Ostial LAD : Stenting technique in the DES era LM stenting or not

Ostial LAD : Stenting technique in the DES era LM stenting or not

Dr. Alfonso Medina
Ostial LAD :
Stenting technique in the DES era
LM stenting or not
LM
CORPAL registry 2002-2008
LM bifurcation involvement (78%)
LCX
LAD
29%
1,1,1 (n= 174)
14%
25%
7%
1,1,0 (n=150)
1,0,1 (n=42)
16%
7%
0,1,1 (n=42)
2%
Two components 39%
One component 32%
1,0,0 (n=84)
0,1,0 (n=96)
0,0,1 (n=12)
TRIFURCATION OR
MORE 9 %
Ostial LAD (n=96): LM stenting or not
2005
2002
LM stenting (n=25)
Precise (n =71)
2008
21
4
6
65
“Precise” stent deployment
Ostial LAD stenting technique
Ostial LAD
EEM CSA 12,64 mm2
Lumen CSA 3,10 mm2
Plaque burden 76%
Ostial stent CSA 8,33 mm2
Reference stent CSA
10,87 mm2
Ostial LAD stenting technique
LCX
LAD
LCX
LCX
Stent 2.75 x 15 mm
Fluoroscopic
Fluoroscopic &
& IVUS
IVUS guidance
guidance of
of stent
stent positioning
positioning at
at the
the level
level of
of carina
carina
Ostial LAD lesions n=71
BASELINE CLINICAL CHARACTERISTICS
(%)
Age, yrs …………………………………………….....
Male gender ………………………………………….
Hypertension …………………………………………
Diabetes mellitus ……………………………………
Hypercholesterolemia …………………………......
Current smoking …………………………………….
Previous PCI ………………………………………….
Unstable ……………………………………………….
Multivessel disease (≥ 2 vessels) ……………….
Left ventricular EF,% ………………………………
62 ± 12
49 (69)
41 (58)
22 (31)
37 (52)
20 (28)
12 (17)
57 (80)
29 (41)
56 ± 10
Ostial LAD lesions n=71
QUANTITATIVE ANGIOGRAPHIC CHARACTERISTICS
Lesion length, mm ………………………………
13,8 ± 5,1
LM Ø, mm …………………………………………
4,37 ± 0,70
LAD reference Ø, mm ………………………….
3,24 ± 0,24
MLD pre, mm …………………………………….
1,02 ± 0,41
Diameter stenosis, % ………………………….
69 ± 11
LCX Ø, mm ………………………………………..
3,18 ± 0,55
LAD-LCX angle,º …………………………………
95 ± 38
LM-LAD angle,º …………………………………
136 ± 26
LCX dominance …………………………………..
11 (15%)
Tapering index *………………………………….
0,73 ± 0,09
(*) Ø LAD distal/ Ø LM
Ostial LAD lesions n=49/71 (70%)
QUANTITATIVE INTRAVASCULAR ULTRASOUND
SHORT AXIS
LM
LM
EEM CSA , mm2
21,42 ± 4,75
Lumen CSA, mm2
15,82 ± 4,41
Plaque burden, %
EEM CSA, mm2
Lumen CSA, mm2
LAD
Plaque burden, %
26 ± 11
11,54 ± 4,55
4,64 ± 2,18
58 ± 17
Reference LAD CSA, mm2
9,29 ± 3,48
Remodeling index*
0,80 ± 0,21
LONG AXIS
Carina free of plaque
36/49 (74 %)
(*) EEM CSA ostial / EEM CSA distal reference
Ostial
Reference LAD
LAD
LM
LCX
Ostial LAD lesions n=71
PROCEDURAL CHARACTERISTICS
(%)
Intervention of other coronary lesions ……………….
37 (52)
Guidance of intravascular ultrasound ………………...
49 (69)
Direct stenting ……………………………………………….
52 (73)
Debulking (Rotablator) …………………………………..
1 (1)
Use of postdilation …………………………………………
11 (15)
Stents per lesion ……………………………………………
1,15 ± 0,36
Stent diameter, mm ………………………………………..
3,25 ± 0,36
Stent length, mm …………………………………………..
20,11 ± 7,83
Inflation pressure, atm …………………………………..
16,57 ± 1,51
LCx ostium dilation ………………………………………..
2 (3)
LCx ostium stenting ……………………………………….
1 (1)
Elective IABP ………………………………………………..
1 (1)
Use of Reopro ……………………………………………….
5 (7)
LCx damage (angiography)
60
52 (73%)
LCx intervention
Patients
50
3/71 (4%)
40
30
19 (26%)
20
12 (17%)
10
No
<50%
>50%
7 (10%)
LCx ostium dilation*
2
LCx ostium stenting
1
(*) final balloon dilation of LAD
0
No
<50%
Mild
>50%
Significant
Pre
Post
FFR 0.94
FFR 0.89
LCx damage (IVUS observations n=49)
LM
LCX
Bite
Pre
Eyebrow
sign
LAD
Post
LAD
Compromise 13/14
(93%)
LCX
LM
LAD
LCX
Pre
Post
Compromise 1/35
(3%)
LAD
LCX
LCx damage mechanism (IVUS observations n=49)
Pre
Post
LAD
LM
LCX
Bite
mechanical carina displacement
Pre
Post
LAD
LM
LCX
LAD
LM
LCX
Ostial LAD lesions - LCx ostium
ANGIOGRAPHY (n=71)
COMPROMISE
Angle LAD-LCX (º)
88,63 ± 36,46
96,88 ± 39,09
0,42
LM diameter (mm)
4,31 ± 0,54
4,40 ± 0,76
0,66
LAD diameter (mm)
3,24 ± 0,42
3,23 ± 0,45
0,95
LCX diameter (mm)
3,41 ± 0,59
3,10 ± 0,51
0,10
68,53 ± 12,83
69,25 ± 11,63
0,83
3,24 ± 0,37
3,26 ± 0,36
0,82
Plaque burden (%)
56 ± 19
60 ± 16
0,58
Lumen CSA (mm2 )
4,63 ± 1,87
4,64 ± 2,38
0,98
11,41 ± 4,97
11,60 ± 4,41
0,90
0,72 ± 0,23
0,85 ± 0,19
0,07
13
1
<0,01
2,3 ± 1,5
0,18
% stenosis LAD
Stent diameter (mm)
n=19
NO COMPROMISE
n=52
p
IVUS (n=49)
EEM CSA (mm2)
Remodeling index
“Eyebrow” sign present
Length LCX jailed ostium (mm)
LCx jailing ≥ 2,5 mm
3 ± 1,6
61%
53%
0,93
Ostial LAD lesions n=71
IN HOSPITAL OUTCOME
• Angiographic success (LAD) ..……………………... 71 (100%)
• Angiographic success (LCx) ………………………... 64 (90%)
• Death ……………………………………………………. 0
• Q wave MI ……………......................................... 0
• Non Q wave MI ………………………………………… 2 (3%)
• Emergency bypass ……………………………………. 0
• Repeat PCI ……………………………………………… 0
• LAD stent thrombosis ………………………………… 0
Ostial LAD lesions n=71
FOLLOW UP (16 ± 12 months)
• Death …………………………………………… 0
• Q wave MI ……………………………………. 0
• Non Q wave MI ………………………………. 0
• Stent thrombosis …………………………….. 0
• TLR ………………………………………………. 1 (1%)
• Composite …………………………………….. 3 (4%)
Outcome of floating struts n=37/49 (75%)
LM
LAD
LAD
LCX
LCX
I know so
very little
about you…
LM
LAD
LCX
Floating
Outcome of floating struts
It is all
right
7 months later
Trifurcation or more {0,1,0,0,0} n=13/71 (18%)
Pre
Pre
Post
Post
LAD
RI
LM
RI
LCx
Tapering index LAD/LM 0,68
LM
LM
stent
stent
LM
LM
LAD
LAD
Pre
Pre
Angiographic success
LAD ………………………………. 13 (100%)
LCx ……………………………….. 13 (100%)
RI ………………………………... 12 (92%)
LAD
LAD
Post
Post
Conclusions
Precise stent deployment for ostial LAD lesion is simple, safe
and effective
In most patients, the carina was free of plaque in the IVUS
study
Floating stent struts are frequently observed, and do not relate
to MACE, probably due to high flow at this level
The presence of an “eyebrow” sign is a predictor of LCx ostial
compromise, which does not need intervention in most cases.
Carina displacement seems to be the main mechanism of this
damage
OCT at follow-up demonstrates endothelization of the floating
struts