Ostial LAD lesion

Ostial Left Anterior DescendingCoronary Artery Lesion

Michalis Hamilos MD, PhD, FESCInterventional Cardiologist

ICE16-17 Δεκεµβρίου

Ιωάννινα

Ostial LAD lesion

Ostial LAD: a “special” lesion

§ Important because LAD supplies a large myocardialterritory

§ Complex PCI options:§ Involvement of the distal Left Main§ High elastic recoil§ Higher restenosis rate§ Plaque/Carina shift to LCx

ICE 2011, Ioannina

Ostial LAD lesion

Ostial LAD: a “special” lesion

§ Ostial LAD is a bifurcation lesion

ICE 2011, Ioannina

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Ostial LAD lesion

The impact of LAD/LCx angle

ICE 2011, Ioannina Asakaura et al CCI 1998

§PCI of ostial LAD is feasible§When LAD/LCx angle <800 - significant narrowing of LCx ostium

Ostial LAD lesion

PCI for ostial LAD lesions

ICE 2011, Ioannina Park et al CCI 2000

§111 consecutive pts, angio FU in 69pts§Angio-restenosis 26%, TLR 11.7%, only predictor final lumen diameter

§ Precise positioning§ Stents with high radial force

Ostial LAD lesion

SES for ostial LAD: J Cypher registry

ICE 2011, Ioannina Kishi et al, Circulation Card Interv 2011

Ostial LAD lesion

ICE 2011, Ioannina

SES for ostial LAD: J Cypher registry

Kishi et al, Circulation Card Interv 2011

Ostial LAD vs Proximal LAD

Ostial LAD lesion

ICE 2011, Ioannina

SES for ostial LAD: J Cypher registry

Kishi et al, Circulation Card Interv 2011

One stent vs Two stents

Ostial LAD lesion

SES for ostial LAD: J Cypher registry

§ 3-year outcomes of PCI using SES for ostial LAD lesions werecomparable to those for nonostial proximal LAD lesions

§ The 2-stent approach compared with the 1-stent approach wasassociated with a significantly higher rate of TLR

§ Clinical outcomes after crossover stenting with the 1-stentapproach for ostial LAD lesions were similar to those afterostial stenting.

ICE 2011, IoanninaKishi et al, Circulation Card Interv 2011

Ostial LAD lesion

Case Presentation

§ 55 year old male smoker and hyperlipidemic§ Clinical presentation: Stable angina class II-III (CCS)§ Stress test was high risk (3 min Bruce: Downsloping ST

depression of 2.5mm in anterior and inferior leads + chestpain)

§ Cardiac echo: apical hypokinesia with preserved EF§ Very low bleeding risk score (CRUSADE=9)§ Normal renal function

ICE 2011, Ioannina

Ostial LAD lesion

ICE 2011, Ioannina

Ostial LAD lesion

ICE 2011, Ioannina

Ostial LAD lesion

Case Summary

ICE 2011, Ioannina

§Male with stable angina§Single ostial LAD lesion, with preserved EF and apical hypokinesia

Ostial LAD lesion

Question 1

1. Medical therapy2. PCI3. Off pump Surgery4. Routine CABG

ICE 2011, Ioannina

How to treat this patient?

Ostial LAD lesion

Minimal invasive LIMA vs PCI for isolated LAD

ICE 2011, Ioannina Aziz et al, BMJ 2007

Post procedural MI

MI at Follow Up

Stroke or TIA

Mortality

Metaanalysis of 12 studies/1952 patients– 6 RCT

Ostial LAD lesion

ICE 2011, Ioannina

Minimal invasive LIMA vs PCI for isolated LAD

Aziz et al, BMJ 2007

RepeatRevascularization

Recurrent Angina

MACE

Ostial LAD lesion

PCI vs CABG for proximal LAD

Metaanalysis: 9 RCT, 1210 pts (633 PCI, 577 CABG)

ICE 2011, Ioannina Kapoor et al, JACC Interv 2008

Survival

Ostial LAD lesion

PCI vs CABG for proximal LAD

ICE 2011, Ioannina Kapoor et al, JACC Interv 2008

Ostial LAD lesion

PCI vs CABG for proximal LAD

1. No survival difference2. No difference in stroke/MI within 1 month3. More transfusions, arrhythmias, longer hospital stay for

CABG patients4. More repeat revascularization and less angina relief in PCI

patients

ICE 2011, Ioannina Kapoor et al, JACC Interv 2008

Ostial LAD lesion

§ Retrospective non randomised study, 257pts with SA§ 147 pts DES implantation, 110 CABG with LIMA§ Follow up of 18 months§ MACE :Death, MI, repeat revascularisation

ICE 2011, Ioannina

DES vs CABG for proximal LAD in SA patients

Toutouzas et al, CCI 2007

Ostial LAD lesion

DES vs CABG for proximal LAD in SA patients

ICE 2011, Ioannina

§Similar results for PCI/CABG in pLAD lesions§PCI has reduced hospitalisation length/in hospital complications

Toutouzas et al, CCI 2007

Ostial LAD lesion

Patients with isolated proximal LAD

ICE 2011, Ioannina Muller et al JACC Interv 2011

0 12 24 36 48 600

20

40

60

80

100

ControlsMedical group

P = 0.7384

No at riskMedical group 466 410 341 262 173 109Controls 1868 1839 1803 1772 1725 1675

Months

% survival

Ostial LAD lesion

Guidelines

ICE 2011, Ioannina

Wijns et al: Guidelines on myocardial revascularization, ESC EACTS 2010

Ostial LAD lesion

Question 2

1. BMS2. DES3. Atherectomy + Stent

ICE 2011, Ioannina

What is the best stent to use?

Ostial LAD lesion

Debulking for Ostial LAD lesions

§ Retrospective comparison of directional atherectomy+stent(46pts) vs stenting alone (71 pts)

§ Similar technical success and periprovedural MACE§ Angio FU in 80% at 6 months§ Larger MLD and lower restenosis in DA+stent group

ICE 2011, IoanninaAiroldi et al, Heart 2003

Ostial LAD lesion

Debulking for Ostial LAD lesions

§ Randomized comparison of directional atherectomy+stent vsstenting alone (86pts)

§ IVUS pre and post intervention§ 6 months angioFU§ Better acute gain-worse late loss in DA+stent group§ Similar restenosis rates

ICE 2011, IoanninaKim et al, Am Heart J 2004

Ostial LAD lesion

ICE 2011, Ioannina

Minimal lumen diameter

Debulking for Ostial LAD lesions

Kim et al, Am Heart J 2004

Ostial LAD lesion

ICE 2011, Ioannina

Change of lumen diameter

Debulking for Ostial LAD lesions

Kim et al, Am Heart J 2004

Ostial LAD lesion

SES vs BMS for ostial LAD stenosis

§ 68 pts SES vs 77 pts BMS for ostial LAD-6 months angio FU§ 5.1% vs 32.3% angiographic restenosis, 0% vs 17% TLR

ICE 2011, IoanninaSeung et al, JACC 2005

Ostial LAD lesion

DES vs BMS for ostial LAD

§ Retrospective comparison of DES (SES/PES) (n=43) withmatched BMS patients (n=43)

ICE 2011, Ioannina Tsagalou et al, Am J Cardiol 2006

Ostial LAD lesion

How did I treat

ICE 2011, Ioannina

Predilatation with 2.5/15mm scballoon Endeavor Resolute 3.5/15 mm stent

Ostial LAD lesion

How did I treat

ICE 2011, Ioannina

Ostial LAD lesion

Take home messages

1. Study data for ostial LAD treatment are scarce2. PCI of ostial LAD lesions is feasible and safe3. One-stent technique seems to have favorable results in

most of the cases4. Need for new studies to address the issue “PCI or CABG”,

in the era of newer DES.

ICE 2011, Ioannina

Ostial LAD lesion

Ευχαριστώ!ICE 2011, Ioannina

Ostial LAD lesion

Question 3

1. Single “floating” stent2. Double stenting (LM-LAD & LCx)3. Crossover stenting

ICE 2011, Ioannina

What is the best PCI strategy?