Estrategias de Revascularizacion en Tronco de Coronaria

Izquierda Complejo Ruben Piraino, MD

Conflicto de Intereses

Yo, Ruben Piraino, no tengo conflicto de Intereses

PRESENTACION CLINICA

• Hombre 76 años

• FRC: Hipertension, Dislipidemia

• Angina, Inestable Dolor de Resposo

• ECG: cambios dinamicos depresion ST cara anterior

• Eco: Funcion Ventricular Izquierda Normal

• Comorbilidades: NO

ANGIOGRAFIA

• TRONCO: Lesion Distal

• DA: ostial

• CX: ostial

• Ramo Intermedio: origen

• CD: normal

angiografia

angiografia

Angiographic Findings

Cual estrategia de tratamiento: Angina Inestable + Lesion de Tronco Distal (trifurcacion)

Angioplastia/Cirugia

Preferencia Paciente?

EVIDENCIA? (SCORES)

2011 ACCF/AHA/SCAI Guideline for PCI. Circulation. 2011;124:e574-e651

Revascularization to Improve Survival: Recommendations Left Main CAD Revascularization

Class IIa

• PCI to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (>50% diameter stenosis) unprotected left main CAD with: 1) anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (eg, a low SYNTAX score [<22], ostial or trunk left main CAD); and 2) clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (eg, STS-predicted risk of operative mortality >5%). (Level of Evidence: B)

• PCI to improve survival is reasonable in patients with UA/NSTEMI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG. (Level of Evidence: B)

• PCI to improve survival is reasonable in patients with acute STEMI when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than TIMI (Thrombolysis In Myocardial Infarction) grade 3, and PCI can be performed more rapidly and safely than CABG. (Level of Evidence: C)

DECISION CLINICA Relacion Riesgo/Beneficio Del Metodo de Revascularizacion vs. Preferencia del Paciente SYNTAX: 27 Euro Score: 1.4

Global Risk Categorization (GRC)

SYNTAX score (SX) & EuroSCORE (€S)

euro & syntax

€s 0 - 2

€s 3 - 5

€s > 6

SX < 22

LOW

LOW

INT

SX 23 - 32

LOW

LOW

INT

SX > 33

INT

INT

HIGH

www.JACC.TCTAbstracts2011 (Patrick W Serruys et al. TCT-317)

The combination of these scores gives us a GRC. This new score is a more reliable predictor in terms of mortality and mace. It can separate low risk groups from intermediate and high risk groups, and identify better the patients with Left Main lesions Who Could be Safely & Effectively

Treated With Percutaneous Coronary Intervention

Risk Prediction of Combined Models Kaplan-Meier estimates of 2-year cardiac mortality by baseline Global Risk Classification (GRC) and

Clinical SYNTAX score (CSS) risk categories in patients treated by PCI (A, B) or CABG (C, D).

Global Risk Classification and Clinical SYNTAX Score in Patients Undergoing Percutaneous or Surgical Left Main Revascularization

Capodano D et a. J Am Coll Cardiol Intv. 2011;4(3):287-297

Clin

ical SYNTA

X Sco

re Glo

bal

Ris

k C

lass

ific

atio

n

Revascularizacion en TCI y Múltiples Vasos Syntax Score <32

SYNTAX Left Main Score <32 – 5y FU

Muerte, Stroke, Infarto + Revascularizacion

EXCEL Left Main Score <32 – 3y FU

Muerte, Stroke, Infarto

Morice MC et al. Circulation. 2014;129:2388-94 . EXCEL Trial Investigators. NEJM October 31, 2016

Evaluate if significant disease extends

beyond the LCX ostium

NO

Provisional T-Stenting

YES

Two stent technique

SB angle >60 SB angle <60

LAD>LCX

Crush

TAP

V Stent

LCX=LAD

CULOTTE

Mini CRUSH

TAP

SKS

Seleccion de Tecnica Como elegir la mejor estrategia?

Angiografia CULOTTE: Tronco a DA+LV(CX)

PROVISIONAL T STENTING: AV (CX)

Cuerda CX

El paciente comienza con Dolor Precordial y Elevaciondel ST. TIMI Flow en DA cae a nivel II

Fracaso de poner 3er cuerda en CX (AV)

Pre KBD

KBD

Diseccion Tronco-DA ostium Dolor Precordial

Cambios ST

2011 ACCF/AHA/SCAI Guideline for PCI. Circulation. 2011;124:e574-e651

Revascularization to Improve Survival: Recommendations Left Main CAD Revascularization

Class IIa

• PCI to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (>50% diameter stenosis) unprotected left main CAD with: 1) anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (eg, a low SYNTAX score [<22], ostial or trunk left main CAD); and 2) clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (eg, STS-predicted risk of operative mortality >5%). (Level of Evidence: B)

• PCI to improve survival is reasonable in patients with UA/NSTEMI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG. (Level of Evidence: B)

• PCI to improve survival is reasonable in patients with acute STEMI when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than TIMI (Thrombolysis In Myocardial Infarction) grade 3, and PCI can be performed more rapidly and safely than CABG. (Level of Evidence: C)

Stent a CX BIOLIMUS 3.0 x 24 Dolor Precordial

Cambios ST

Post Stent CX, diseccion en ostium DA Dolor Precordial

Cambios ST Flujo TIMI 2 DA

• Se coloco una 3er cuerda en razon de re cruzar el Stent hacia la DA • La cuerda previa fue dejada en el lugar en la DA • Se removio la cuerda enjaulada • Dolor Precordial + ST

Pre stent a DA dilatacion balon 2.5 Dolor + ST

STENT a DA en posicion para implante Dolor + ST

IMPLANTE DE STENT A DA 3.0 X 33 BIOLIMUS

STENT implantado a DA Biolimus 3.0 x 33 NO Dolor Precordial

NO cambios ST QUE DEBEMOS HACE AHORA?

Re Cruzar a la CX post 2do Stent pre FKBD NO Dolor Precordial

NO cambios ST

FKBD

RESULTADO FINAL NO Dolor Precordial

NO cambios ST Flujo TIMI III

LEFT MAIN to :

LCX 66%

LAD 90%

DA+CX 62%

ONLY to :

LCX 17%

LAD 9%

Oviedo C et al. Circ Cardiovasc Interv 2010;3:105-112

IVUS classification for LMCA bifurcation plaque distribution Continuous involvement from the distal LMCA into the proximal LAD artery

is present in 90%.

MAIN IVUS PATTERNS AND THEIR CIRCUMFERENTIAL PLAQUE

DISTRIBUTION In general, continuous plaque involvement from the LMCA into both the LAD and LCX arteries is

associated with more diffuse circumferential plaque

distribution

BIFURCACION 1/1/1

• Left Main’s branches are Large vessels

• Two Stents Technique is indicated to preserve the size of the vessels

• If we implant only one sent, as the Carina is not affected by atherosclerotic lesions because it is protected by the shear stress

• … it will move towards the opposite side

“FKBD & Carina”

“FKBD & Carina”

Lumen Area loss << Angiographic diameter loss

Lumen Area loss << Angiographic diameter lossSTENT

Pre-intervention MB stenting Kissing balloon

““Gentle kissGentle kiss”” to relocate the carina to relocate the carina

* Gentle kiss: Balloon/Artery < 1* Gentle kiss: Balloon/Artery < 1

Pre-intervention MB stenting Kissing balloon

““Gentle kissGentle kiss”” to relocate the carina to relocate the carina

* Gentle kiss: Balloon/Artery < 1* Gentle kiss: Balloon/Artery < 1

CARINA

LCX

CARINA

LCX

LAD

LAD

• After the second stent implantation the first stent is compressed

• Again, after the stent implantation the Carina moves toward the opposite side

• Then, a FKBD is performed, and both branches keep the same size

WHAT HAPPENS IF WE IMPLANT TWO STENTS? “FKBD & Carina”

Lesión de Tronco no Protegido Tasa de Eventos Clínicos Meta-Análisis (Boudriot, PRECOMBAT, SYNTAX, NOBLE, EXCEL)

13,7

23,3

6 7,4

2

14,2 14,1

18,2

4,8 7

2,2

8,3

Angioplastia Cirugia

Nitesh Nerlekar et al. Circ Cardiovasc Interv.

2016;9:e004729

POT

KBI

RePOT