SCAI 2015 FELLOWS COURSE 6-9 DECEMBER PCI Left Main and Multi-vessel. Antonio Colombo

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1 SCAI 2015 FELLOWS COURSE 6-9 DECEMBER 2015 PCI Left Main and Multi-vessel Speaker 12 Antonio Colombo Centro Cuore Columbus and S. Raffaele Scientific Institute, Milan, Italy

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4 MACCE (%) MACCE to 5 Years by SYNTAX Score Tercile LM Subset High Scores CABG (N=149) TAXUS (N=135) P=0.003 LM Disease 46.5% CABG PCI P value Death 14.1% 20.9% 0.11 CVA 4.9% 1.6% % MI 6.1% 11.7% 0.13 Death, CVA or MI 22.1% 26.1% Months Revasc. 11.6% 34.1% <0.001 Serruys PW et al. Lancet 2013;381:629 38

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10 SYNTAX: Definite/Probable ARC Stent Thrombosis to 5 Years (Per Patient) ~4.5% ST in year 1 ~1.2% ST/yr in years (3/896) (23/893) (15/874) (11/850) (12/830) Acute 1d 2.6 Subacute 2-30d 1.7 Late d d d Very Late Days Post-procedure (10/803) (7/768) d d Rate was ~ same in the LM and 3VD cohorts, and roughly independent of Syntax Score 0 (76/730) Total 5 year Serruys PW. JACC 2013:

11 Interpretation In randomised studies completed to date, CoCr- EES has the lowest rate of stent thrombosis within 2 years of implantation. The finding that CoCr-EES also reduced stent thrombosis compared with bare-metal stents, if confirmed in future randomised trials, represents a paradigm shift.

12 NEJM 2015 Randomized study 442 pts. CABG vs. 438 EES 40% diabetics, over 75% 3V ; mean Syntax score 24; 3 stents per patient; IVUS 70%

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15 Crude Incidence, % Crude Incidence, % Crude Incidence, % Crude Incidence, % Diabetic Subgroup Death, MI, Stroke, or Repeat Revascularization P interaction =0.053 Death from any cause P interaction =0.77 PCI CABG HR (95%CI) 2.29 ( ) HR (95%CI) 1.16 ( ) HR (95%CI) 1.25 ( ) HR (95%CI) 1.47 ( ) Death, MI, or Stroke Repeat Revascularization P interaction =0.54 P interaction =0.041 HR (95%CI) 1.46 ( ) HR (95%CI) 1.13 ( ) HR (95%CI) 4.31 ( ) HR (95%CI) 1.38 ( ) Percentages are crude rates throughout the available follow-up period

16 NEJM 2015 Registry with propensity matching

17 Mean FU 2.9 yrs.

18 Circulation 2011

19 Indications for Reasonable Incomplete Revascularization Reasonable Incomplete Revascularization Anatomy Guided Function Guided Physiology Guided Very small vessels Only 1 epicardial vessel unrevascularized Jailed asymptomatic side branches Not culprit artery (thrombus) Area supplied has nonviable myocardium Less than 5% residual ischemic territory expected Small territory of ischemia Fractional flow reserve >0.80 Dauerrman: Circ, 2011

20 Cumulative survival Impact of Reasonable Incomplete Revascularization in Patients with LIMA to LAD 8,806 pt MVD 936 pt IR Cx RCA 1,0 All Cause Mortality Reasonable IR Non-dominant RCA Non-viable myocardium Off-pump CAB Limited graft material Small distal vessels Severe calcification Rastan: Circ, ,8 0,6 0,4 0,2 0,0 Complete revascularization (CR) Incomplete revascularization (IR) P=0.457 No difference between RCA and Cx Follow-up (years)

21 Fractional Flow Reserve following IV adenosine

22 Controversy between Angio /IVUS/FFR Lumen Area 2.6 mm FFR = 0.83

23 Reasonable incomplete revascularization PCI or LIMA PCI Medicine

24 In order to complete the revascularization: With CABG you need to open the chest With PCI you need to puncture an artery

25 A case for surgery even in the era of 2 gen Drug Eluting Stent