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
MACCE (%) MACCE to 5 Years by SYNTAX Score Tercile LM Subset High Scores 33 50 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% 0.13 25 29.7% MI 6.1% 11.7% 0.13 Death, CVA or MI 22.1% 26.1% 0.40 0 0 12 24 Months 36 48 60 Revasc. 11.6% 34.1% <0.001 Serruys PW et al. Lancet 2013;381:629 38
SYNTAX: Definite/Probable ARC Stent Thrombosis to 5 Years (Per Patient) 12 12 10.4 ~4.5% ST in year 1 ~1.2% ST/yr in years 2-4 6 6 0 0.3 (3/896) (23/893) (15/874) (11/850) (12/830) Acute 1d 2.6 Subacute 2-30d 1.7 Late 31-365d 1.3 1.4 1.2 0.9 366-730d 731-1095d Very Late Days Post-procedure (10/803) (7/768) 1096-1460d 1461-1825d 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:
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.
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%
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 (1.35-3.87) HR (95%CI) 1.16 (0.78-1.79) HR (95%CI) 1.25 (0.58-2.70) HR (95%CI) 1.47 (0.66-3.28) Death, MI, or Stroke Repeat Revascularization P interaction =0.54 P interaction =0.041 HR (95%CI) 1.46 (0.78-2.74) HR (95%CI) 1.13 (0.66-1.93) HR (95%CI) 4.31 (1.76-10.6) HR (95%CI) 1.38 (0.75-2.53) Percentages are crude rates throughout the available follow-up period
NEJM 2015 Registry with propensity matching
Mean FU 2.9 yrs.
Circulation 2011
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
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, 2009 0,8 0,6 0,4 0,2 0,0 Complete revascularization (CR) Incomplete revascularization (IR) P=0.457 No difference between RCA and Cx 0 1 2 3 4 5 6 7 8 Follow-up (years)
Fractional Flow Reserve following IV adenosine 29072008
Controversy between Angio /IVUS/FFR Lumen Area 2.6 mm 2 102 83 FFR = 0.83
Reasonable incomplete revascularization PCI or LIMA PCI Medicine
In order to complete the revascularization: With CABG you need to open the chest With PCI you need to puncture an artery
A case for surgery even in the era of 2 gen Drug Eluting Stent