Aγγειοπλαστική σε ασθενή με CABG (πότε και πως) Β. Βούδρης ΜD FESC FACC Ωνάσειο Καρδιοχειρουργικό Κέντρο Αθήνα

Aγγειοπλαστική σε ασθενή με CABG (πότε και πως) Β. Βούδρης ΜD FESC FACC Ωνάσειο Καρδιοχειρουργικό Κέντρο Αθήνα

SVG grafts David Sabiston performed anastomosis of a saphenous vein to RCA on April 4th, 1962 First aortocoronary SVG implantation in a human being by Garrett and colleagues in May 1967 Subsequent pioneering work of Favaloro established surgical revascularization for the global epidemic of ischemic heart disease

The post - CABG patient Despite increased use of secondary prevention measures, post-cabg patients suffer from: Progression of native coronary atherosclerosis Accelerated atherosclerosis in SVGs

Coronary bypass graft failure rates The VA Cooperative Study 85% 61% SVG-LAD: 69% SVG-RCA: 56% SVG-Circ: 58% SVG- >2mm: 88% SVG- 2mm: 55% Goldman et al, JACC 2004

Η συχνότητα απόφραξης των φλεβικών μοσχευμάτων τον πρώτο χρόνο από την τοποθέτηση τους είναι : < 5% 10-15% 20-40% > 40%

SVG failure 1 st year up to 15% of SVGs occluded 1-6 years SVG attrition rate 1% to 2% per year 6-10 years SVG attrition rate 4% per year

Native coronary artery disease progresses in 5% of pts annually

Clinical Presentation of CAD in post- CABG Patients Angina recurs in up to 20% of patients during the 1 st year and in 4% annually during the ensuing 5 years Chen L, et al. JACC 1996 Douglas JS Jr. Semin Thorac Cardiovasc Surg. 1994

Angina after CABG Progression of disease in native vessels Disease of SVG Disease of arterial grafts Subclavian artery disease

Clinical Presentation of CAD in post-cabg Pts Despite the indisputable benefit of CABG surgery in reducing morbidity and mortality, AMI still reported in 3-8% annually following CABG Fitzgibbon GM, et. Al. (1996) NRMI Investigators. Coronary bypass graft fate and patient outcome: angiographic follow- up of 5,065 grafts related to survival and reoperation in 1,388 patients during 25 years. J Am Coll Cardiol 28: 616 626.

Σε ασθενείς που εμφανίζουν οξύ στεφανιαίο σύνδρομο μετά από επέμβαση CABG η ένοχη βλάβη εντοπίζεται : Στο φλεβικό μόσχευμα Στο γηγενές αγγείο Στο αρτηριακό μόσχευμα Ισοδύναμα στο φλεβικό μόσχευμα και το γηγενές αγγείο

AMI post-cabg: Culprit vessel Angiographic studies indicate that among pts who present with UA, non Q-MI, or Q-MI post-cabg, the culprit lesion in 70-85% of cases is an atherosclerotic SVG stenosis, often with superimposed thrombus Balanced IRA distribution (NV vs. SVG) in the APEX-AMI study Chen L, et al. JACC 1996; Douglas JS Jr. Semin Thorac Cardiovasc Surg. 1994 ; Welsh, R. C. et al. APEX-AMI study J Am Coll Cardiol Intv 2010

Clinical Presentation of CAD in post-cabg Pts PCI in Native Subjected Arteries vs. Bypass to PCI Grafts in Prior CABG Pts: A Report From the National Cardiovascular Data Registry Brillakis et al. J Am Coll Cardiol Intv. 2011;4(8):844-850

PCI in Saphenous Vein Grafts: How & When?

SVG vs. Native Coronary Artery disease Is vein graft disease different from NCA disease??? Nature of SVG disease: pathologic studies First month: Technical failure, thrombosis First year: Fibro-intimal hyperplasia Beyond 1 st year: Atherosclerosis Spray & Roberts, AHJ 1976; Walts et al, Circulation 1983

SVG vs. Native Coronary Artery atherosclerosis Friable plaque: degenerated, loose, fibrocellular fibroatheromatous debris lining on the internal surface of the vessel commonly found in SVGs 1-3 yrs post-cabg but is unusual in NCA-AS appearance of an irregular or serrated luminal border

PCI in SVGs Elderly with co-morbidities Friable material with increased risk of embolization / MI /death / late thrombosis TVR for disease progression Increase late restenosis in native vessels

SAphenous VEin De Novo Trial (SAVED) Stent (n=110) SVG lesion PTCA (n=110) Pt (%) 100 P<0.001 92 69 Stent PTCA P=NS 37 P=0.03 46 42 27 Trial design 1/93 6/95 Multicenter Palmar Schatz stent 0 Procedural efficacy Angiographic restenosis MACE - 6 months Savage et al, NEJM 1997

PCI in Saphenous Vein Grafts with BMS 30 days MACE 6-15% 6 months restenosis 17-50%

Σε πρώιμη (< 5 έτη) νόσο των φλεβικών μοσχευμάτων η αγγειοπλαστική επιχειρείται : Στο φλεβικό μόσχευμα Στο γηγενές αγγείο

PCI in post-cabg pts: Graft vs. Native Vessels Worse TIMI flow in SVG PCI Nguyen et al. Am. J. Cardiol 2003

Prior CABG Patients With STEMI Treated With ppci APEX-AMI When IRA was a graft: Worse TIMI flow Welsh, R. C. et al. J Am Coll Cardiol Intv 2010;3:343-351 Despite similar (or better) pre- PCI TIMI flow grade and a higher use of thrombectomy devices; those with a graft IRA had decreased post-pci TIMI flow grade compared to NCAs

Prior CABG Patients With STEMI Treated With PPCI APEX-AMI 90-Day Outcomes according to prior CABG - graft vs. native IRA: Prior CABG pts with graft-ira had the worse outcomes Welsh, R. C. et al. J Am Coll Cardiol Intv 2010;3:343-351

PCI in Native Arteries vs. Bypass Grafts in Prior CABG Pts: A Report From the National Cardiovascular Data Registry PCI in prior CABG pts represented 17.5% of the total PCI volume (300,902 of 1,721,046) Comparison of the PCI target vessel in pts with prior CABG during different time intervals from CABG. p < 0.001 Brillakis et al. J Am Coll Cardiol Intv. 2011;4(8):844-850

PCI in Native Arteries vs. Bypass Grafts in Prior CABG Pts: A Report From the National Cardiovascular Data Registry PCI of a bypass graft independently associated with higher in-hospital mortality: adjusted OR for SVG 1.20 (95% CI:1.10-1.30) p<0.001 Brillakis et al. J Am Coll Cardiol Intv. 2011;4(8):844-850

PCI in SVGs: Distal Embolization Distal embolization of atheroembolic debris Slow or no-reflow phenomenon: 10-15% of cases Periprocedural angina and ischemic ST-segment changes Subsequent MI: 31% of pts In-hospital mortality increases 10-fold However, distal embolization remains difficult to predict Lee et al. J Am Coll Cardiol Intv. 2011;4(8):831-843

Increase CK-MB post- SVG PCI without Embolic Protection Devices (EPD) (n=1056) 60% 53% 50% 40% 30% 20% 10% 0% Prevalence 32% 4.8% P < 0.05 P < 0.05 15% 11.7% 6.5% 1 Year Mortality Normal CK-MB 1-5x CK-MB >5x CK-MB Hong et al, Circulation 1999

Συσκευές προστασίας θρόμβων 1. Εγγύς απόφραξη St Jude (Proxis ) 2. Φίλτρα BSI (FilterWire ) ev3 (Spider ) 3. Περιφερική απόφραξη Medtronic (GuardWire )

Used in <25% of 19,546 SVG PCI in the ACCNCDR Registry

Role of Embolic Protection Beneficial across all pt subsets in 6 studies Plaque volume and SVG degeneration strongest predictors of MACE (Coolong et al Circulation 2008) Used in <25% of 19,546 SVG PCI in the ACCNCDR Registry Mehta et al AJC 2007

Eμπόδια στη χρήση EPD 1. Αδυναμία πρόβλεψης του no reflow 2. Εξοικίωση με τις συσκευές 3. Χρόνος επέμβασης + ακτινοσκόπησης 4. Tεχνικές ιδιαιτερότητες ελίκωση εντόπιση της στένωσης 5. Κόστος των συσκευών σε σχέση με το κόστος των επιπλοκών

2010

PCI in SVGs: IIb or not IIb?

PCI in SVGs @ EPD: IIb or not IIb? Procedural outcomes and 30-day MACE rates SVG thrombus is usually large with relative lack of platelet and platelet-fibrin aggregates, which translates into poor response to Gp IIb/IIIa inhibitors. Jonas M et al. Eur Heart J 2006;27:920-928

Technical Aspects Predilatation Pre dilatation before stenting? NO! Always plan on direct stenting Predilatation often associated with distal embolization

Technical Aspects Direct Stenting 507 pts (672 lesions) with 12 m f/u, 229 direct stenting Direct stenting had - less CK MB >4x, less NQMI (10.7 vs 18.4 p< 0.024), less TLR at 1 yr (p<0.02), improved EFS at 12 mo DPDs, no better than direct stenting in 188 pts at Washington Hospital Center in an observational study Leborgne et al. AHJ 2003; Okabe et al CCI 2008

Technical Aspects Postdilatation Post dilatation after stenting? It is the most common cause of distal embolization Do it only if severe stent under expansion is evident Always with distal protection

Do Covered Stents offer an advantage in SVG s? Jomed International AB Boston Scientific

Do Covered Stents offer an advantage in SVG s? 30.6% vs., 26.6%, p = 0.43) 23.5% vs. 15.6%, p = 0.055 Turco M.A., et al. Catheter Cardiovasc Interv. 2006

Do Covered Stents offer an advantage in SVG s? RECOVERS trial: PTFE-covered JoStent balloon-expandable stent 10.9% vs. 4.1%, p = 0.047 10.3% vs. 3.4%, p = 0.037 5 years FU Stankovic et al. Circ 2003

DES IN SVGs

DES in SVGs - Delayed RRISC Τυχαιοποίηθηκαν 75 ασθενείς 38 ασθενείς, 47 στενώσεις, 60 SES 37 ασθενείς, 49 στενώσεις, 54 BMS Επιβίωση για μέση διάρκεια 32 μήνες Vermeersch P et al., JACC 2007

SOS trial centers Univ. of Iowa PI: James Rossen, MD Univ. Arkansas Medical Sciences PI: Joe K. Bissett, MD UTSW Dallas VA Coordinating Ctr Univ. of Arizona PI: Hoang Minh Thai, MD Houston VA PI: Biswajit Kar, MD Onassis Cardiac Surgery Ctr Athens, Greece PI: Vassilis Voudris, MD

SOS Study In saphenous vein graft lesions, compared to a similar bare metal stent, the Taxus PES resulted in: Significant reduction in 12-month binary angiographic restenosis, target lesion revascularization and target vessel failure Trends for lower target vessel revascularization, myocardial infarction No difference in mortality and stent thrombosis

Kitabata et al. Am J Cardiol 2013 All-cause mortality, myocardial infarction, and TVR

SVG PCI When & How When diseased SVGs cause ischemic syndromes, PCI of the native CAs should be considered whenever possible PCI not recommended for chronic SVG occlusion Success of SVG intervention is limited by high rates of: periprocedural MACE (e.g., no reflow, periprocedural MI) intermediate-term restenosis SVG disease progression outside of the treated segments

SVG PCI When & How GPIs are not beneficial as adjunctive Tx during SVG PCI Direct stenting potential benefit of decreasing distal embolization Covered stents failed to demonstrate clinical benefit in reducing periprocedural MI and restenosis rates Restenosis after SVG PCI is high with BMS; DES may decrease restenosis Embolic protection devices Class I indication and should be used whenever feasible The optimal pharmacological treatment for slow or no reflow is unclear, although a variety of vasodilators have shown promise

Ο πιο ασφαλής τρόπος να διατηρηθεί ανοιχτή η σαφηνής φλέβα είναι να παραμείνει στη θέση της στο πόδι του ασθενούς

Thank you!

DES vs. BMS in SVGs Lesions : TLR/TVR TLR TVR

Τακτική αντιμετώπισης στενώσεων SVG στην εποχή των DES Τα βραχυχρόνια αποτελέσματα των DES σε στενώσεις SVG είναι καλύτερα, αλλά τα απώτερα αποτελέσματα δεν είναι γνωστά Η επιλογή του stent θα πρέπει να εξαρτηθεί από τη δυνατότητα μακρόχρονης λήψης διπλής αντιαιμοπεταλιακής αγωγής Αναγκαία η χρήση συσκευών προστασίας θρόμβων Προσπάθεια πρόληψης της εξέλιξης της νόσου - στατίνες