proxis proximal embolic protection in saphenous vein graft and infarct pci dan blackman leeds...
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Proxis
Proximal embolic protection in saphenous vein graft and infarct PCI
Dan BlackmanLeeds General Infirmary
Advanced Angioplasty 2006
Proxis embolic protection systemProxis embolic protection system
- short flexible catheter, short flexible catheter,
- attached to a hypertube-catheter attached to a hypertube-catheter shaftshaft
-short distal circumferential short distal circumferential balloon balloon at the tipat the tip
-proximal balloon within guide proximal balloon within guide – –
-- deployed in proximal vessel (10mm - deployed in proximal vessel (10mm landing zone) landing zone)
- balloon inflated at 2/3 atm, causing - balloon inflated at 2/3 atm, causing stasis of flowstasis of flow
Embolic protection in saphenous vein grafts
Two key problems remain
(1) Residual MACE of c.10% despite distal
protection
30-day MACE with distal protection
9.6 9.9
11.6 11.210.1
9.18.4
16.5
0
2
4
6
8
10
12
14
16
18
SAFERcontrol
SAFERGW
FIREFW
FIREGW
PRIDETriactiv
PRIDEFW/GW
SPIDER SPIDERFW/GW
30-d
ay M
AC
E
Causes of residual MACE
Distal Filter Distal balloon Proxis
Embolisation on wiring ± pre-dilatation
+ + -
Embolisation on device crossing
+ + -
Failure to capture debris < 100μm
+ - -
Failure to capture soluble mediators
+ - -
Ischaemia during balloon occlusion
- + +
Embolic protection in saphenous vein grafts
Two key problems remain
(1) Residual MACE of 10% despite distal
protection
(2) Distal protection cannot be used for distal
lesions (25-30mm landing zone required)
Proxis in saphenous vein grafts
• Proximal balloon occlusion embolic protection offers theoretical benefits over distal protection
• Proxis is at least as effective as distal protection in a large randomised controlled trial
• Proxis allows protection of distal vein graft lesions not amenable to distal protection
Embolic protection in acute myocardial infarction
• Do we need another embolic protection device?
• Do we need any embolic protection device?
Embolic protection in acute myocardial infarction
EMERALD no benefit with Guardwire distal balloon occlusion in unselected primary/rescue
PCI
ASPARAGUS no benefit from FilterWire distal filter in unselected primary PCI
PROMISE no benefit from FilterWire distal filter in infarct PCI
Why has embolic protection failed to improve outcome in infarct PCI?
• Distal embolisation does not contribute to adverse outcome
• Predictive variables for no-reflow include:-– Angiographic heavy thrombus burden– IVUS findings of lipid-rich plaque
• Loss of plaque volume at the lesion site correlates with occurrence of no-reflow
• Macroscopic distal embolisation correlates with poor outcome
Why has embolic protection failed to improve outcome in infarct PCI?
• Distal embolisation does not contribute to adverse outcome
• Study patients were low-risk– Select patients may benefit
• Heavy thrombus burden• Large vessels• Lipid-rich plaque
• Risk/benefit of Embolic protection devices used unfavourable – Increased procedure time and complexity– Embolisation on crossing the lesion– Failure to protect side-branches– Incomplete protection from small particles and soluble mediators
Might Proxis provide more effective embolic protection in infarct PCI?
• Reduced complexity No need to cross occlusion or visualise distal vessel
• Reduced risk Avoid embolisation caused by device crossing
• Improved protection Protect all stages inc. wire crossing
• Improved protection Aspiration of thrombus, small particles and soluble mediators
• Improved protection Protection of side branches
Early experience with Proxis Early experience with Proxis combined embolic protection/ thrombectomy system combined embolic protection/ thrombectomy system
in ac in acuute myocardial infarctionte myocardial infarction
Karel T. Koch MD, PhD, Robbert J. de Winter MD, PhD, Jose Henriques MD, PhD, Karel T. Koch MD, PhD, Robbert J. de Winter MD, PhD, Jose Henriques MD, PhD, Rene J. vd Schaaf MD, Saskia Rittersma MD, Jan G.P. Tijssen PhD, Rene J. vd Schaaf MD, Saskia Rittersma MD, Jan G.P. Tijssen PhD,
Allart J. vd Wall MD, PhD, Jan J. Piek MD, PhDAllart J. vd Wall MD, PhD, Jan J. Piek MD, PhD
Academic Medical CentreAcademic Medical Centre
Amsterdam, The NetherlandsAmsterdam, The Netherlands
TIMITIMI--flow flow after PCI:after PCI: 33 96%96%
22 3% 3%
11 1% 1%
MBG-3MBG-3 96%96%
ST resolution at 60 minutes:ST resolution at 60 minutes:> 50%> 50% 100%100%> 70%> 70% 81%81%
Total MACE at 30 daysTotal MACE at 30 days 4%4%
Koch et al. Procedural outcome
Proxis in infarct PCI
• Distal embolic protection is ineffective in unselected patients with acute MI
• Distal embolisation must contribute to adverse outcome in some patients
• Proxis proximal protection + aspiration offers convincing theoretical advantages over distal protection with encouraging registry data
• A randomised controlled trial of Proxis in selected high-risk patients is required
Conclusions
• Proxis is the first proximal embolic protection device
• In vein graft PCI Proxis is at least as effective as distal protection
• In vein graft PCI Proxis enables protection of distal lesions not eligible for distal protection
• In infarct PCI Proxis offers convincing theoretical advantages over distal protection
• Early registry data of Proxis in AMI are encouraging, but randomised controlled trial data are required
• 48 year old male
• First presentation with transient inferior ST • Coronary angiogram 12 hours after presentation