drug eluting stent implantation for unprotected left main

Angioplasty Summit Seoul

Sunao Nakamura M.D,Ph.D.New Tokyo Hospital

New Tokyo Circulation Research Group

Drug Eluting Stent Implantation For Unprotected Left Main Coronary

Arteries

Drug Eluting Stent Implantation For Unprotected Left Main Coronary

Arteries


1. Park SJ, Kim YH, Lee BK, et al.Sirolimus-eluting stent implantation for unprotected left main coronaryartery stenosis. Comparison with bare metal stent implantation.

J Am Coll Cardiol 2005;45:351-62. Jose Suarez de Lezo, Alfonso Medina, Manuel Pan, et al.

Rapamycin-eluting stents for the treatment of unprotected left main coronary disease.

Am Heart 2004;148:481-53. Marco Valgimigli, Carlos A.G. van Mieghem, Andrew T.L. Ong, et al.

Short- and Long-Term Clinical Outcome After Drug-Eluting Stent Implantation for the Percutaneous Treatment of Left Main Coronary Artery Disease.

Circulation. 2005;111:1383-13894. Alaide Chieffo, Goran Stankovic, Erminio Bonizzoni, et al.

Early and Mid-Term Results of Drug-Eluting Stent Implantation in Unprotected Left Main.

Circulation 2005;111:791-7955. Marco Valgimigli, Patrizia Malagutti, Jiro Aoki, et al.

Sirolimus-Eluting Versus Paclitaxel-Eluting Stent Implantation for the Percutaneous Treatment of Left Main Coronary Artery Disease.

J Am Coll Cardiol 2006;47:507-146. Matthew J. Price, Ecaterina Cristea, Neil Sawhney, et al.

Serial Angiographic Follow-up of Sirolimus-Eluting Stents for Unprotected Left Main Coronary Artery Revascularization.

J Am Coll Cardiol 2006;47:871-7

Drug-Eluting Stent for Left Main Coronary ArteryDrug-Eluting Stent for Left Main Coronary Artery


1. S Nakamura, et al. Initial clinical experience of Sirolimus-eluting stent for treatment of left main coronary artery disease.

JSC 2004

2. S Nakamura, et al.Durable clinical benefit following Sirolimus-eluting stent deployment on the outcome of patients with unprotected left main coronary arteries.

TCT 2004, ACC 2005

3. S Nakamura, et al.Comparison of efficacy and safety between Sirolimus-eluting stent and Paclitaxel-eluting stent in unprotected left main coronary.

ACC 2005, ESC 2005

Drug-Eluting Stent for Left Main Coronary ArteryDrug-Eluting Stent for Left Main Coronary Artery


Saint Louis Hospital

Siriaj Hospital

-Multicenter Registry in Asia--Multicenter Registry in Asia-

Tamil Selvan Muthusamy M.D. (Malaysia)

Jang-Ho Bae M.D. (Korea)

Sudaratana Transapasawasdikul M.D.(Thailand)

Sunao Nakamura M.D., Ph.D. (Japan)

Yeo Hans Cahyadi M.D. (Indonesia)

Damras Tresukosol M.D. (Thailand)

Wasan Udayachalerm M.D. (Thailand)

New Tokyo Hospital

Chest Disease Institute

Konyang University Hospital

Husada Hospital

King ChulalongkornMemorial Hospital

Boonsert Chatlaong M.D. (Thailand)

Damansara Heart Center

Far Eastern Hospital Chao Loun Lai M.D. (Taiwan)


20022002 20032003 20042004

MarMar

20052005

Study Patients : LMTStudy Patients : LMT

Patients n=118Patients n=118

FebFeb




TAXUS: Asian Multicenter LMT Registry

FebFeb FebFeb

20062006

FebFeb

Cypher: Asian Multicenter LMT Registry



BMS: Japanese Multicenter Registry


> 2 yearｓ

> 1 year

> 3 yearｓ

> 3 yearｓ

> 2 yearｓ

> 2 yearｓ

> 1 year


Can We Improve Clinical Outcome of LMT PCI ?Can We Improve Clinical Outcome of LMT PCI ?

In hospital outcome

Can reduce restenosis ?

Long term durability ?

Cypher and TAXUS registry

Other DES ?

In hospital outcome


Cypher(n=193)

In-Hospital OutcomeIn-Hospital Outcome

Angiographic success (%)

Clinical success (%)

MACE (n)DeathQMIUrgent CABGUrgent PCI

Minor complication (%)Vascular hematoma

100

99.0

0101

4.9

100

100

0000

5.2

BMS(n=102)

(SAT)

(SAT)

p

NS

NS

NSNSNSNS

NS

100

100

0000

6.0

TAXUS(n=118)

Cypher TAXUSvsvs 2years2years

No SAT


0

5

10

15

5.55.5 5.95.9

00

10.010.0

00

Valgimigli

Chieffo

NakamuraPark

Price

30 DAYS: MACE30 DAYS: MACE

NO SAT

DES in LMT

(%)



In hospital outcome




Other DES ?



Restenosis RateRestenosis Rate

0

20

40(%)

14.114.1 12.012.0

7.17.1

38.038.0

7.07.0

Valgimigli

Chieffo

NakamuraPark

Price

DES in LMT


Angiographic Follow-UpAngiographic Follow-Up

Clinical f/u (n)Angiographic f/u (n)

Ref. diameter (mm:mean)MLD (mm:mean)

Late loss (mm:mean)Loss index (%:mean)

Restenosis rate (%)TLR (%)

102/102100/102

3.52.6

0.936.0

19.614.7

193/193170/193

3.53.3

0.28.0

6.24.7

NSNS

NS0.01

0.010.01

0.010.01

BMS12 mo

(n=102)

Cypher12 mo

(n=193)

118/118110/118

3.53.0

0.412.6

8.47.6

TAXUS12 mo

(n=118)

BMS24 mo

(n=102)

102/10294/102

3.52.6

0.936.0

19.614.7

Cypher24 mo

(n=193)

193/193146/193

3.63.2

0.28.0

6.24.7

118/11882/118

3.63.0

0.412.6

8.47.6

TAXUS24 mo

(n=118)

Cypher TAXUSvsvs 2years2years

p


Restenosis Patients !!Restenosis Patients !!

Ostium Mid shaft Bifurcation

BMS Cypher TAXUS

3.93.9

1.01.0

14.714.7

7.67.66.26.2

15

10

5

0

(%)

00 0.80.800 00


TLR Patients: 4.7%TLR Patients: 4.7%

LCX ostiumCulotteBifurcationM68No.5




LCX ostiumCrushingBifurcationF65No.9

LAD ostiumCrushingBifurcationM62No.8

LCX ostiumModified TBifurcationM77No.6

LCX ostiumStenting across LCXBifurcationF78No.1

Distal stent edgeLCX ostiumCrushingBifurcationM82No.7

Location of restenosisStenting strategyLesion locationGenderAge

Cypher


TLR Patients: 7.6%TLR Patients: 7.6%

4 moLAD ostiumTAXUSCulotteBifurcationM70No.3

7 moLCX ostiumTAXUSCrushBifurcationM73No.4

LMT - LAD diffuse

LCX ostium

Distal stent edge

LCX ostium

LCX ostium

LCX ostium

Location ofrestenosis

5 moTAXUSStenting across LCXBifurcationM54No.9

6 moTAXUSCulotteBifurcationM68No.8

4 moTAXUSKissing stentBifurcationM82No.7

6 moTAXUSStenting across LCXBifurcationF78No.6



Timing of restenosisStentStenting strategyLesion locationGenderAge

6 moLCX ostiumTAXUSCrushBifurcationM73No.5

TAXUS


Severely calcified cases

Bifurcation lesion

CTO

ISR

Low EF: Improve LV contraction ?

Bifurcation lesion

Can We Perform LMT PCI in ALL Cases ?Can We Perform LMT PCI in ALL Cases ?


Stenting Procedure of bifurcation lesion in LMTStenting Procedure of bifurcation lesion in LMT

Park SingleSingle KissingKissing

Valgimigli CulotteCulotteT-stentT-stent

Chieffo SingleSingle CrushCrush V-stentV-stent

Price SingleSingle

0 50 100 (%)

Nakamura SingleSingle

CrushCrushOthersOthers

CulotteCulotteT-stentT-stent

CrushCrushKissingKissing OthersOthers

CulotteCulotteT-stentT-stent

CrushCrushKissingKissingSingleSingle

CrushCrush


PreLMT bifurcation lesion Culotte stenting Post

Follow-up

LMT1

LCX ostial ISR

Distal

Cypher

Restenosis LCX ost.

Case 7 :LMT bifurcation lesionCase 7 :LMT bifurcation lesion


1st step

2nd step

Main Artery

Advance the two stentsin the bifurcation lesion simultaneously

anddilated of stent in side branch only

Double wiring to theboth branch

andkissing ballooning

Mini-Crushing Stenting Technique (1)

Side branchSide branch

If we really want double stenting….


3rd step

4th step

5th step

Recross the wire through the stent strut in the main vessel to the side branch

Remove the stent balloon and wire from the side branch

andDeploy the stent in the main vessels

Kissing ballooning to the both vessels

Mini-Crushing Stenting Technique (2)


Angiographic follow-up (%)Angiographic restenosis (n)

BothLMT - LADLMT - LCX

In-hospital MACE

12-month total MACE (n)DeathMICABGTLR

88.6

0010

0001

91.3

1130

0004

85.7

0010

0001

91.7

0030

0003

Follow-Up Results 12moFollow-Up Results 12moSingle

stentingCulottestenting

n=79 n=46

Crushingstenting

n=42 n=24

ModifiedT-stenting

Cypher



In hospital outcome




Other DES ?Other DES ?



Bifurcation lesion

CTO

ISR






Bifurcation lesion

CTO

ISR


CTO




Bifurcation lesion

CTO

ISR

Low EF: Improve LV contraction ?Low EF: Improve LV contraction ?



Conclusions Conclusions 1. Treatment of unprotected left main trunk coronary artery disease with

Cypher Sirolimus-eluting stent and Paclitaxel-eluting stent are safe and feasible.

2. Implantation of Cypher Sirolimus-eluting stent and Paclitaxel-eluting stent result in a larger MLD at follow-up and dramatically decrease the restenosis rate and target lesion revascularization compared with implantation of bare metal stent.

3. Implantation of Cypher Sirolimus-eluting stent and Paclitaxel-eluting stent with modified T-stenting with mini-crush stenting technique and single stenting technique seems to be able to decrease the restenosis rare at follow-up compared with other stenting techniques.

4. These clinical benefits with Cypher Sirolimus-eluting stent and Paclitaxel-eluting stent are durable at least 2 years.

drug eluting stent implantation for unprotected left main

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