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PCI v. CABG for multivessel disease: Time for a hybrid approach?

PCI v. CABG for multivessel disease: Time for a hybrid approach?. Creighton W. Don, MD, PhD Associate Director, Interventional Cardiology Fellowship Assistant Professor of Medicine University of Washington. Trends in revascularization.

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PCI v. CABG for multivessel disease: Time for a hybrid approach?

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  1. PCI v. CABG for multivessel disease:Time for a hybrid approach? Creighton W. Don, MD, PhD Associate Director, Interventional Cardiology Fellowship Assistant Professor of Medicine University of Washington

  2. Trends in revascularization Riley RF, Don CW, Dean LS. Circulation CardiovascQual Outcomes. 2011

  3. Multivessel interventions Riley RF, Don CW, Dean LS. Circulation CardiovascQual Outcomes. 2011

  4. PCI or CABG for multivessel disease

  5. CABG v. PCI • Clinical trials • Vein grafts versus stents • Guidelines • Hybrid Approaches

  6. CABG v. PCI • PTCA • BARI (1996) • ERACI (1996) • CABRI (2001) • BMS • ARTS (2005) • ERACI II (2005) • MASS II (2005) • SOS (2008) • DES • SYNTAX (2009) • CARDIa (2010) • Freedom (2012) Non-randomized-DES • ARTS II (2006) • ERACI III (2010)

  7. NCDR 2004-2008 Weintraub W. NEJM. 2012.

  8. Technology – data gap • What does an interventional cardiologist say when shown data that doesn’t favor PCI? • You weren’t using the right: <choose any answer from below> • Patients • Stents • Anticoagulants • Antiplatelet agents • New technology not invented yet

  9. The surgical turn down • Hostile chest • Poor rehabilitation potential • Wheelchair bound • Walker dependent • Peripheral vascular disease • Severe lung disease • Left ventricular dysfunction • Renal failure • Obesity

  10. PCI vs. cabg in multivessel CAD(revascularization) POBA Era STENT Era 40 40 STENT 33.7 CABG CABG POBA 30 30 (%) (%) 20 20 17 16.8 16.8 10 10 4.8 4 3.5 3.3 0 0 Metanalysis (Pocok) ARTS (1 y) ERACI II (18m) SOS (1 y)

  11. PCI vs. cabg in multivessel CAD(revascularization) (%) (%) Bare Metal STENT Era DES Era 40 40 STENT STENT CABG CABG 30 30 20 20 17 16.8 16.8 8.8 8.5 10 10 4.8 4.8 4 3.5 3.5 0 0 ERACI II SOS ARTS II ERACI III ARTS

  12. Increased revascularization Meta-analysis of ARTS, SOS, ARTS2 PCI CABG Mercado N et al. J Thoracic and Cardiov Surgery. 2005

  13. Syntax study 1-year outcomes • 1800 patients • 3 vessel disease or left main disease • Randomization to PCI versus surgery N Engl J Med 2009; 360:961-972.

  14. Syntax 5-year outcomes

  15. Syntax 5-Year mace outcomes Left main 3V Disease Syntax 0-22 Syntax 23-32 Syntax ≥ 33 Mohr. Lancet. 2013

  16. Left main interventions • Instent thrombosis/restenosis CABG v. PCI Death Death, MI, CVA TVR IVUS v. Angio guided PCI Seung KB. NEJM. 2009. Park SJ. Circ: CardiovInterv. 2009.

  17. From AM et al. Eurointervention. June 2010.

  18. DM and CABG—Mortality Levine, G. N. et al. J Am CollCardiol 2011

  19. Revascularization and dM • FREEDOM • 1900 pts with DM • 2+ vessels • CABG v. PCI Farkouh ME et al. N Engl J Med 2012;367:2375-2384.

  20. CABG v. PCI • Clinical trials • Vein grafts versus stents • Guidelines • Hybrid Approaches

  21. LIMA v. Saphenous Vein grafts • Retrospective review of coronary angiograms 1996-2001 • Selection bias Khot,UN et al. Circulation 2004;109:2086-2091

  22. Proper comparison? SVG graft failure Harskamp. Annals of Surgery. 2013.

  23. SYNTAX: Stent v. graft occlusion • 5 year f/u • 1676 pts • Stent thrombosis • 109 total • 48 definite • Graft occlusion • 84 total • 32 definite Farooq. JACC. 2013.

  24. Location of ST/Graft occlusion • CABG graft occlusion • 42% in the RCA • PCI stent thrombosis • 19% Left main • 31% Prox LAD • Unknown… • Clinically silent ST/GO Farooq. JACC. 2013.

  25. Arterial v. Vein grafts • VA Cooperative Studies Trial (July 1983 to September 1988) • 1254 men undergoing CABG • Routine angiography 3, 5 10 years If graft was open 1 week post surgery From time of surgery IMA: 85% patency 10 y SVG: 60% patency 10 y *P < 0.001 Goldman S. JACC. 2004.

  26. Saphenous vein graft failure Platinum Trial Ischemia driven TLR • VA Cooperative Studies Trial Goldman S. JACC. 2004. Meredith IT. AJC. 2013.

  27. Saphenous Vein Target Vessel • VA Cooperative Studies Trial Variation by target vessel Variation by target size Goldman S. JACC. 2004. *P < 0.001

  28. Arterial graft patency by target • Retrospective study of patients with CABG undergoing coronary angiography for symptoms • 2127 conduits evaluated • 0 to 15 years post-op Tatoulis J. Annals of Thoracic Surg. 2004.

  29. Functional syntax score • 497 patients enrolled in the FAME study Nam CW, J Am CollCardiol. 2011;58:1211-1218

  30. Ischemic burden Hachamovitch R et al. Circulation 2003;107:2900-2907

  31. MAE Outcomes Based on the Extent of Revascularization Extensive Revasc. Limited Revasc. p=0.03 90 day MAE 1stTercile 2ndTercile 3rdTercile (0-2) (3-5) (6-11) Extent of Revascularization (change in ischemic zones)

  32. COURAGE: Ischemia and Outcomes All patients Patients with mod-sev ischemia Shaw L J et al. Circulation 2008;117:1283-1291

  33. CABG v. PCI • Clinical trials • Vein grafts versus stents • Guidelines • Hybrid Approaches

  34. AHA/ACC Guidelines 2013

  35. Appropriate mis-use criteria Patel, et al. JACC 2012; 59:

  36. CABG v. PCI • Clinical trials • Vein grafts versus stents • Guidelines • Hybrid Approaches

  37. Hybrid Revascularization Harskamp RE. Ann Thorac Surg. 2013.

  38. Hybrid revascularization • One stage: • Simultaneous • Two stage • PCI followed by CABG (LIMA-LAD) • CABG (LIMA-LAD) followed by PCI • Surgical techniques • Sternotomy • MID-CAB • Endoscopic/Robotic • On/Off-pump

  39. US Practice patterns STS Database (July 2011 to March 2013) • CABG procedures 198,622 • Conventional CABG 197,672 • Staged Hybrid-CABG 809 • Concurrent Hybrid-CABG 141 • Similar baseline characteristics • Trend toward reduced strokes Hybrid-CABG IMA used Coronary stent placed Harskamp RE. Circulation. 2014.

  40. Hybrid v. cabg cohorts Harskamp RE. Ann Thorac Surg. 2013.

  41. Costs and Quality of life • Improved quality of life (SF-12) • More pain (MID-CAB), but faster recovery Harskamp RE. Ann Thorac Surg. 2013. Bachnisky WB. J IntervCardiol. 2012.

  42. Meta-analysis Hybrid v. CABG • 6 studies—single center registries • 1,190 patients (366 Hybrid, 824 CABG) • LAD/LM + other lesions • Less transfusion, shorter LOS Harskamp RE. Am Heart J. 2014.

  43. Ongoing Studies • Hybrid Revascularization Outcomes Study (observ cohort) • 298 patients • LAD + other vessels • Excluded LM disease, CTOs in LAD or >2 vessels, EF < 30% • 12 month f/u (death, stroke, MI, revasc) • POL-MIDES (RCT hybrid revasc v. CABG) • 200 patients randomized to CABG v. hybrid • LAD+ other vessel • Excluded LM, CTOs • PCI success rate 93.9%, with 6.1 % conversion to CABG • MACE free 1-yr • CABG 92.2% (2.9% mortality) • Hybrid 89.9% (2.0% mortality)

  44. Current strategy • CABG • Diffuse disease • Lower surgical risk • PCI • Focal disease (SYNTAX <23) • Higher surgical risk, limited conduit • Small targets (<2 mm) • Non-LAD disease • Hybrid • LAD/LM + other disease • Higher surgical risk • Small targets • Off pump/minimal invasive benefits? • Concomitant, sequential?

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