PCI For MVD: Complete vs Partial Revascularization --Partial More Realistic in Most Patients

1. PCI For MVD: Complete vs Partial Revascularization--Partial More Realistic in Most Patients Yuejin Yang MD, PhD, FACC Cardiovascular Institute and Fu-Wai Hopital, CAMS & PUMC CIT 2010, Mar.31-April.3,2010, Beijing, China

2. Indications for Revascularization • Myocardial ischemia due to chronic severe coronary mechanical blockages (stable AP) • Acute myocardial ischemia due to acute coronary severe mechanical stenosis (UA or NSTEMI) • AMI due to acute coronary thrombotic total blockages (STEMI) • The evidence of myocardial ischemia or infarction • The evidence of coronary mechanical severe stenosis even obstructions except for non-mechanical one

3. Why Revascularization? • Solve the coronary mechanical blockages • Bypass a new conduit (CABG) • Open and scarfolding the blockage lesions (PCI: stenting) • Not for the non-mechanical obstructions • Not for thrombotic stenosis except for total obstructions (STEMI) • Medications for the non-mechanical and less severe coronary obstructions • Anti-spasm • Anti-platelet and anti-coagulation • Stablizing the vulnerable plaque

4. Why Complete Revarscularization • CABG era • Once bypass surgery, complete Revars. • No routine dual-antiplatelet therapy • No statins • No medications for stabilizing even preventing from progression of the atherosclerotic plaque lesions

5. Why Partial Revarscularization • DES period • Routine dual anti-platelet regimen • Routing statins • Medical treatment can stabilize or prevent from lesion progression • Borderline lesions(50%-70%): no need for stenting without evidence of myocardial ischemia

6. PCI: Complete Revascularization? • No need in some pts with MVD • No improving long term outcomes • Just prevent myocardial ischemia and relieve ischemic symptoms • In pts without symptoms and ischemic evidence • In disdal coronary lesions • In senior persons • In small vessels • In 1-V CTO lesion with abundant collateral circulations

7. PCI: Complete Revascularization? • Technically impossible in some Pts • 3-V diffused disease • Diffused lesions • Small vessel CTOs • Distal severe stenosis even CTOs • Non-dominant RCA stenosis • High risk lesions (severe calcifications ) • In very old, weak and high risk pts • In AMI pts with another coronary CTOs

8. PCI: Complete Revascularization? • No more benefits even harmful for the pts • More stents • Much more costs • Over treatment • High risks for stent thrombosis • High risks for stent restenosis and revascularizations • Not criterion of PCI • No faithfulness between Drs and Pts • Waste limited medical sources

9. PCI: Partial Revascularization • More realistic in most pts with MVD • Stenting the ischemia related vessel • Ischemic symptoms alleviated even no more • PCI only for IRA in Pts with STEMI can save life • PCI only for proximal severe stenosis can improving quality of life and outcomes • Cost much less • Save the huge amount of medical sources and social expenses • Affordable for more pts and families

10. Cases 1: No need PCI for Samll LCX CTO Mr. Wang MX M 46yrs 698802 09-9-18 Baseline CAA: LM: OK LAD: unremarkable Mid-LCX: CTO, but small Mid-RCA: 100% occluded (2 stents deployed) 3 days later STEMI occurred CAA: mid-RCA stent totally occluded

11. Baseline CAA (09-18-09)

12. RCA: 2 DES deployed

13. LM-Bif. with Severe Calcification: Technically Impossible for complete revas. • 杜贵荣 F 80 Yrs • ACS • LM bifurcation with severe calcification lesion • CABG strong suggested and contraindicated • IABP inserted • Kissing stenting performed • Sequential high pressure and final kissing • High pressure pre- and post-dilatation(20 atm) • IVUS checked

14. Baseline CAA+LVG

15. IABP+TFI+Balloon Predilatation

16. Kissing Stenting with High Pressure Deployment and Post-dilatation

17. Final Optimal Results

18. Triple-VD with Diffused Lesions:Technically Impossible for Complete Revas. 陈立忠 M 55yrs 682710 3-VD: 均弥漫病变 LAD 弥漫病变最重90%（做） LCX弥漫病变最重90%（做） Nondominant RCA弥漫病变最重90%（未做）

19. Baseline CAA

20. LAD Stenting

21. Dominant LCX Stenting

22. STEMI: No More Benefit of Complete Revascularization Cases 3 Mr. Yang XP M 62 yrs 456039 09-8-26 STEMI (IPW)×4 hrs 2001 Mid-LCX BMS×1 2004 follow-up CAA: normal 2006 Ischemic symptom-driven Second BMS (driver) in Prox-LCX Statin discontinued for 2 yrs due to side effects Severe chest pain for 4 hrs

23. Baseline CAA: LCX(IRA) definite ST occlusion

24. OCT Exam first, then Ballooning was done

25. Conclusions • PCI of complete revascularization in multi-vessel disease is not needed, technically impossible, no benefit and even harmful to the patients. • On the other hand, partial revascularization of PCI is cost effective, technically feasible, and also can improve quality of life and outcomes • Partial revascularization in PCI is more realistic in most patients with multi-vessel disease • It can save huge amount of money even though revascularization rate might be 10% higher in partial vs complete revascularization.

26. Welcome Attend China Heart Conference (IHF2010)： 2nd international TR Coronary Therapeutics (TRCT) Chaired by Yue-Jin Yang MD. PhD. FACC Co-Chaired by Dr. Saito Dr. kiemeneiji NCC, 2010/08/13-15, Beijing, China

27. Thank you very much !