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Washington Cardiology Center

PCI in Small Vessels: A Comprehensive Approach. Augusto Pichard , L. Satler, K. Kent, R. Waksman, J. Laird, W. Suddath, J. Sharretts, S. Epstein, N. Weissman, A. Fuisz, G. Weigold, J. Lindsay. Washington Cardiology Center. Augusto Pichard, MD.

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Washington Cardiology Center

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  1. PCI in Small Vessels: A Comprehensive Approach Augusto Pichard, L. Satler, K. Kent, R. Waksman, J. Laird, W. Suddath, J. Sharretts, S. Epstein, N. Weissman, A. Fuisz, G. Weigold, J. Lindsay Washington Cardiology Center Augusto Pichard, MD

  2. A true small vessel: A Vessel that Perfuses Small Amount of Myocardium Definition

  3. First Conclusion: True small vessels do not need PCI Conclusion (1)

  4. Is this proximal LAD a small vessel ? IVUS: 4 mm Insights From IVUS No a large vessel with diffuse disease

  5. Patient Referred for ISRS of a 2.5 mm stent in the LAD. Vessel size ? 4 mm 2.5 mm Insights From IVUS IVUS RAO cranial

  6. LAD size assessment by IVUS Laborgne, Cheneau et al. 2002 WHC IVUS Core Lab Insights From IVUS

  7. Vessel size: Angiography vs IVUS Insights From IVUS

  8. Second Conclusion: The proximal LAD is almost never a small vessel. (The same is often true for the proximal RCA and CX). Conclusion (2)

  9. PCI of Small Vessels Which one is the best tool ? 1. Balloon? 2. Cutting Balloon ? 3. Stent ? 4. Specialized Stents (PC coating, Pixel, Silicon Carbide coating, etc.)? 5. Drug eluting stents ? Materials

  10. PCI of Small Vessels Stents

  11. Stent vs. Balloon in Small VesselsKastrati et al. JACC 38:1604 Percent Difference in Restenosis between Balloon and Stent Stent vs Balloon Final Diameter Stenosis in the Balloon Arm

  12. Provisional Stenting in Vessels <2.7 mmWHC: Abizaid, Pichard et al. ACC 2001 286 lesions with provisional stenting under IVUS guidance. 45% crossed-over to stent. 453 control lesions with elective stenting. Results

  13. Why are Stents Less Effective in Small Vessels ?IVUS Core LAB. Washington Hospital Center Small vessels develop the same amount of intimal hyperplasia as large vessels ISRS is highest in small vessels Limitations WHC: Hoffmann AJC 1998;82:1168-72 WHC: Mintz et al. 1997

  14. 1.6 1.4 1.2 1 .8 .6 .4 .2 0 -.2 2 3 4 5 6 7 8 9 10 11 12 1.6 1.6 1.4 1.4 1.2 1.2 1 1 .8 .8 .6 .6 .4 .4 .2 .2 0 0 -.2 -.2 2 3 4 5 6 7 8 9 10 11 12 2 3 4 5 6 7 8 9 10 11 12 Mean IH thickness vs Stent CSA at 6-month follow upin Non-Polymeric Paclitaxel-coated Stents.Mintz et al. TCT 2003 Control High dose Low dose R=0.009 P=0.87 R=0.126 P=0.01 R=0.002 P=0.96 DES Stent CSA (mm²) Per slice bases

  15. Small Vessel PCI Any benefit with specialized approach ? • Rotablator • Cutting balloon • Special coatings Specialized Approach

  16. Rotablator vs. Balloon for Small Vessels. DART Trial.Mauri et al. AHJ 2003; 145:847-54 • 446 patients randomized • Vessel diameter (mean 2.46). • Lesion length: 10±6 mm. • Procedural success: 92% (R) vs 94% (B). • 12 months follow up: • angio restenosis: 50.5% in both. • late loss: 0.49 (R) vs 0.56 (B). Conclusion: no benefit of Rotablator in Small Vessels Rotablator

  17. Cutting Balloon vs. Balloon in Small Vessels Cutting balloon

  18. Cutting Balloon vs. Stentin Small Vessels Cutting Refer. Vess. Diam: 2.2 mm 2.3 mm 2.2 mm 2.4 mm n= 86 pts. 310 lesions 48 pts. 174 pts. balloon 1: Kawaguchi. JACC 2002;39:48a; 2: Kawaguchi JACC 2002;39:7A; 3: Kinoshita AJC 2003; 92:170L; 4:Umeda JACC 2002;39:52 A

  19. TENAX Stent (Silicon Carbide Coated Stent).SVS Trial (Small Vessel Study).Bonnier et al. CRT 2003 495 patients with Small Vessels (2.5-3.0 mm) randomized SiC coating

  20. Heparin-Coated Stent in Small Vessels. COAST Trial. Haude et al. Circulation. 2003;107:1265-70 588 pts. randomized to angioplasty with provisional stent (n=195), bare stenting (n=196), or Corline heparin-coated stenting (n=197). (JomedFlex Stent) Heparin Restenosis: 32.2% after PTCA with provisional stenting, 24.8% after bare stenting, and 29.6% after heparin-coated stenting. (P=0.34).

  21. BiodivYsio PC Coating Stent in Small Vessels.Lasmal Trial. Rodriguez et al. Buenos Aires PC Coating

  22. ISAR SMART-II: Randomized vessels <2.5 mm BiodivYsio PC Coating PC Coating Kastrati; TCT 2003

  23. Third conclusion • Bare metal stents have the same restenosis rate as optimal balloon angioplasty. • Cutting balloon seems to offer a restenosis benefit in small vessels. • Stents with special coatings offer no detectable advantage. Conclusion (3)

  24. ISAR SMART-II: Randomized vessels <2.5 mm Abciximab Anti-GPIIb/IIIa

  25. Restenosis with Cilostazol in PCI.CREST Trial Diabetic restenosis p=0.0108 Small vessel restenosis p=0.0038 Diabetics >2.75mm p=ns Diabetics <2.75mm p=ns Drug C P C P C P C P C=Cilostazol P=Placebo Devireddy. Circulation 2004;110:III-489

  26. Drug Eluting Stents in Small Vessels

  27. DES vs BMS in Small Vessels. Randomized Trials % RS DES

  28. Late Loss in Small Vessels. BMS vs DES Randomized Trials mm DES

  29. DES Diameters Oct 04

  30. SES diameters used (n=16251) 30% SES Diameters

  31. Fourth conclusion Drug Eluting Stent is clearly the device of choice for small vessels. Conclusion (4)

  32. Is the “Bigger is Better” Stent Strategy Necessary when Stenting Small Vessels?

  33. MACE in Small Vessels and Stent Lumen Area Iakovou et al. AJC 2003;92:1171-6 423 pts with 446 stents in vessels <2.75mm. Group 1: 308 pts with final CSA <6 mm2. Group 2: 115 pts with final CSA > 6mm2. 1 year f/u IVUS

  34. How Big is Better in Small Vessels ?Moussa et al. AJC 1999;83:1012-1017 IVUS

  35. Final Stent Area and Restenosis.SIRIUS IVUS sub study. 72 SES and 50 BMS.Sonoda, et al. JACC2004;43: 1959-63 IVUS Drug Eluting Stents

  36. Final Stent Area and Follow up Lumen AreaSIRIUS IVUS sub study. 72 SES and 50 BMS.Sonoda, et al. JACC2004;43: 1959-63 IVUS

  37. Stent area and Outcome at 6 monthsN=209 patients, N= 319 lesions treated with Cypher Minimal stent CSA (mm2) by Ivus % TLR MACE P=0.068 P=0.54 4.4% 2.9% 2.2% 2.2% Follow up 0% 0% <6 6-7.5 >7.5 <6 6-7.5 >7.5

  38. IVUS Findings in SAT.Cheneau et al. Circulation. 2003;108:43. 7484 PCI’s with IVUS: 27 SAT (0.36%) Inadequate Stent Expansion 18 (78%) Stent malappostition 2 (5%) Dissection 4 (17%) Tissue protrusion 1 (4%) Thrombus post PCI 1 (4%) IVUS

  39. Summary • True small vessels do not need PCI. • The proximal LAD is almost never a small vessel. • Bare metal stent has same restenosis as optimal balloon angioplasty. Cutting balloon seems to offer a restenosis benefit. • Drug Eluting Stent is the device of choice for small vessels. • Adequate expansion in DES seems important (final stent area >6 mm2). Summary

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