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Complex Lesion Subsets: Indications for DES

Complex Lesion Subsets: Indications for DES. Andreas Baumbach, MD, FRCP, FESC Bristol Heart Institute. MY CONFLICTS OF INTEREST ARE Advisory Board Boston Scientific Advisory Board Abbott Vascular Educational Grants Cordis Educational Grants Boston Scientific. Complex Lesion Subsets.

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Complex Lesion Subsets: Indications for DES

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  1. Complex Lesion Subsets:Indications for DES Andreas Baumbach, MD, FRCP, FESC Bristol Heart Institute

  2. MY CONFLICTS OF INTEREST ARE Advisory Board Boston Scientific Advisory Board Abbott Vascular Educational Grants Cordis Educational Grants Boston Scientific

  3. Complex Lesion Subsets What is complex ? What is a B2/C lesion ?

  4. Type B2/C Lesions % of lesions Type B2/C Stent length

  5. Lesion Complexity Ellis SG, Vandormael MG, Cowley MJ, DiSciascio G, Deligonul U, Topol EJ, Bulle TM. Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease: implications for patient selection. Circulation. 1990;82:1193–1202

  6. Complex: B2/C • 10-20mm length • Eccentric • Mod tortuosity • Mod angulation 45-90º • Irregular contour • Mod/heavy calcification • Ostial location • Bifurcation requiring double wires • Thrombus • Total occlusion <3months • >20mm length • Excessive tortuosity • Extremely angulated >90º • Inability to protect major branch • Degenerated vein graft • Total occlusion > 3months B C

  7. Complex: B2/C • 10-20mm length • Eccentric • Mod tortuosity • Mod angulation 45-90º • Irregular contour • Mod/heavy calcification • Ostial location • Bifurcation requiring double wires • Thrombus • Total occlusion <3months • >20mm length • Excessive tortuosity • Extremely angulated >90º • Inability to protect major branch • Degenerated vein graft • Total occlusion > 3months B C

  8. Complex Lesion Subsets • Type B2/C • Long Lesions • Small Vessels • CTO • Vein Grafts • Bifurcation Lesions • LMS • In-Stent Restenosis

  9. Data • Randomised Trial • Randomised Trials Subgroup Analyses • Published

  10. FREEDOM CORPAL-BIF Park LL2 CARDIA DIABETES SISR ISAR-DESIRE ISAR-DIABETES TRIAL: randomized, multicenter, blinded, actively controlled trial involving an independent core lab and CEC SYNTAX SYNTAX SYNTAX SYNTAX RIBS II TAXUS V ISR RAVEL TRIAL: feasibility studies involving only 1 to 3 centers often not using an independent core lab or CEC SES-SMART TAXUS VI TAXUS VI SIRIUS TAXUS V TAXUS V TAXUS V TAXUS V ISAR-SMART REALITY-TAXUS REALITY-TAXUS PRISONII TAXUS IV TAXUS IV REALITY-CYPHER Complexity in DES Trials left maindisease multi-vesseldisease Data currently all 1st generation DES bifurcated lesions CTO ISR diabetes long lesions smallvessels work-horse Increasing complexity

  11. High Proportion of Type B2/C Lesions

  12. Complex Lesions SCANDSTENT: Stenting in non-stress/benestent disease CTO (36%) /Bifurcation (34%)/Ostial (22%) /Angulated N: 322, randomised % P<0.001 6 months outcome p<0.001 Kelbaek et al. JACC 2006; 47:449

  13. Long Lesions

  14. Long Lesions TAXUS VI: 3 yr Target Lesion Revascularisation

  15. Long Lesions C-Sirius (Sirolimus eluting stent in the treatment of long de-novo lesions) • Single de novo lesion 15-32mm length N: 100, randomised % 9 months outcome p<0.001 p<0.001 C Sirius Investigators JACC 2004; 43: 1110

  16. Long Lesions E-Sirius (Sirolimus eluting stents for the treatment of patients with long atherosclerotic lesions in small coronary arteries) • Single de novo lesion 15-32mm length, Vessel <3mm N: 352, randomised 8 months outcome % p<0.001 p<0.002 p<0.0001 Schofer et al. Lancet 2003; 362: 1093

  17. Small Vessels SES Smart • Single lesion <2.75mm native coronary N: 257, randomised % 8 months outcome p<0.001 P<0.001 p<0.002 p<0.04 Ardissino et al. JAMA 2004; 292: 2727

  18. Small Vessels

  19. Chronic Total Occlusion PRISON II • Single CTO >2 weeks, crossed and predilated N: 200, randomised % 6 months outcome p<0.001 P<0.001 p<0.001 Suttorp et al. Circulation 2006;114:921

  20. Chronic Total Occlusion SCANDSTENT Subgroup analysis • CTO, crossed and predilated N: 127, randomised % p<0.001 6 months outcome P<0.001 Kelbaek et al; Am Heart J 2006: 152:882

  21. Saphenous Vein Grafts RRISC Trial • Lesions in SVG Grafts N:75pts, 96 lesions, randomised % 6 months outcome P=0.024 P=0.012 Vermeersch et al JACC 2006; 48:2423

  22. Bifurcation Lesions SCANDSTENT subgroup • Bifurcations: 126 pts randomised % P<0.001 P<0.001 p=0.01 6 months outcome Thuesen et al. Am Heart J 2006: 152:1140

  23. Conclusion • In the complex lesion subsets presented, use of DES significantly reduces the incidence of restenosis and the need for repeat revascularisation, when compared to bare metal stents

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