Lefevre T - Left main PCI

Left Main PCI Via TRA
How to Keep Things Simple
Thierry Lefèvre, Massy, France

% TR PCI

TRA for PCI in France/Europe/USA

France
Europe
USA

Why TRA ?
Price to
ü Early ambulation Pay
ü Patient confort
ü Very low access site complication
ü Less transfusion

Learning curve

ü Shorter hospital stay

Guide size limitation
ü Less staff workload
ü Lower cost
ü Less death ?

Learning Phase

Consensus document on the radial approach in PCI.
EuroIntervention, publish-ahead-of-print January 2013

Why LM PCI ?
ü Results at least as good as surgery in
patients with Syntax score < 32.
ü Even better for ostial, mid shaft LM, when
distal LM can be treated with one stent.
ü Results have improved since Syntax with
better experience, strategy, new
generation DES and leaving less residual
syntax score.

Why LM PCI via TRA ?
After the Learning Phase
üSame results as TFA
üWith all the advantages of TRA

The French LM Taxus Registry: TRA vs TFA
Main Clinical Characteristics
Radial
Patients (n)
Age (years)
Diabetes (%)
Hypertension (%)
Hypercholesterolemia (%)
Smoker (%)
Previous MI (%)
Unstable angina (%)
Additive Euroscore

Femoral

P value

168
67.0+11.9
28.9
63.6
65.1
45.2
11.4
42.9
4.3+3.2

123
71.2+10.4
28.7
63.9
59.8
41.0
11.6
30.6
5.5+3.5

<0.005
NS
NS
NS
NS
NS
0.04
<0.005

T. Lefèvre et al. ESC 2006

Main Angiographic Characteristics
Radial

Femoral

P value

EF (%)
3 Vessel disease (%)
Bifurcation lesion (%)
Medina 1,1,1 0,1,1 or 1,0,1
Left main proximal ref. (mm)

61.6+12.5
27.5
90.9
61.6
3.65+0.45

59.2+13.1
25.5
77.5
64.5
3.62+0.60

NS
NS
0.003
NS
NS

LAD proximal reference (mm)

3.20+0.52

3.28+0.62

NS

LCx proximal reference (mm)

2.78+0.39

2.82+0.52

NS


Main Procedural Characteristics
IABP (%)
Guiding size 6 Fr (%)
Other treated vessel (%)
LM stent length (mm)
Stent side branch (%)
Total stent length (mm)

Radial
4.2
94.6
81.2
19.6+6.3
36.2
54+22

Final kissing balloon (%)

98.6

93.8

0.06

100
263+145
60.0+31.9

98.7
230+132
56.2+30.3

NS
NS
NS

Angiographic success (%)
Contrast media (ml)
Procedural duration (min.)

Femoral
4.9
73.8
76.7
16.0+5.7
47.5
56+23


P value
NS
<0.0001
NS
<0.0001
0.07
NS

In-Hospital Outcome
Radial

Femoral

P value

0

0

NS

4.2

1.6

NS

Emergency CABG (%)

0

0.4

NS

Emergency PCI (%)

0

1.6

NS

Stroke (%)

0

0

NS

Access site complication (%)

0

3.4

0.056

Death (%)

0

3.3

NS

MACCE (%)

4.2

4.9

NS

3.8+2.2

5.6+4.8

<0.0001

Q wave MI (%)
Non-Q-wave MI (%)

Hospital stay (days)


12-months Outcome
Radial

Femoral

P value

0

1.6

NS

Coronary angiogram (%)

63.4

62.1

NS

TVR Left Main (%)

5.6

5.1

NS

TVR other vessel (%)

13.5

10.2

NS

Death (%)

3.0

4.1

NS

Cardiac death (%)

1.8

2.5

NS

Non cardiac death (%)

1.2

1.6

NS

Stroke (%)


Mr ROB…
64 years old
172 cm – 95 Kg
Dyslipidemia on statin therapy
Previous smoker
Previous LCx-Mg PCI 10 years ago
De novo effort angina since 5 days

How to Keep Things Simple ?
ü Optimal view
ü Optimal guide support
ü Pre defined strategy
ü Consider IABB

Compatible with TRA

ü Optimal DAPT

ü Optimal anticoagulation (ACT)
ü Optimal stent positioning
ü Consider IVUS
ü Follow-up

Define a strategy

4.4 mm
3.4 mm

Define a strategy
Provisional SB stenting
ü Optimal view
ü Two wires
ü Respect the fractal anatomy
ü Stent choice

2.7 mm

Element

Xience V

Taxus

Integrity

BioMatrix

Cypher

2.25

Very Small WH
(2 cells) max
exp.: 2.8mm

2.50

Small
workshorse (8
crowns, 2 cells)
max expansion :
3.5mm

Medium
Workhorse (6
crowns , 3 cells)
max. expansion:
4.4mm

Small
workshorse (6
crowns, 2 cells)
max expansion:
3.3mm

Small workhorse
(7crowns, 2
cells*) max
expansion:
4.0mm
*1.5 cell in
Resolute

Medium
workhorse (6
crowns, 2 cells)
max expansion:
4.4mm

Medium
workhorse (6
crowns, 6 cells)
max expansion:
4.75mm

Large workhorse
(9 crowns, 3
cells) max
expansion:
5.75mm

Large workhorse
(7 crowns, 7
cells) max
expansion:
5.7mm

2.75

Medium
Workhorse (9
crowns, 3 cells)
max expansion:
4.7mm

3.00

3.50

4.00

4.50

Medium
Workhorse (8
crowns, 2 cells)
max expansion :
4.5mm
Large workhorse
(10 crowns, 2
cells) max
expansion:
5.4mm

Large
workhorse: (9
crowns , 3 cells)
max expansion :
5.7mm

Large workhorse
(9 crowns, 3
cells) max
expansion:
5.75mm

Medium
workhorse (10
crowns, 2 cells)
max expansion :
4.8mm

5.00

N. Foin et al. EBC 2012

EBU 4 6F
Runthrough
wire
Hyriu 3.5x10

Xience 3.5 x 18

Xience 3.5 x 18
14 Atm.

Xience 3.5 x 18
18 Atm.

Hyriu 4.5 x 10
20 Atm.

Proximal Optimization Technique

O. Darremont et al. EBC 2009

Runthrough
Distal strut

Hyriu 3.5 x 10
Hyriu 2.5 x 10

Conclusion
ü Transradial approach is an attractive,
safe and feasible route for PCI to the LM.
ü In experienced hands, it is associated
with similar procedural data, in-hospital
and mid-term outcome.
ü Hospital stay is shorter probably due to
earlier ambulation and a lower rate of
access site complication.

To Keep Things Simple
ü Like for TFA, provisional SB stenting should
be the default approach (with two wires).
ü Guide choice for good stability and support.
ü Good NC balloons compatible with Kissing in
6 Fr guides (7 French for Trifurcation or LM
> 4.5 mm).
ü Remember TFA is also possible !

Start with Two Guidewires
ü Modify Favorably the angle between both branches1,2
ü Increase the rate of SB success3
ü Wire is a good marker of SB in case of occlusion
ü Keep the side branch open ?4
ü There is always a solution when the SB is wired5
1. Louvard et al. TCT 2003
2. Louvard et al. ESC 2004
3. Brunel et al. CCVI 2006
4. Colombo, personal data
5. Lefèvre et al. EBC 2009

LEMAX and TAXUS LM french registries

P. Garot et al. AHA 2011

Left main Taxus/Xience French Registry
Predictors of MACCE by multiple logistic regression
Death + MI + clinically-driven TLR + CABG + Stroke
Variable

Odds Ratio

p

95% Conf.
Interval

Paclitaxel-Eluting Stent

2.11

0.043

[1.02-4.34]

Syntax score

1.05

0.009

[1.01-1.09]

Euro score

1.13

0.007

[1.03-1.24]

Diabetes

1.98

0.061

[0.97-3.99]

Previous MI

0.38

0.148

[0.10-1.42]

Nb stents in LM

1.54

0.148

[0.86-2.78]

P. Garot et al. AHA 2011

Baseline LM Bifurcation Stenting
Techniques Requiring Re-treatment in Syntax

J-CYPHER Registry: Distal Left Main
TLR rates among various two-stent techniques
Provisional SB stenting

11.1% (22/261)

Culotte Stenting

28.1% (9 of 32)

T stenting

25.4% (17 of 67)

Crush stenting

26.7% (4 of 15)

Kissing stenting

60.0% (3 of 5)
Toyofuku, M. et al. Circulation 2009;120:1866-1874

Lessons from NORDIC II (LM Subpopulation)
Cardiac death, MI, TVR and stent thrombosis

Cumulative Event Rate (%)

SYNTAX, MACCE to 12 Months - LM PCI Subset
Provisional T-stenting (n=135)

40

2-stent strategy (n=49)

22.4%

20

P=0.03*
10.4%

0

0

6
Months Since Allocation

Event Rate ± 1.5 SE, *Fisher exact test

12
ITT population

J-CYPHER Registry: Distal Left Main
Outcomes according to bifurcation stenting strategy

Toyofuku, M. et al. Circulation 2009;120:1866-1874

Distal LM is frequently involved
%
Murasato
Taxus registry
Park

Le mans
Kozuga
French LM
Cypher Re

Chinese R

Park

Syntax
ISAR LM
Agostini

Suarez de Lezo

Pre-Combat
Friend

Erglis

Lemax

Chieffo

Current DES workhorse designs

Element

Xience V

Taxus

Integrity

BioMatrix

Cypher

2.25

Very Small WH
(2 cells)

Medium
Workhorse (6
crowns , 3 cells)

Small
workshorse (6
crowns, 2 cells)

Medium
workhorse (6
crowns, 2 cells)

Medium
workhorse (6
crowns, 6 cells)

2.50

Small
workshorse (8
crowns, 2 cells)

Small workhorse
(7crowns, 2
cells*) *1.5 cell
in Endeavor
Resolute

Large workhorse
(9 crowns, 3
cells)

Large workhorse
(7 crowns, 7
cells)

2.75

Medium
Workhorse (9
crowns, 3 cells)

3.00

3.50

4.00

Medium
Workhorse (8
crowns, 2 cells)

Large workhorse
(10 crowns, 2
cells)

Medium
workhorse (10
crowns, 2 cells)

Large
workhorse: (9
crowns , 3 cells)
Large workhorse
(9 crowns, 3
cells)

4.50

5.00

Off Label Use

Ø Company do not usually provide data on DES workhorse and max. expansion (only up to RBP is required for approval)

Foin, 2011

Proximal vs Distal Cross
Proximal cross

Distal cross

SB
dilatation

Kissing
balloon

Ormiston et al. EBC IV, Prague Ormiston
2008

Respect the Fractal Anatomy
Respect Murray’s or Finet’s law:
dMBprox = dMBdis+dSB x 0.678
1. Stent diameter according to
the Distal MB reference
ü No Carena shift
ü Jailed wire not realy jailed

Respect the Fractal Anatomy
Respect Murray’s or Finet’s law:
dMBprox = dMBdis+dSB x 0.678
2. POT Technique
ü No carena Shift
ü Better stent apposition
ü Higher chance to access a distal strut

Respect the Fractal Anatomy and Rheology

3. Final Kissing
ü Better stent apposition
ü Optimal rheology
ü Optimal further access to LCx

Lefevre T - Left main PCI

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