presentación de powerpoint - solaci...presentacion clinica •hombre 76 años •frc: hipertension,...
TRANSCRIPT
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Estrategias de Revascularizacion en Tronco de Coronaria
Izquierda Complejo Ruben Piraino, MD
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Conflicto de Intereses
Yo, Ruben Piraino, no tengo conflicto de Intereses
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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
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ANGIOGRAFIA
• TRONCO: Lesion Distal
• DA: ostial
• CX: ostial
• Ramo Intermedio: origen
• CD: normal
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angiografia
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angiografia
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Angiographic Findings
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Cual estrategia de tratamiento: Angina Inestable + Lesion de Tronco Distal (trifurcacion)
Angioplastia/Cirugia
Preferencia Paciente?
EVIDENCIA? (SCORES)
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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)
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DECISION CLINICA Relacion Riesgo/Beneficio Del Metodo de Revascularizacion vs. Preferencia del Paciente SYNTAX: 27 Euro Score: 1.4
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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
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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
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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
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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?
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Angiografia CULOTTE: Tronco a DA+LV(CX)
PROVISIONAL T STENTING: AV (CX)
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Cuerda CX
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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)
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Pre KBD
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KBD
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Diseccion Tronco-DA ostium Dolor Precordial
Cambios ST
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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)
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Stent a CX BIOLIMUS 3.0 x 24 Dolor Precordial
Cambios ST
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Post Stent CX, diseccion en ostium DA Dolor Precordial
Cambios ST Flujo TIMI 2 DA
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• 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
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Pre stent a DA dilatacion balon 2.5 Dolor + ST
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STENT a DA en posicion para implante Dolor + ST
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IMPLANTE DE STENT A DA 3.0 X 33 BIOLIMUS
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STENT implantado a DA Biolimus 3.0 x 33 NO Dolor Precordial
NO cambios ST QUE DEBEMOS HACE AHORA?
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Re Cruzar a la CX post 2do Stent pre FKBD NO Dolor Precordial
NO cambios ST
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FKBD
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RESULTADO FINAL NO Dolor Precordial
NO cambios ST Flujo TIMI III
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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
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BIFURCACION 1/1/1
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• 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”
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“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
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• 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”
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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
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POT
KBI
RePOT