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Jeffrey J. Popma, MD Director, Interventional Cardiology Brigham and Women’s Hospital Associate Professor of Medicine Harv...
New Insights into Periprocedural MI, Multiple Stents and Sidebranches <ul><li>Distal platelet embolization was felt to be ...
Multiple Overlap Stenting in TAXUS V All Patients (n=1156) Multiple Stents in  Target Vessel (n=379) Planned Procedures (n...
Objective:  Multiple Stent Analysis <ul><li>TAXUS V Multiple Stent Patients: </li></ul><ul><ul><li>62.7% Lesions >26mm </l...
MACE in QCA Analysis Subgroup 0.08 8.7% 3.9% MI 0.0027 16.3% 29.8% TVR 1.00 0.5% 0.6% Cardiac Death 0.0172 20.7% 32.0% 9-M...
TAXUS V Multiple Stent Analysis Methodology <ul><li>Blinded core lab analysis of all multiple stent patients </li></ul><ul...
Side Branch Analysis in Multiple Stenting Sidebranch Occlusion TIMI Flow Reduction Side Branch Narrowing  ( Δ  ≥  70%    ...
Main Vessel Analysis in Multiple Stenting Peri-procedural Ischemic Complicatons 0.50 3.2 1.6 Final (%) 1.00 7.4 7.6 Transi...
Side Branch Analysis in Multiple Stenting 0.74 89.1 87.5 % pts with Sidebranch 289 268 Total Sidebranches (n) 0.45 1.42 ± ...
Side Branch Analysis in Multiple Stenting TIMI Flow: Timing, Any Time Point Timeline Control (n=263) TAXUS (n=285) Baselin...
Impact of the Overlap Region (per side branch) Any Sidebranch Occlusion Any Sidebranch Narrowing Any TIMI Flow Reduction C...
Non-Q-Wave MI in Multiple Stent Patients: Transient Side Branch Compromise 28.6% 41.9% (65/155) Side Branch (42/147) P=0.0...
Possible Causes of Sidebranch Compromise <ul><ul><li>Likely related to geometric narrowing from increased strut thickness ...
Side Branch Analysis in Multiple Stenting Patients with and without CK-MB>3x ULN Myonecrosis <0.0001 20.5 % 41.3 % Narrowi...
TLR benefit among Multiple Stent Groups Patients (%) All patients Multiple Stents Multiple Overlapping stents p=0.0005 p=0...
What Are The Predictors of Late Mortality? Jeremias et al JACC 2004:44:1210-4
Unsuccessful Procedure = > 50% residual stenosis, TIMI <3, Final Dissection > C; SAT, Urgent TVR < 24 hours Mortality Risk...
Multiple Stent Patients: Early Non-Q-Wave MI is not Associated with Long-Term Sequelae; Taxus Benefits Persist Taxus N=193...
Freedom from  Cardiac Death  to 2-Years Multiple Stent Patients,  TAXUS II, IV, V, VI 0 100 200 300 400 500 600 700 100% 9...
Conclusions There was slightly higher Non QWMI rate in patients treated with multiple TAXUS stents in the TAXUS 5 trial du...
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Jeffrey J. Popma, MD Director, Interventional Cardiology

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Jeffrey J. Popma, MD Director, Interventional Cardiology

  1. 1. Jeffrey J. Popma, MD Director, Interventional Cardiology Brigham and Women’s Hospital Associate Professor of Medicine Harvard Medical School Boston, MA TAXUS – Myonecrosis and sidebranch patency concerns are short-term issues with no long-term consequences, and the benefits are undeniable
  2. 2. New Insights into Periprocedural MI, Multiple Stents and Sidebranches <ul><li>Distal platelet embolization was felt to be a major component of myonecrosis during PCI. GPIIb-IIIa inhibitors reduced this risk </li></ul><ul><li>Differential cardiac enzyme elevation was noted in the Taxus 5 Trial in patients treated with multiple stents, leading to a re-examination of the root cause of this event </li></ul>
  3. 3. Multiple Overlap Stenting in TAXUS V All Patients (n=1156) Multiple Stents in Target Vessel (n=379) Planned Procedures (n=248) Emergent Procedures (n=78) QCA-confirmed Overlapping Stents (n=326) Received no stents (n=8) Single Stents (n=769) Planned Procedures (n=281) Emergent Procedures (n=98) No overlap (n=53)
  4. 4. Objective: Multiple Stent Analysis <ul><li>TAXUS V Multiple Stent Patients: </li></ul><ul><ul><li>62.7% Lesions >26mm </li></ul></ul><ul><ul><li>86.0% QCA-confirmed overlapping stents </li></ul></ul><ul><ul><li>44.0% 2.25 and 2.5 mm stents </li></ul></ul><ul><ul><li>34.3% Patients with diabetes </li></ul></ul><ul><ul><li>73.1% Type C lesions </li></ul></ul>
  5. 5. MACE in QCA Analysis Subgroup 0.08 8.7% 3.9% MI 0.0027 16.3% 29.8% TVR 1.00 0.5% 0.6% Cardiac Death 0.0172 20.7% 32.0% 9-Month MACE 0.5% 3.3% 0.0% 3.3% Control n=184 0.62 1.6% TVR 0.0457 8.6% MI 0.0% Cardiac Death 0.0457 8.6% 30-Day MACE P value TAXUS n=188
  6. 6. TAXUS V Multiple Stent Analysis Methodology <ul><li>Blinded core lab analysis of all multiple stent patients </li></ul><ul><li>Main Vessel Analysis: </li></ul><ul><ul><li>Main vessel No Reflow, TIMI flow, Dissection, Distal Embolization, Abrupt Closure </li></ul></ul><ul><li>Side Branch Analysis (for branches >1 mm): </li></ul><ul><ul><li>Branch occlusion (total occlusion) </li></ul></ul><ul><ul><li>Branch narrowing ( Δ ≥ 70%  100%) </li></ul></ul><ul><ul><li>Branch TIMI flow </li></ul></ul>
  7. 7. Side Branch Analysis in Multiple Stenting Sidebranch Occlusion TIMI Flow Reduction Side Branch Narrowing ( Δ ≥ 70%  100%)
  8. 8. Main Vessel Analysis in Multiple Stenting Peri-procedural Ischemic Complicatons 0.50 3.2 1.6 Final (%) 1.00 7.4 7.6 Transient (%) No Reflow - 0.0 0.0 Final (%) 0.28 3.2 1.1 Transient (%) TIMI Flow - 0.0 0.0 Final (%) 0.62 1.6 0.5 Transient (%) Abrupt Closure Control n=184 pts P value TAXUS n=188 pts
  9. 9. Side Branch Analysis in Multiple Stenting 0.74 89.1 87.5 % pts with Sidebranch 289 268 Total Sidebranches (n) 0.45 1.42 ± 0.37 1.40 ± 0.36 Sidebranch RVD (mm) 0.55 1.66 ± 0.99 1.60 ± 1.01 # Branches (per pt.) Control n=184 pts P value TAXUS n=188 pts
  10. 10. Side Branch Analysis in Multiple Stenting TIMI Flow: Timing, Any Time Point Timeline Control (n=263) TAXUS (n=285) Baseline 1.5% 2.5% p=0.55 After Pre- Dilatation 3.8% 6.3% p=0.24 After First Stent 10.3% 15.1% p=0.10 After Additional Stent(s) 12.9% 20.7% p=0.02 After Post- Dilatation 12.9% 22.1% p=0.05
  11. 11. Impact of the Overlap Region (per side branch) Any Sidebranch Occlusion Any Sidebranch Narrowing Any TIMI Flow Reduction Control TAXUS 37/203 34/207 8/48 15/55 51/203 68/207 12/48 26/55 56/203 58/207 21/48 24/55 Non-overlap region Overlap region Non-overlap region Overlap region Non-overlap region Overlap region p=0.74 p=0.23 p=0.10 p=0.025 p=1.00 p=1.00
  12. 12. Non-Q-Wave MI in Multiple Stent Patients: Transient Side Branch Compromise 28.6% 41.9% (65/155) Side Branch (42/147) P=0.0164 MI 3.3% 8.3% 30 Days Taxus N=193 Control N=184 (6/184) (16/193) P=0.0472 1.1% (2/184) Main Branch (6/188) 3.2% P=0.284 3.9% (7/181) (16/191) 8.4% P=0.0858 MI 9 Months 17.7% (25/155) (26/147) 16.1% P=0.760 TIMI Flow Reduction Side Branch 62% decrease 38% decrease Peri-procedure TIMI Flow reduction
  13. 13. Possible Causes of Sidebranch Compromise <ul><ul><li>Likely related to geometric narrowing from increased strut thickness </li></ul></ul><ul><ul><li>Less likely related to </li></ul></ul><ul><ul><ul><li>Polymer webbing and/or clumping </li></ul></ul></ul><ul><ul><ul><li>Platelet and/or thrombus deposition </li></ul></ul></ul><ul><ul><ul><li>Paclitaxel-induced spasm </li></ul></ul></ul>
  14. 14. Side Branch Analysis in Multiple Stenting Patients with and without CK-MB>3x ULN Myonecrosis <0.0001 20.5 % 41.3 % Narrowing <0.0001 9.9 % 35.6 % Occlusion 42.3 % + Myonecrosis n=106 branches <0.0001 20.0 % ↓ Branch TIMI Flow P Value no Myonecrosis n=451 branches
  15. 15. TLR benefit among Multiple Stent Groups Patients (%) All patients Multiple Stents Multiple Overlapping stents p=0.0005 p=0.0003 p=0.0003 34/123 89/567 51/181 12/121 48/560 24/191 Control TAXUS 55% 64% 45%
  16. 16. What Are The Predictors of Late Mortality? Jeremias et al JACC 2004:44:1210-4
  17. 17. Unsuccessful Procedure = > 50% residual stenosis, TIMI <3, Final Dissection > C; SAT, Urgent TVR < 24 hours Mortality Risk Confined to Those with Procedural Failure Jeremias et al JACC 2004:44:1210-4
  18. 18. Multiple Stent Patients: Early Non-Q-Wave MI is not Associated with Long-Term Sequelae; Taxus Benefits Persist Taxus N=193 Control N=184 8.3% (16/193) MI 3.3% 30 Days (6/184) P=0.0472 1.1% 0.6% 7.4% (2/189) (14/180) 12 Months 3.9% (7/180) MI Cardiac Death (1/180) P=0.0852 P=0.284 14.3% (27/189) 12 Months (57/180) 31.7% P=0.0001 TLR
  19. 19. Freedom from Cardiac Death to 2-Years Multiple Stent Patients, TAXUS II, IV, V, VI 0 100 200 300 400 500 600 700 100% 95% 90% 85% 80% 75% 70% 65% 60% Days Since Index Procedure 99.4% (T) Freedom from Cardiac Death 99.1% (C) p=0.63 TAXUS N = 348 Control N = 336
  20. 20. Conclusions There was slightly higher Non QWMI rate in patients treated with multiple TAXUS stents in the TAXUS 5 trial due to sidebranch reduction in flow in the region of stent overlap The sidebranch flow returned toward baseline at 9 month follow-up There was a 64% reduction in TLR in patients treated with multiple overlapping stents No late mortality differences up to 2 years in patients treat with multiple stents in a TAXUS meta analysis

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