Left main pci via transradial approach: How to keep things simple.

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

2. % TR PCI
TRA for PCI in France/Europe/USA
France
Europe
USA

3. % TR PCI
TRA for PCI in France/Europe/USA
France
Europe
USA

4. % TR PCI
TRA for PCI in France/Europe/USA
France
Europe
USA

5. % TR PCI
TRA for PCI in France/Europe/USA
France
Europe
USA

6. 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 ?

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

8. 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.

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

10. 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

11. The French LM Taxus Registry: TRA vs TFA
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
T. Lefèvre et al. ESC 2006

12. The French LM Taxus Registry: TRA vs TFA
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
T. Lefèvre et al. ESC 2006
P value
NS
<0.0001
NS
<0.0001
0.07
NS

13. The French LM Taxus Registry: TRA vs TFA
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)
T. Lefèvre et al. ESC 2006

14. The French LM Taxus Registry: TRA vs TFA
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 (%)
T. Lefèvre et al. ESC 2006

15. 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

16. Mr ROB… De novo angina

17. Mr ROB… De novo angina

18. Mr ROB… De novo angina

19. 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

20. How to Keep Things Simple ?
Define a strategy

21. How to Keep Things Simple ?
Define a strategy

22. How to Keep Things Simple ?
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

23. 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

24. How to Keep Things Simple ?
EBU 4 6F
Runthrough
wire
Hyriu 3.5x10

25. How to Keep Things Simple ?

26. How to Keep Things Simple ?
Xience 3.5 x 18

27. How to Keep Things Simple ?
Xience 3.5 x 18

28. How to Keep Things Simple ?
Xience 3.5 x 18
14 Atm.

29. How to Keep Things Simple ?
Xience 3.5 x 18
18 Atm.

30. How to Keep Things Simple ?
Hyriu 4.5 x 10
20 Atm.

31. Proximal Optimization Technique
O. Darremont et al. EBC 2009

32. How to Keep Things Simple ?

33. How to Keep Things Simple ?
Runthrough
Distal strut

34. How to Keep Things Simple ?
Hyriu 3.5 x 10
Hyriu 2.5 x 10

35. How to Keep Things Simple ?

36. How to Keep Things Simple ?

37. How to Keep Things Simple ?

38. Mr ROB… De novo angina

39. 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.

40. 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 !

42. 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

43. LEMAX and TAXUS LM french registries
P. Garot et al. AHA 2011

44. 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

45. Baseline LM Bifurcation Stenting
Techniques Requiring Re-treatment in Syntax

46. 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

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

48. 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

49. J-CYPHER Registry: Distal Left Main
Outcomes according to bifurcation stenting strategy
Toyofuku, M. et al. Circulation 2009;120:1866-1874

50. 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

51. 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

52. Proximal vs Distal Cross
Proximal cross
Distal cross
SB
dilatation
Kissing
balloon
Ormiston et al. EBC IV, Prague Ormiston
2008

53. 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

54. 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

55. Respect the Fractal Anatomy and Rheology
3. Final Kissing
ü Better stent apposition
ü Optimal rheology
ü Optimal further access to LCx

56. Respect the Fractal Anatomy and Rheology
3. Final Kissing
ü Better stent apposition
ü Optimal rheology
ü Optimal further access to LCx

57. Respect the Fractal Anatomy and Rheology
3. Final Kissing
ü Better stent apposition
ü Optimal rheology
ü Optimal further access to LCx

58. Respect the Fractal Anatomy and Rheology
3. Final Kissing
ü Better stent apposition
ü Optimal rheology
ü Optimal further access to LCx

59. Respect the Fractal Anatomy and Rheology
3. Final Kissing
ü Better stent apposition
ü Optimal rheology
ü Optimal further access to LCx