Mann T 201110

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Transradial Approach for Left Main Stenting

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Mann T 201110

  1. 1. Transradial approach for left main stenting Tift Mann, MD, FACC Duke advanced TR 2011
  2. 2. Meta-analysis of randomized LM Trials: (1y death and MI same) Capodanno et al. JACC2011;58:1426
  3. 3. Meta-analysis of randomized LM Trials: 1y MACCE Ferrante et al Eurointervention 2011
  4. 4. MACCE to 3 Years LM Subset CABG (N=348) TAXUS (N=357) P=0.20 Cumulative Event Rate (%) 40 Before 1 year* 1-2 years* 2-3 years* 13.7% vs 15.8% 7.5% vs 10.3% 5.2% vs 5.7% 26.8% P=0.44 P=0.22 P=0.78 20 22.3% 0 0 12 24 36 Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value; *Binary rates ITT populationTCT 2010 • Three-year Outcomes of the SYNTAX Trial: Left Main Subgroup • Serruys • Slide 4
  5. 5. Effect of PCI on MACCE Stratified by Burden of Coronary Artery Disease Capodanno et al. JACC2011;58:1426
  6. 6. MACCE to 3 Years in LM Subgroups CABG TAXUS 40 P=0.20 P=0.52 P=0.33 P=0.09 P=0.20 31.7 31.1 30 26.8 26.7 Patients, % 22.3 22.8 21.2 19.4 20 17.0 11.9 10 0 n= 348 357 49 42 71 67 106 112 122 136 All LM LM LM LM LM Isolated + 1VD + 2VD + 3VDTCT 2010 • Three-year Outcomes of the SYNTAX Trial: Left Main Subgroup • Serruys • Slide 6
  7. 7. Pooled meta-analysis:Stratification by Burden of Disease Capodanno et al. JACC2011;58:1426
  8. 8. PCI for unprotected left main I IIa IIb III PCI of the left main coronary artery using stents as an alternative to CABG may be considered in patients with anatomic conditions that are associated with low risk of PCI procedural complications and Clinical conditions that predict an increased risk of adverse surgical outcomes“Based on the present study, revision of the guidelinesregarding left main PCI is warranted, raising the level ofevidence of current recommendations from B to A.” Capodanno et al JACC 2011 8
  9. 9. 5 Years after LM/LAD TAXUS…stopped Plavix for a nonsurgical procedure
  10. 10. Symptomatic Graft Occlusion & Stent Thrombosis to 3 Years LM Subset CABG (n=348) TAXUS (n=357) Patients (%) P=0.80 3.7 4.1 n=12 n=14 CABG TAXUS Post-procedure; ITT populationTCT 2010 • Three-year Outcomes of the SYNTAX Trial: Left Main Subgroup • Serruys • Slide 10
  11. 11. EXCELEvaluation of XIENCE PRIME™ or XIENCE V® versus CABG for Effectiveness of Left Main Revascularization (syntax score <32)
  12. 12. Once the guide catheter is in place, there is no difference between radial and femoral access Complex PCI in daily practice Women Age > 75 ACS/STEMI Type C lesions Multivessel Rotational athrectomy Bifurcations CTO SVBG/IMA Left Main disease
  13. 13. Left Main PCI:Outcomes According to Vascular Access Transradial Transfemoral P Value (n = 353) (n = 468) Cardiovascular 0.6% 0.6% 1.00 Death Nonfatal MI 2.8% 1.5% 0.22 LM-Specific TVR 0.6% 1.1% 0.70 MACE 4.0% 3.2% 0.57 Hospital Stay 8.5 ± 5.9 days 9.9 ± 5.9 days 0.001 TIMI Major and 0.6% 2.8% 0.02 Minor Bleeding Yang et al JACCInt 2010
  14. 14. TR vs TF in UPLM Patients Yang et al. JACCIntv 2010
  15. 15. OSTIAL LM 1,0,0 :DIRECT TAXUS STENTING RAO CRANIAL 6F KIMNY guide
  16. 16. Second generation stents: Ostial Recoil
  17. 17. Current ostial/main stem(1,0,0) technique: Prepare the lesion prior to stenting Predilate to ensure complete balloon expansion… Consider cutting balloon or roational atherectomy 6F guide
  18. 18. Finish with IVUS 6F
  19. 19. Longitudinal stent compression
  20. 20. Use guidewire or buddy wire to keepguide catheter away from proximal stent
  21. 21. What about LM bifurcations? STRATEGY: STENT MAIN BRANCH WITH PROVISIONAL STENTING OF SB
  22. 22. LEFT MAIN 0,1,0TAXUS, 6F KIMNY guide
  23. 23. Provisional sidebranch stenting
  24. 24. TAP
  25. 25. 6F Kissing Balloons Yes Maverick(Boston) Voyager/Trek(Abbott) NO Apex(Boston)
  26. 26. Planned 2 stent techniques for true LM distal bifurcation disease • T • TAP • Mini-crush (or step crush) • Culotte • V stent • SKS (simultaneous kissing stents)
  27. 27. Generally speaking, a planned 2 stentstrategy with today‟s second generation stents requires 7F guide
  28. 28. 6F SHEATH 7F GUIDE
  29. 29. Sheathless: smaller diameter catheter improves transition (7F 100cm guide with 4F 125cm dx)
  30. 30. “Proximal optimization” SHORT BALLOON to „optimize” prox stent
  31. 31. “Sloppy kiss”
  32. 32. MACCE to 3 Years by SYNTAX Score Tercile Left Main SYNTAX Score 33 CABG (N=149) CABG PCI P value TAXUS (N=135) Left Main Death 7.6% 13.4% 0.10 40 P=0.003Cumulative Event Rate (%) 37.3 CVA 4.9% 1.6% 0.13 30 % 20 MI 6.1% 10.9% 0.18 21.2% Death, 10 CVA or 15.7% 20.1% 0.34 MI 0 0 12 24 36 Revasc. 9.2% 27.7% <0.001 Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value Site-reported data; ITT populationTwo-year Outcomes of the SYNTAX Trial • EOC unblinding
  33. 33. When considering all the variables when making a left main stent decision in a given patient, whether or not to go transradial is the easiest
  34. 34. Effect of PCI on MACCE and theComposite of Death, MI, or Stroke Capodanno JACC2011;58:1426-1432
  35. 35. PCI for unprotected left main DELETEDRecommendation It is reasonable that patients I IIa IIb III undergoing PCI to unprotected left main coronary obstructions be followed up with coronary angiography between 2 and 6 months after PCI. 38
  36. 36. Meta-analysis of randomized LM Trials: MACE Ferrante et al Eurointervention 2011

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