Estrategias de Revascularizacion en Tronco de Coronaria Izquierda Complejo. Ruben Piraino, MD

Transcripción

1 Estrategias de Revascularizacion en Tronco de Coronaria Izquierda Complejo Ruben Piraino, MD

2 Conflicto de Intereses Yo, Ruben Piraino, no tengo conflicto de Intereses

3 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

4 ANGIOGRAFIA TRONCO: Lesion Distal DA: ostial CX: ostial Ramo Intermedio: origen CD: normal

5 angiografia

6 angiografia

7 Angiographic Findings

8 Cual estrategia de tratamiento: Angina Inestable + Lesion de Tronco Distal (trifurcacion) Angioplastia/Cirugia Preferencia Paciente? EVIDENCIA? (SCORES)

9 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) 2011 ACCF/AHA/SCAI Guideline for PCI. Circulation. 2011;124:e574-e651

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

11 Global Risk Categorization (GRC) SYNTAX score (SX) & EuroSCORE ( S) euro & syntax SX < 22 SX SX > 33 s 0-2 LOW LOW INT s 3-5 LOW LOW INT s > 6 INT INT HIGH 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 (Patrick W Serruys et al. TCT-317)

12 Global Risk Classification Global Risk Classification and Clinical SYNTAX Score in Patients Undergoing Percutaneous or Surgical Left Main Revascularization Clinical SYNTAX Score 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). Capodano D et a. J Am Coll Cardiol Intv. 2011;4(3):

13 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: EXCEL Trial Investigators. NEJM October 31, 2016

14 Seleccion de Tecnica Como elegir la mejor estrategia? 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 LCX=LAD Crush TAP V Stent CULOTTE Mini CRUSH TAP SKS

15 Angiografia CULOTTE: Tronco a DA+LV(CX) PROVISIONAL T STENTING: AV (CX)

16 Cuerda CX

17 Fracaso de poner 3er cuerda en CX (AV) El paciente comienza con Dolor Precordial y Elevaciondel ST. TIMI Flow en DA cae a nivel II

18 Pre KBD

19 KBD

20 Diseccion Tronco-DA ostium Dolor Precordial Cambios ST

21 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) 2011 ACCF/AHA/SCAI Guideline for PCI. Circulation. 2011;124:e574-e651

22 Stent a CX BIOLIMUS 3.0 x 24 Dolor Precordial Cambios ST

23 Post Stent CX, diseccion en ostium DA Dolor Precordial Cambios ST Flujo TIMI 2 DA

24 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

25 Pre stent a DA dilatacion balon 2.5 Dolor + ST

26 STENT a DA en posicion para implante Dolor + ST

27 IMPLANTE DE STENT A DA 3.0 X 33 BIOLIMUS

28 STENT implantado a DA Biolimus 3.0 x 33 NO Dolor Precordial NO cambios ST QUE DEBEMOS HACE AHORA?

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

30 FKBD

31 RESULTADO FINAL NO Dolor Precordial NO cambios ST Flujo TIMI III

32

33 IVUS classification for LMCA bifurcation plaque distribution Continuous involvement from the distal LMCA into the proximal LAD artery is present in 90%. LEFT MAIN to : ONLY to : LCX 66% LAD 90% DA+CX 62% LAD 9% LCX 17% 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 Oviedo C et al. Circ Cardiovasc Interv 2010;3:

34 BIFURCACION 1/1/1

35 FKBD & Carina 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

36 FKBD & Carina Gentle kiss LCX Area loss << Angiographic diameter loss CARINA LAD Gentle kiss to relocate the c Pre-intervention * Gentle kiss: Balloon/Artery < 1 LCX CARINA STENT LAD Pre-intervention MB stenting * Gentle kiss: Balloon/Artery < 1

37 WHAT HAPPENS IF WE IMPLANT TWO STENTS? FKBD & Carina 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

38 Lesión de Tronco no Protegido Tasa de Eventos Clínicos Meta-Análisis (Boudriot, PRECOMBAT, SYNTAX, NOBLE, EXCEL) 13,714,1 23,3 Angioplastia 18,2 Cirugia 14,2 6 4,8 7, ,2 8,3 Nitesh Nerlekar et al. Circ Cardiovasc Interv. 2016;9:e004729

39 POT KBI RePOT