cath conference
DESCRIPTION
Cath Conference. 7/9/08 Priya Pillutla, M.D. History. HPI 58 y/o M presented in May ‘08 w/escalating chest pressure at rest and with exertion Symptoms relieved with NTG; exertional chest pain better with rest - PowerPoint PPT PresentationTRANSCRIPT
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7/9/08Priya Pillutla, M.D.
Cath Conference
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History
Priya Pillutla, MD
• HPI – 58 y/o M presented in May ‘08 w/escalating
chest pressure at rest and with exertion – Symptoms relieved with NTG; exertional
chest pain better with rest– Cath planned but patient eloped; referred
back from clinic for persistent chest pain• PMH – CAD, DJD
– NSTEMI 11/07. Cath showed R dominant system, 90% proximal LAD stenosis s/p PCI (3.5x12mm taxus and 4x18mm driver)
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History
Priya Pillutla, MD
• Meds – Metoprolol, clopidigrel, simvastatin, lisinopril, NTG as needed, adderal
• Allergies - ?iodine (no complications 11/07)
• Social hx - Marginally housed, denies substance abuse – Utox + meth, cannabis
• Family hx - noncontributory
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Physical Exam
Priya Pillutla, MD
VS – BP 128/65, HR 60, RR 13, 98% RADisheveled JVP 7 cm H20. Neck supple, normal carotid
upstrokesPMI nonsustained, nondisplaced. RRR nl
s1/s2. No s3/s4. No murmurs.Lungs clearAbdomen soft, nontenderNo edema2+ radial, femoral and dorsalis pedis pulses
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Laboratory Data
Priya Pillutla, MD
Electrolytes - K 4.5, Cr 0.8Hematocrit - 40.8Platelets - 230KINR - 1Cardiac biomarkers - Troponin neg, CKMB
normal x 3
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Priya Pillutla, MD
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Cardiac Catheterization
Priya Pillutla, MD
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Summary
Priya Pillutla, MD
• High-grade (95-99%) in-stent restenosis of the proximal LAD and proximal stent 40% stenosis
• PCI of proximal LAD using cutting balloon (4x10mm)– Probable compliance issues given living situation and
+utox
• Excellent angiographic result with TIMI 3 flow and resolution of chest pain
• Patient observed overnight and discharged the following day without complications
• Missed cath f/u appointment
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In-stent restenosis
Priya Pillutla, MD
Can be seen in 5-35%1 of patients after PCI Somewhat lower after DES
Mechanisms include:Negative remodelingElastic recoilNeointimal hyperplasia
1Stone et al, JAMA, 2005
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Treatment options
Priya Pillutla, MD
Angioplasty (PTCA, cutting balloon)High rates of restenosis1 (39-67%)
Mechanical debulking (rotational, laser)Repeat stenting (BMS, DES)Intracoronary radiation (brachytherapy)
1Scheller et al, NEJM, 2006
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Priya Pillutla, MD Dauerman, JACC, 2006
(Not shown - TAXUS V, showing that PES is better than brachytherapy)
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Current effective treatments
BrachytherapyWorks well but considerable safety, logistical
and technical issuesRisk of stent-edge restenosis and thrombosis
DESRecurrence rates 13-22%1
DES + DES = higher rate of restenosis2 (43%)Very small but serious risk of stent
thrombosis1Scheller et al, NEJM, 2006
2Lemos et al, Circulation, 2004
Priya Pillutla, MD
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What’s special about DES?Drug-elution is key
Can drug be delivered for a shorter time?Can lower levels of drug still attain
antiproliferative effects?Data (cell-culture and swine experiments)
suggest that both of the above are true!
Priya Pillutla, MD
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Paclitaxel-Coated Balloon Angioplasty – PACCOCATH ISR NEJM, 2006 (Scheller et al)Hypothesis - Angioplasty using paclitaxel-
coated balloons will prevent in-stent restenosisBalloon delivers all of the drug at once and is
then withdrawn
Priya Pillutla, MD
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Study designDouble-blind, randomized pilot study Inclusion
Angina or +functional studySingle restenotic lesion
ExclusionRecent MI, CKD, allergySick or noncompliantLong (>30mm) or small (<2.5mm) lesions<70% stenosisSignificant calcificationThrombus
Priya Pillutla, MD
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Study DesignPatients randomized to
Conventional PTCA PTCA with paclitaxel-coated balloon (3 ug/mm2)
Angiography before, after and at 6 months using QCA (quantitative coronary angiography)
ASA, plavix x 1 month then ASA aloneEndpoints
Primary – late luminal loss (lumen at 6 months vs after PTCA)
Secondary – restenosis, combined clinical events
Priya Pillutla, MD
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Results52 patients
26 patients in each groupSimilar baseline and procedural
characteristicsMean age 64 years71% menMost patients had multi-vessel disease with
diffuse ISR
Priya Pillutla, MD
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Angiographic findings – 6 months
Uncoated Coated p value
MLD (in-stent) 1.6 mm 2.3 mm 0.004
LLL (in-segment)
** primary endpoint
0.74 mm 0.03 mm 0.002
Restenosis (%) 43 5 0.002
MLD = minimal lumen diameter; LLL = late lumen lossPriya Pillutla, MD
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Priya Pillutla, MD
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Priya Pillutla, MD
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Priya Pillutla, MD
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Adverse events – related or possibly related to procedureUncoated group
2 small groin hematomas 6 revascularizations, 1 unstable angina
Coated group3 small groin hematomas1 MI (possibly related)** Second MI noted in a patient randomized
to uncoated balloon who erroneously received coated balloon, possibly related to balloon
Priya Pillutla, MD
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LimitationsExtremely smallNot truly blinded – coated balloons had
distinct appearanceShould be studied in comparison with
standard of care (DES)Anti-platelet agents only given for 1 monthWas LLL an appropriate parameter?
DES trials show that early LLL may not correlate well with restenosis
Nevertheless results are encouraging
Priya Pillutla, MD
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SummaryIn-stent restenosis continues to complicate
PCIsNeoproliferation, negative remodeling and
elastic recoil are causative factorsTherapy
Data most strongly supports DES at this timeDrug-coated balloon PTCA is likely to be an
emerging modality
Priya Pillutla, MD