina (%) Additive Euroscore Femoral P value 168 67.0+11.9 28.9 63.6 65.1 45.2 11.4 42.9 4.3+3.2 123 71.2+10.4 28.7 63.9 59.8 41.0 11.6 30.6 5.5+3.5 <0.005 NS NS NS NS NS 0.04 <0.005 T. Lefèvre et al. ESC 2006
  11. 11. The French LM Taxus Registry: TRA vs TFA Main Angiographic Characteristics Radial Femoral P value EF (%) 3 Vessel disease (%) Bifurcation lesion (%) Medina 1,1,1 0,1,1 or 1,0,1 Left main proximal ref. (mm) 61.6+12.5 27.5 90.9 61.6 3.65+0.45 59.2+13.1 25.5 77.5 64.5 3.62+0.60 NS NS 0.003 NS NS LAD proximal reference (mm) 3.20+0.52 3.28+0.62 NS LCx proximal reference (mm) 2.78+0.39 2.82+0.52 NS T. Lefèvre et al. ESC 2006
  12. 12. The French LM Taxus Registry: TRA vs TFA Main Procedural Characteristics IABP (%) Guiding size 6 Fr (%) Other treated vessel (%) LM stent length (mm) Stent side branch (%) Total stent length (mm) Radial 4.2 94.6 81.2 19.6+6.3 36.2 54+22 Final kissing balloon (%) 98.6 93.8 0.06 100 263+145 60.0+31.9 98.7 230+132 56.2+30.3 NS NS NS Angiographic success (%) Contrast media (ml) Procedural duration (min.) Femoral 4.9 73.8 76.7 16.0+5.7 47.5 56+23 T. Lefèvre et al. ESC 2006 P value NS <0.0001 NS <0.0001 0.07 NS
  13. 13. The French LM Taxus Registry: TRA vs TFA In-Hospital Outcome Radial Femoral P value 0 0 NS 4.2 1.6 NS Emergency CABG (%) 0 0.4 NS Emergency PCI (%) 0 1.6 NS Stroke (%) 0 0 NS Access site complication (%) 0 3.4 0.056 Death (%) 0 3.3 NS MACCE (%) 4.2 4.9 NS 3.8+2.2 5.6+4.8 <0.0001 Q wave MI (%) Non-Q-wave MI (%) Hospital stay (days) T. Lefèvre et al. ESC 2006
  14. 14. The French LM Taxus Registry: TRA vs TFA 12-months Outcome Radial Femoral P value 0 1.6 NS Coronary angiogram (%) 63.4 62.1 NS TVR Left Main (%) 5.6 5.1 NS TVR other vessel (%) 13.5 10.2 NS Death (%) 3.0 4.1 NS Cardiac death (%) 1.8 2.5 NS Non cardiac death (%) 1.2 1.6 NS Stroke (%) T. Lefèvre et al. ESC 2006
  15. 15. Mr ROB… 64 years old 172 cm – 95 Kg Dyslipidemia on statin therapy Previous smoker Previous LCx-Mg PCI 10 years ago De novo effort angina since 5 days
  16. 16. Mr ROB… De novo angina
  17. 17. Mr ROB… De novo angina
  18. 18. Mr ROB… De novo angina
  19. 19. How to Keep Things Simple ? ü Optimal view ü Optimal guide support ü Pre defined strategy ü Consider IABB Compatible with TRA ü Optimal DAPT ü Optimal anticoagulation (ACT) ü Optimal stent positioning ü Consider IVUS ü Follow-up
  20. 20. How to Keep Things Simple ? Define a strategy
  21. 21. How to Keep Things Simple ? Define a strategy
  22. 22. How to Keep Things Simple ? 4.4 mm 3.4 mm Define a strategy Provisional SB stenting ü Optimal view ü Two wires ü Respect the fractal anatomy ü Stent choice 2.7 mm
  23. 23. Element Xience V Taxus Integrity BioMatrix Cypher 2.25 Very Small WH (2 cells) max exp.: 2.8mm 2.50 Small workshorse (8 crowns, 2 cells) max expansion : 3.5mm Medium Workhorse (6 crowns , 3 cells) max. expansion: 4.4mm Small workshorse (6 crowns, 2 cells) max expansion: 3.3mm Small workhorse (7crowns, 2 cells*) max expansion: 4.0mm *1.5 cell in Resolute Medium workhorse (6 crowns, 2 cells) max expansion: 4.4mm Medium workhorse (6 crowns, 6 cells) max expansion: 4.75mm Large workhorse (9 crowns, 3 cells) max expansion: 5.75mm Large workhorse (7 crowns, 7 cells) max expansion: 5.7mm 2.75 Medium Workhorse (9 crowns, 3 cells) max expansion: 4.7mm 3.00 3.50 4.00 4.50 Medium Workhorse (8 crowns, 2 cells) max expansion : 4.5mm Large workhorse (10 crowns, 2 cells) max expansion: 5.4mm Large workhorse: (9 crowns , 3 cells) max expansion : 5.7mm Large workhorse (9 crowns, 3 cells) max expansion: 5.75mm Medium workhorse (10 crowns, 2 cells) max expansion : 4.8mm 5.00 N. Foin et al. EBC 2012
  24. 24. How to Keep Things Simple ? EBU 4 6F Runthrough wire Hyriu 3.5x10
  25. 25. How to Keep Things Simple ?
  26. 26. How to Keep Things Simple ? Xience 3.5 x 18
  27. 27. How to Keep Things Simple ? Xience 3.5 x 18
  28. 28. How to Keep Things Simple ? Xience 3.5 x 18 14 Atm.
  29. 29. How to Keep Things Simple ? Xience 3.5 x 18 18 Atm.
  30. 30. How to Keep Things Simple ? Hyriu 4.5 x 10 20 Atm.
  31. 31. Proximal Optimization Technique O. Darremont et al. EBC 2009
  32. 32. How to Keep Things Simple ?
  33. 33. How to Keep Things Simple ? Runthrough Distal strut
  34. 34. How to Keep Things Simple ? Hyriu 3.5 x 10 Hyriu 2.5 x 10
  35. 35. How to Keep Things Simple ?
  36. 36. How to Keep Things Simple ?
  37. 37. How to Keep Things Simple ?
  38. 38. Mr ROB… De novo angina
  39. 39. Conclusion ü Transradial approach is an attractive, safe and feasible route for PCI to the LM. ü In experienced hands, it is associated with similar procedural data, in-hospital and mid-term outcome. ü Hospital stay is shorter probably due to earlier ambulation and a lower rate of access site complication.
  40. 40. To Keep Things Simple ü Like for TFA, provisional SB stenting should be the default approach (with two wires). ü Guide choice for good stability and support. ü Good NC balloons compatible with Kissing in 6 Fr guides (7 French for Trifurcation or LM > 4.5 mm). ü Remember TFA is also possible !
  41. 41. Start with Two Guidewires ü Modify Favorably the angle between both branches1,2 ü Increase the rate of SB success3 ü Wire is a good marker of SB in case of occlusion ü Keep the side branch open ?4 ü There is always a solution when the SB is wired5 1. Louvard et al. TCT 2003 2. Louvard et al. ESC 2004 3. Brunel et al. CCVI 2006 4. Colombo, personal data 5. Lefèvre et al. EBC 2009
  42. 42. LEMAX and TAXUS LM french registries P. Garot et al. AHA 2011
  43. 43. Left main Taxus/Xience French Registry Predictors of MACCE by multiple logistic regression Death + MI + clinically-driven TLR + CABG + Stroke Variable Odds Ratio p 95% Conf. Interval Paclitaxel-Eluting Stent 2.11 0.043 [1.02-4.34] Syntax score 1.05 0.009 [1.01-1.09] Euro score 1.13 0.007 [1.03-1.24] Diabetes 1.98 0.061 [0.97-3.99] Previous MI 0.38 0.148 [0.10-1.42] Nb stents in LM 1.54 0.148 [0.86-2.78] P. Garot et al. AHA 2011
  44. 44. Baseline LM Bifurcation Stenting Techniques Requiring Re-treatment in Syntax
  45. 45. J-CYPHER Registry: Distal Left Main TLR rates among various two-stent techniques Provisional SB stenting 11.1% (22/261) Culotte Stenting 28.1% (9 of 32) T stenting 25.4% (17 of 67) Crush stenting 26.7% (4 of 15) Kissing stenting 60.0% (3 of 5) Toyofuku, M. et al. Circulation 2009;120:1866-1874
  46. 46. Lessons from NORDIC II (LM Subpopulation) Cardiac death, MI, TVR and stent thrombosis
  47. 47. Cumulative Event Rate (%) SYNTAX, MACCE to 12 Months - LM PCI Subset Provisional T-stenting (n=135) 40 2-stent strategy (n=49) 22.4% 20 P=0.03* 10.4% 0 0 6 Months Since Allocation Event Rate ± 1.5 SE, *Fisher exact test 12 ITT population
  48. 48. J-CYPHER Registry: Distal Left Main Outcomes according to bifurcation stenting strategy Toyofuku, M. et al. Circulation 2009;120:1866-1874
  49. 49. Distal LM is frequently involved % Murasato Taxus registry Park Le mans Kozuga French LM Cypher Re Chinese R Park Syntax ISAR LM Agostini Suarez de Lezo Pre-Combat Friend Erglis Lemax Chieffo
  50. 50. Current DES workhorse designs Element Xience V Taxus Integrity BioMatrix Cypher 2.25 Very Small WH (2 cells) Medium Workhorse (6 crowns , 3 cells) Small workshorse (6 crowns, 2 cells) Medium workhorse (6 crowns, 2 cells) Medium workhorse (6 crowns, 6 cells) 2.50 Small workshorse (8 crowns, 2 cells) Small workhorse (7crowns, 2 cells*) *1.5 cell in Endeavor Resolute Large workhorse (9 crowns, 3 cells) Large workhorse (7 crowns, 7 cells) 2.75 Medium Workhorse (9 crowns, 3 cells) 3.00 3.50 4.00 Medium Workhorse (8 crowns, 2 cells) Large workhorse (10 crowns, 2 cells) Medium workhorse (10 crowns, 2 cells) Large workhorse: (9 crowns , 3 cells) Large workhorse (9 crowns, 3 cells) 4.50 5.00 Off Label Use Ø Company do not usually provide data on DES workhorse and max. expansion (only up to RBP is required for approval) Foin, 2011
  51. 51. Proximal vs Distal Cross Proximal cross Distal cross SB dilatation Kissing balloon Ormiston et al. EBC IV, Prague Ormiston 2008
  52. 52. Respect the Fractal Anatomy Respect Murray’s or Finet’s law: dMBprox = dMBdis+dSB x 0.678 1. Stent diameter according to the Distal MB reference ü No Carena shift ü Jailed wire not realy jailed
  53. 53. Respect the Fractal Anatomy Respect Murray’s or Finet’s law: dMBprox = dMBdis+dSB x 0.678 2. POT Technique ü No carena Shift ü Better stent apposition ü Higher chance to access a distal strut
  54. 54. Respect the Fractal Anatomy and Rheology 3. Final Kissing ü Better stent apposition ü Optimal rheology ü Optimal further access to LCx
  55. 55. Respect the Fractal Anatomy and Rheology 3. Final Kissing ü Better stent apposition ü Optimal rheology ü Optimal further access to LCx
  56. 56. Respect the Fractal Anatomy and Rheology 3. Final Kissing ü Better stent apposition ü Optimal rheology ü Optimal further access to LCx
  57. 57. Respect the Fractal Anatomy and Rheology 3. Final Kissing ü Better stent apposition ü Optimal rheology ü Optimal further access to LCx
  58. 58. Respect the Fractal Anatomy and Rheology 3. Final Kissing ü Better stent apposition ü Optimal rheology ü Optimal further access to LCx

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