Angioplastía del TCI: El Papel de la Imagen Intracoronaria

Mauricio G. Cohen, MD, FACC

Associate Professor of Medicine,

Director Cardiac Cath Lab

@DrMauricioCohen

#RadialFirst

Disclosure Statement of Financial Interest

Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or

affiliation with the organization(s) listed below.

Affiliation/Financial Relationship Company

Grant/Research Support

Consulting Fees/Honoraria Abiomed / Terumo Medical / Medtronic /

Merit Medical / The Medicines Company

Major Stock Shareholder/Equity Accumed

Royalty Income None

Ownership/Founder None

Intellectual Property Rights None

Other Financial Benefit None

Circ Cardiovasc Interv. 2016;9:e003700

Major Adverse Cardiac Events

7 RCTs

3192 patients

IVUS associated with larger post-PCI MLD,

and greater reduction in the diameter stenosis

Circ Cardiovasc Interv. 2016;9:e003700

Cardiovascular Mortality

Myocardial Infarction

TLR

Stent Thrombosis 0.49 (0.24–0.99) 0.04

0.60 (0.43–0.84) 0.003

0.52 (0.26–1.02) 0.06

0.46 (0.21–1.00) 0.05

OR (95% CI) p value

ADAPT DES: How IVUS changed the procedure?

38

23 22

13

7 8

0

10

20

30

40

50

Larger stentor balloon

Higherinflationpressure

Longer stent Incompleteexpansion

Incompleteapposition

Additionalstent

Pati

en

ts, %

Post Dilation

Operator changed the PCI strategy in 74% (2484/3349) of patients

IVUS used:

• before PCI only 7%

• after PCI only 30%

• before and after PCI 63%

Witzenbichler B et al.

Circulation 2014;129:463-470

“All-comers” study of 8,583 patients to determine the frequency,

timing, and correlates of stent thrombosis and adverse clinical

events after DES. IVUS utilized in 3349 patients (39%)

Definite/P

robable

ST

(%

)

Time in Months

3361 3260 3182 3065 1791

5221 5019 4886 4713 2279

Number at risk:

IVUS Used

IVUS Not Used

P = 0.004

HR: 0.47 [95% CI: 0.28, 0.80]

0.55%

1.16%

0

1

2

0 6 12 18 24

IVUS Used

No IVUS Used

Witzenbichler B et al. Circulation. 2014;129:463-470

Relationship Between IVUS Use and Definite/Probable Stent

Thrombosis Within 2 Years

Case Presentation

• 74 yo woman, DM, HTN, DLP, CKD III, Obesity (BMI 44)

2008: BKA of the left / right iliac stent

2015: Lateral wall MI – PCI of LCx

• Current presentation: NSTEMI

• Diffuse 2 mm down sloping ST segment depression

• Troponin 0.3, GFR 33 (Cr 1.44), Hb 12.5, Plts 144

• Small R radial artery, 2.5-3 mm L radial artery

• STS PROM 4.042%

• CT surgery said NO

Diagnostic

Cath

Syntax Score 29

Left Main Disease – Rules

• Heart Team discussion - Guidelines

• Stenting strategy

Location: ostium, shaft and/or bifurcation

Understanding of bifurcation stenting techniques

• Imaging is critical: IVUS or OCT

• Focus on access safety

Transradial access with slender 7-in-6

Transfemoral for support

• Pelvis CT to assess iliofemoral vessel size

• Ultrasound guided access with micropuncture

Recommendations for LM Revascularization

Levine G, et al. J Am Coll Cardiol. 2011;58:44-122

Windecker S, et al. Eur Heart J. 2014;35:2541-619

United States Europe

PCI CABGLow

SxScore 0-22 IIa B I B

Intermediate

SxScore 23-32 IIb B I B

High

SxScore >32 III B I B

PCI CABGLow

SxScore 0-22 I B I B

Intermediate

SxScore 23-32 IIa B I B

High

SxScore >32 III B I B

8,1

10,8

15

8,3

12,7 12,4

0

2

4

6

8

10

12

14

16

SS 0-22 SS 23-32 SS >33

PCI CABG

Head SJ et al. Lancet 2018; 391: 939–48

Left Main Disease

All Cause Mortality11 Trials 1·02 (0·77–1·34)

P= 0·91

1·20 (0·94–1·51)

P= 0·14

1·52 (1·15–2·02)

P=0·0029

Mortality According to

Syntax Score

Pinteraction

0·21

Relative Risk Reduction with PCI

vs. CABG in the EXCEL TrialProcedure

Early Peri-procedure

Stone GW et al. N Engl J Med 2016;375:2223-2235

-50%

-38%

-58%

-75%

-86% -87%-100%

-90%

-80%

-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

Str

oke

MI

Ble

ed

ing

Rena

l fa

ilure

Pro

lon

ged

intu

bation

Arr

hyth

mia

s

**

*

*

**

*P<0.05

Short Term Outcomes

Pre-stent deployment assessment of lesion

characteristics, calcification, and size for LM

Disease feature Studied cutoff

Plaque characterization Thin cap fibroadenoma, fibrotic,

lipid-rich, or calcified

Minimal luminal area (MLA) < 6 mm2

Lesion calcification requiring

atherectomy

> 270°

Landing zone evaluation Ideally, < 50% stenosis and without

lipid-rich plaque.

IVUS to Guide the LM Intervention

de la Torre Hernandez J et al. JACC CV Int 2014;7:244–54

Pooled analysis of 4 registries in Spain – 2 propensity-matched

groups of 1010 pts (505 x 2) with and without IVUS

IVUS No IVUS P

Overall, n 505 505

MACE (Death, MI, TLR) 14.4 22.2 0.006

- Death 7.4 13.0 0.01

- Cardiac 3.3 6.0 0.07

- MI 4.5 6.5 0.4

- TLR 7.7 6.3 0.7

Stent thrombosis (def/prob) 0.6 2.2 0.04

Subgroup with distal lsns, n 221 226

Cardiac death, MI, TLR 11.0 19.0 0.03

Distal lsns + 2 stents, n 63 62

Cardiac death, MI, TLR 16.7 41.0 0.02

MACEAdj HR (95%CI) =

0.70 (0.52–0.99)

P = 0.04

Days

Surv

ival (%

)

IVUS

No IVUS

100

90

80

70

60

0 200 400 600 800 1000 1200

Slide Courtesy: Gregg Stone

EXCEL Trial: IVUS-Guided PCI

in 690/935 pts (74%)

Pre and Post-Stenting

Post-Stenting Only

Pre-Stenting Only

43.2%

39.1%

16.4%

Maehara A. TCT 2016

EXCEL: Change in LM stenting by IVUS

YESNO

51.7%

N=357

48.3%

N=333

• Used larger balloon: 30% (107)

• Post-dilated: 29% (102)

• Used higher pressure: 17% (62)

• Treated stent under-expansion: 16% (57)

• Led to provisional 1 stent strategy rather

than planned 2 stents: 11% (41)

• Led to planned 2 stent strategy rather

than provisional 1 stent: 9% (33)

Maehara A. TCT 2016

*IDR: ischemia driven revascularization

IVUS MSA tertiles (range)Low: 4.4-

8.7 (n=172)

Inter: 8.8-

10.9 (n=169)

High:

11.0-17.8

(n=163)

P

L vs I

P

L vs H

Death/MI/stroke 19.4% (32) 16.1% (26) 9.6% (15) 0.45 0.01

Death/MI/stroke/IDR* 26.6% (44) 23.8% (39) 18.3% (29) 0.66 0.08

All cause death 13.8% (22) 10.0% (16) 5.2% (8) 0.34 0.01

Cardiovascular death 7.4% (12) 4.8% (8) 4.0% (6) 0.39 0.16

MI 10.5% (17) 8.2% (13) 3.7% (6) 0.49 0.02

Stroke 1.8% (3) 1.2% (2) 2.1% (3) 0.66 0.98

Stent thrombosis (D/P) 3.1% (5) 1.2% (2) 0.0% (0) 0.26 0.03

Left main IDR 12.0% (19) 8.3% (13) 8.8% (14) 0.30 0.41

Non-TV IDR 1.9% (3) 3.3% (5) 1.3% (2) 0.48 0.65

3-Year Outcomes by LM Minimal Stent Area

Maehara A. TCT 2016

Conclusions of EXCEL IVUS Substudy

• In the EXCEL trial, 73% of PCI cases were performed

using IVUS guidance. In the half of IVUS guidance cases,

the procedure was changed by the IVUS findings.

• After treatment with CoCr-EES, a small final MSA of the

left main coronary artery measured by IVUS was strongly

associated with death, MI and stent thrombosis during

long-term follow-up.

Maehara A. TCT 2016

• 11.4% with ISR at 9 months

• 33.8% with underexpansion of one segment

• Angiographic ISR 24.1% with underexpansion

vs. 5.4% without underexpansion.

• Although acute malapposition was observed in

28 pts, malapposition was not related to MACE

at follow-up.

LAD

ostium

LCX ostiumPOC

Proximal

LM 8mm2

Criteria for Underexpansion

Kang et al. Circulation Cardiovasc Interv. 2011;4:562-9

MACE98.1%

90.2%

Months after Initial Procedure

Eve

nt F

ree

Su

rviv

al R

ate

(%

)

P<0.001

100

Log-rank test

Underexpansion (+)

Underexpansion (-)

No. at risk

Underexpansion (+)

Underexpansion (-)

133

260

131

260

126

255

121

246

75

129

90

80

70

60

50

40

0 6 12 18 24

TLR

98.5%

90.9%

Months after Initial Procedure

Eve

nt F

ree

Su

rviv

al R

ate

(%

)

P=0.001

100

Log-rank test

Underexpansion (+)

Underexpansion (-)

No. at risk

Underexpansion (+)

Underexpansion (-)

133

260

131

260

126

255

121

246

75

129

90

80

70

60

50

40

0 6 12 18 24

MACE-free and TLR-free Survival

Kang et al. Circulation Cardiovasc Interv. 2011;4:562-9

• Strut protrusion into the aorta was seen in 68%, with a

protrusion length of 3.4±1.7mm

• Incomplete stent ostial coverage seen in 23%, with uncovered

ostial length of 2.3±1.3mm and residual plaque burden of

38±12%

• Acute malapposition seen 18.8%

• Only 1.2% of LMCA developed ostial restenosis; and not

related to strut protrusion or ostial coverage or acute

malapposition

Kang et al. Am J Cardiol 2013;111:1401-7

n=199 (Left main)

When treating an ostial or proximal lesion with a DES, the

decision of whether to protrude the proximal end of the stent or

leave the ostium uncovered does not appear to be critical

Algorithm for LM Bifurcation PCI

Rab T, et al. JACC Interv 2017;10:849–65

• Provisional stenting of side branch (usually LCx)

• Culotte: narrow angle, similar vessel diameters of

LAD and LCX

• DK Crush: narrow or wide angle, dissimilar vessel

diameters.

• DK crush better than Culotte, provisional

• TAP: wide angle, dissimilar vessel diameters

• T-stent: wide angle

• V-stent: Y bifurcation – Unstable patients

• Simultaneous kissing stents: patient unable to

tolerate ischemia

• Tryton Stent: Non DES

Chen, S-L et al. J Am Coll Cardiol 2017;70:2605–17

Kandzari D et al. Circ Cardiovasc Interv. 2018;11:e007007

DK Crush VDouble Kissing and Double Crush Versus Provisional T Stenting Technique

Stenting Technique N=529

Provisional stent 65.2%

Sidebranch balloon 70.7%

Sidebranch stent 22.1%

Planned 2-stent 34.8%

T-stent 51.1%

Culotte 23.3%

EXCEL Trial

14,4 21,20

5

10

15

20

25

MACE 3 yrs

Provisional 2-Stent

HR 0.51, 95%CI 0.32, 0.82, adjusted P<0.005

Kandzari DE et al. Circ Cardiovasc Interv. 2018;11:e007007

77

Number at risk:

73 72 69 67 67 64264 246 242 238 233 227 218105 90 88 86 85 83 8278 70 69 64 61 60 55

14.3%

19.2%

13.8%

23.3%

0

5

10

15

20

25

30

Time (Months)

0 6 12 18 24 30 36

Provisional 1-stent and 2 SBs with DS ≥50%

Planned 2-stents and 2 SBs with DS ≥50%

Provisional 1-stent and 0-1 SB with DS ≥50%

Planned 2-stents and 0-1 SB with DS ≥50%

De

ath

, s

tro

ke

or

MI (%

)

HR [95% CI =

0.56 [0.32, 0.99]

P = 0.04

HR [95% CI =

0.71 [0.34, 1.48]

P = 0.36

Provisional 1-Stent vs. Planned 2-Stents

For LM Distal Bifurcation Disease (n=529)

Almost all bifurcation lesions, including the

distal LM bifurcation, can be safely treated by

radial artery access using a 6 Fr guiding catheter.

EuroIntervention 2016;12:38-46

Lesion Preparation: 1.5 Rota Burr

IVUS post Rotational Atherectomy

LAD stenting with short main branch

protrusionResolute

2.75 x 30 mm

LAD

LAD stent

balloon crush

NC 3.5 x 12 mm

LCx

Side (LAD) Branch wire recrossing

First kissing

balloon inflation

• NC 3.5 x 12 mm - LCx

• NC 2.5 x 15 mm - LAD

Side branch wire is removed

Main branch (LCx) stenting

across the Side Branch

Resolute 3.5 x38 mm

POT

Proximal

optimization

technique

Second side branch

wire recrossing

through the main

branch stent and the

crushed SB stent

Second kissing

balloon inflation

• NC 3.5 x 12 mm - LCx

• NC 2.5 x 15 mm - LAD

Re-POT

Re–proximal

optimization

techniqueNC 4.0 x 12 mm

IVUS

Final Result

Access and Hemostasis #ldTRA

Ahn et al. BMC Cardiovascular Disorders (2016) 16:49

Unprotected LM PCI

• Heart Team endorsement

• Use your best stent, endorsed by data

• Always imaging

• Knowledge of devices and bifurcation techniques

Provisional stenting is preferred DKCRUSH

• Access:

Consider radial slender techniques. Usually 7-in-6

Femoral access for support Ultrasound & Micropuncture& Preclose