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B.G. 62 aa. Fumatore attivo, IA, dislipidemia 2009

B.G. 62 aa. Fumatore attivo, IA, dislipidemia 2009 SCA Malattia a. circonflessa : PTCA con stent “metallico”(BMS) 27/12/2013 Ricovero programmato per TE positivo 75 W 28/12/2013

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B.G. 62 aa. Fumatore attivo, IA, dislipidemia 2009

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  1. B.G. 62 aa. Fumatore attivo, IA, dislipidemia 2009 SCA Malattia a. circonflessa : PTCA con stent “metallico”(BMS) 27/12/2013 Ricovero programmato per TE positivo 75 W 28/12/2013 Coronarografia : restenosi subocclusiva intra-stent arteria circonflessa prox ; lesione 50% c destra ; IVA “irregolarità” Angioplastica PCI: impianto di DES (tecnica “stent in stent”) 30/12/2014 Dimissione . Asa 100, Clopidogrel 75, bisoprololo 2,5 , atorvastatina 20

  2. B.G. 62 aa. 05/01/2014 ore 14:00 dolore tipico a riposo ore 14:30 giunge in DEA (Pescia)con mezzi propri (!)

  3. B.G. 62 aa. 05/01/2014 ore 15:30 entra in Sala di Emodinamica al San Jacopo Coronarografia per via radiale destra Diagnosi: Occlusione trombotica in ingresso stent: “Trombosi Subacuta di Stent” Trattamento : In DEA :eparina 5000 U ev In Emodinamica Carico orale Prasugrel Avanzato catetere Export: Reo-Pro (Abcximab) i.c. & Trombectomia manuale

  4. Fine art of thrombus suction in STEMI ! February 29, 2012 by dr s venkatesan

  5. B.G. 62 aa. 05/01/2014 ore 15:45 Trombectomia

  6. B.G. 62 aa. 05/01/2014 ore 15:50 ripristinato flusso TIMI 3 2)Trattamento: PTCA palloncino , con distensione alta pressione dello stent

  7. B.G. 62 aa. 05/01/2014 ore 17:00 in reparto Liv 1 S.I.

  8. Stent Thrombosis(ARC Definite + Probable) 3 Any Stent at Index PCI N= 12,844 2.4(142) Clopidogrel 2 Endpoint (%) 1.1 (68) 1 Prasugrel HR 0.48P <0.0001 NNT= 77 0 0 30 60 90 180 270 360 450 Days

  9. RIVAL Study Design NSTE-ACS and STEMI (n=7021) • Key Inclusion: • Intact dual circulation of hand required • Interventionalist experienced with both (minimum 50 radial procedures in last year) Randomization Radial Access (n=3507) Femoral Access (n=3514) Blinded Adjudication of Outcomes Primary Outcome: Death, MI, stroke or non-CABG-related Major Bleeding at 30 days Jolly SS et al. Am Heart J. 2011;161:254-60.

  10. Site of Non-CABG Major Bleeds (RIVAL definition) *Sites of Non Access site Bleed: Gastrointestinal (most common site), ICH, Pericardial Tamponade and Other

  11. R I V A L Results stratified by High*, Medium* and Low* Volume Radial Centres *High (>146 radial PCI/year/ median operator at centre), Medium (61-146), Low (≤60) Tertiles of Radial PCI Centre Volume/yr p-value HR (95% CI) Interaction Primary Outcome High 0.021 Medium Low Death, MI or stroke 0.013 High Medium Low Non CABG Major Bleed High Medium 0.538 Low Major Vascular Complications 0.019 High Medium Low Access site Cross-over 0.003 High Medium Low No significant interaction by Femoral PCI center volume 0.25 1.00 4.00 16.00 Radial better Femoral better Hazard Ratio(95% CI)

  12. Impact of Therapies on Outcomes Bleeding Ischemic events: MI/CKMB↑ Stent Thrombosis

  13. Bleeding and Mortality Major Bleeding Hypotension Cessation of ASA/Clop Transfusion Ischemia Stent Thrombosis Inflammation Mortality Bhatt DL. In Braunwald EB, Harrison’s Online. 2005.

  14. HORIZONS: 1-Year All-Cause Mortality Bivalirudin alone (n=1800) 4.8% 5 Heparin + GPIIb/IIIa (n=1802) Δ = 1.4% 4 3.4% 3.1% 3 Mortality (%) HR [95%CI] = 0.69 [0.50, 0.97] P=0.029 2 2.1% Δ = 1.0% P=0.049 1 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Time in Months Number at risk 1800 1705 1684 1669 1520 Bivalirudin alone 1802 1678 1663 1646 1486 Heparin+GPIIb/IIIa Mehran R et al. Lancet 2009:on-line

  15. HORIZONS: 30 Day Adverse Events P<0.001 P = 0.90 • *Not related to CABG • ** Plat cnt <100,000 cells/mm3 Stone GW et al. NEJM 2008;358:2218-30

  16. MATRIX Trial NCT01433627 NSTEACS or STEMI with invasive management Aspirin+P2Y12 blocker 1:1 Trans-Radial Access Trans-Femoral Access 1:1 Heparin ±GPI Bivalirudin Mono-Tx 1:1 Is TRI superior to TFI ? Is Bivalirudin superior to UFH ? Stop Infusion Prolong≥ 6 hs infusion Should Bivalirudin be prolonged after PCI ? http://www.cardiostudy.it/matrix

  17. Trattamento delle SCA paziente MATRIX Trial Rischio ischemico vs Rischio emorragico procedura farmacologia Accesso Trombectomia Stenting IABP Nuovi devices ASA +Clopidogrel ASA + nuovi bloccanti 2Py12 Uso selettivo dei GP2b3a Eparina vs Bivaluridina

  18. B.F. 76 aa Familiarità per CI, IA, DM tipo 2, dislipidemia 25/10/2013: dolore toracico tipico insorto a riposo FMC (118) ad un ora circa dall’esordio . Diagnosi ecg di IM anteriore (ST sopra V2-V5) “door to balloon (D2B)” time di 75 min Coronarografia : stenosi “significativa” TC, occlusione trombotica di IVA, stenosi critica 75% “ulcerata” di C.dx prossimale, arteria CX indenne

  19. B.F. coronarografia sinistra Stenosi TC Occlusione IVA

  20. B.F.Angioplastica primaria tramite trombectomia ed impianto di stent (DES) IVA

  21. B.F….Ad un mese (11/12/2013) controllo con “IVUS” su TC ….. Stent di IVA Stenosi TC IVUS : intra vascular ultra sound

  22. ….Ad un mese (13/12/2013) controllo con “IVUS” su TC…. Stent di IVA Stenosi TC IVUS : intra vascular ultra sound

  23. ….Ad un mese controllo con “IVUS” su TC : MLA 4,2 mm2 Stent di IVA Stenosi TC Area luminale minima 4,2 mm2 Valori cut off per TC 6,0 mm2 IVUS : intra vascular ultra sound

  24. B.F. (14/12/2013) PCI di TC mediante impianto di stent su TC-IVA Stent su TC Stent su IVA

  25. B.F. (13/12/2013) PCI di TC mediante impianto di stent su TC-IVA 25/10/2013 Stent su TC Stent su IVA

  26. PCI di c destra con impianto di stent DES 1° tratto Stent su C destra

  27. Ottimizzazione tecnica impianto “Clear Stent” Stent C. destra

  28. PROVE-IT TIMI-224,162 Randomized Pts with ACS 26.3% Pravastatin 40 mg/d 22.4% 16% RR P = 0.005 Atorvastatin 80 mg/d Death, MI, UA requiring hosp, revasc >30d, or stroke (%) How many events were attributable to: 1) Restenosis, stent thrombosis, etc. vs. 2) Significant disease left behind, vs. 3) VP with rapid lesion progression? ACS median 7d PCI 69% Cannon CP et al. NEJM 2004;350:1495-1504

  29. The PROSPECTTrial Background • We therefore performed a prospective, multicenter natural history study using 3 vessel multimodality intracoronary imaging to quantify the clinical event rate due to atherosclerotic progression and to identify those lesions which place pts at risk for unexpected adverse cardiovascular events

  30. The PROSPECTTrial 700 pts with ACS UA (with ECGΔ)or NSTEMI or STEMI >24º undergoing PCI of 1 or 2 major coronary arteries at up to 40 sites in the U.S. and Europe • Metabolic S. • Waist circum • Fast lipids • Fast glu • HgbA1C • Fast insulin • Creatinine • Biomarkers • Hs CRP • IL-6 • sCD40L • MPO • TNFα • MMP9 • Lp-PLA2 • others PCI of culprit lesion(s) Successful and uncomplicated Formally enrolled PI: Gregg W. Stone Sponsor: Abbott Vascular; Partner: Volcano

  31. 3-vessel imaging post PCI Culprit artery, followed by non-culprit arteries Angiography (QCA of entire coronary tree) IVUS Virtual histology Palpography (n=~350) Proximal 6-8 cm of each coronary artery Meds rec Aspirin Plavix 1yr Statin Repeat biomarkers @ 30 days, 6 months MSCT Substudy N=50-100 Repeat imaging in pts with events The PROSPECTTrial F/U: 1 mo, 6 mo, 1 yr, 2 yr, ±3-5 yrs

  32. PROSPECT: MethodologyVirtual histology lesion classification Lesions are classified into 5 main types 1.Fibrotic 2.Fibrocalcific 3.Pathological intimal thickening (PIT) 4.Thick cap fibroatheroma (ThCFA) 5. VH-thincap fibroatheroma (VH-TCFA) (presumedhighrisk)

  33. PROSPECT 82910-012: 52 yo♂ 2/13/06: NSTEMI, PCI of MLAD 2/6/07 (51 weeks later): NSTEMI attributed to LCX Index 2/13/06 Event 2/6/07 QCA PLCX DS 28.6% QCA PLCX DS 71.3%

  34. PROSPECT 82910-012: Index 2/13/06 Baseline PLCX QCA: RVD 2.82 mm, DS 28.6%, length 6.8 mm IVUS: MLA 5.3 mm2 VH: ThCFA 1 * Lesion prox *OM 1. ThCFA 5.3 mm2 38

  35. PROSPECT: MACE All Culprit lesion (CL) related Non culprit lesion (NCL) related Indeterminate 25 20.4% 20 15 12.9% MACE (%) 10 11.6% 5 2.7% 0 0 1 2 3 Time in Years Number at risk

  36. PROSPECT: Multivariable Correlates of Non Culprit Lesion Related Events Independent predictors of lesion level events by logistic regression analysis VariableOR [95% CI]P value PBMLA≥70% 4.99 [2.54, 9.79] <0.0001 VH-TCFA 3.00 [1.68, 5.37]0.0002 MLA ≤4.0 mm22.77 [1.32, 5.81]0.007 Lesion length ≥11.6 mm 1.97 [0.94, 4.16] 0.07 EEMMLA <14.3 mm21.30 [0.62, 2.75] 0.49 Variables entered into the model: Minimal luminal area (MLA); plaque burden at the MLA (PBMLA); external elastic membrane at the MLA (EEMMLA) <median; lesion length ≥ median (mm); VH-TCFA.

  37. I LIMITI DELLA CORONAROGRAFIA NELLO STUDIO DELL’ATS CORONARICA (MALATTIA DI PARETE)

  38. NEW The IVUS technique can detect angiographically ‘silent’ atheroma Angiogram IVUS No evidence of disease Little evidence of disease Atheroma RIMODELL.POSIT. IVUS=intravascular ultrasound Reproduced from Circulation 2001;103:604–616, with permission from Lippincott Williams & Wilkins.

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