Effectiveness of Complete Lesion Effectiveness of Complete Lesion Coverage with Coverage with Sirolimus Sirolimus - - Eluting Eluting Stent Stent for for Ostial Ostial Left Anterior Left Anterior Descending Artery Descending Artery Stenosis Stenosis Ki-Bae Seung, M.D., Ph.D. Division of Cardiovascular Medicine Kang-Nam St. Mary’s Hospital The Catholic University of Korea
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Effectiveness of Complete Lesion Coverage with Sirolimus ...Effectiveness of Complete Lesion Coverage with Sirolimus-Eluting Stent for Ostial Left Anterior Descending Artery Stenosis
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Effectiveness of Complete Lesion Effectiveness of Complete Lesion Coverage with Coverage with SirolimusSirolimus--Eluting Eluting
StentStent for for OstialOstial Left Anterior Left Anterior Descending Artery Descending Artery StenosisStenosis
Ki-Bae Seung, M.D., Ph.D.
Division of Cardiovascular MedicineKang-Nam St. Mary’s Hospital
The Catholic University of Korea
Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
• Stenting at ostial left anterior descending artery (LAD) remains challenging because :- The ostial lesion has prominent elastic recoil and rigidity- The frequent involvement of atherosclerotic lesion to the distal left main coronary
artery(LMCA)- Technical difficulties such as optimal stent deployment and the concern
of left circumflex artery (LCX) occlusion during procedure - Higher rate of in-stent restenosis compared to non-ostial lesion
• There was no published data regarding the results of sirolimus-eluting stent (SES) implantation for ostial LAD stenosis in spite of very promising results of SES implantation for simple coronary lesions.
BackgroundBackground
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• To evaluate the clinical and angiographic outcomes of SES implantation for ostialLAD lesions, compared to bare metal stent (BMS) implantation
ObjectiveObjective
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• From March 2003 to January 2004, SES was implanted for 68 consecutive patients with de novoostial LAD lesions in the three cardiac centers (SES group).
• The control group was composed of 77 patients with BMS during the preceding 2 years (BMS group), who had been included in a randomized study investigating the efficacy of debulking atherectomy before BMS stenting for ostial LAD stenosis.
PatientsPatients
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• Ischemic evidence of anterior myocardial ischemia
• De novo Lesions with diameter stenosis≥70%
• Lesions located ≤3 mm of the LAD ostium• Reference vessel diameter >2.5mm
Inclusion CriteriaInclusion Criteria
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• Contraindication to antiplatelet agents• Bailout stenting• Primary angioplasty in acute myocardial infarction• Left ventricular ejection fraction ≤ 40%• Previous bypass surgery• Involvement (≥50% of diameter stenosis by visual
estimation) of the LMCA or the ostium of the LCX• Chronic total occlusion • An inability to follow the protocol
Exclusion CriteriaExclusion Criteria
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Stenting Strategies for LAD OsStenting Strategies for LAD Os
• Precise location method
• Method covering distal part of LMCA
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Precise LocationPrecise LocationOstial LAD Lesion
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Precise LocationPrecise LocationIVUS Evaluation
Ostial LAD•Lumen CSA:2.86 mm2
•EEM CSA:14.38 mm2
•Plaque burden:80%
Distal LMCA•Lumen CSA: 16.28mm2
•EEM CSA: 17.89mm2
•Plaque burden:10%
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Precise Location MethodPrecise Location Method
Stenting and Final Result
Cypher 3.5×18 mm
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• All the BMS patients• SES patients with normal LMCA bifurcation• Debulking atherectomy was performed to
IVUS<0.0012.73±0.732.06±0.56Acute gain, mm0.027-3.3±11.80.8±15.1DS, %
<0.0014.08±0.573.36±0.47MLD, mm
PBMSSES
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QCA at Follow-up
6259Patients
<0.0011.60±0.81 0.22±0.52 Late loss, mm
<0.00140.9±25.6 -2.1±19.0 DS, %
<0.0012.13±0.91 2.77±0.56 MLD, mm
<0.0013.61±0.54 2.86±0.51 Reference, mm
PBMSSES
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Acute Gain & Late Loss
1.90
0.22
2.67
1.60
0
1
2
3
Acute gain Late loss
Cypher BMS
mm
P<0.001P<0.001
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Restenosis Rate at 6 Months
32.3
5.1
0
10
20
30
40
%
3/59 20/62SES BMS
P<0.001
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Clinical Outcomes at 12 Months
<0.00113 (16.9%)0MACE<0.00113 (16.9%)0TLR
7768Patients
1.000Stent thrombosis00Non-Q MI00Q MI
1.0MI1.000Death
PBMSSES
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LAD Os stenting with cypher stents
Covering LMCAVs
Precise Location
LAD Os stenting with cypher stents
Covering LMCAVs
Precise Location
Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
Restenosis Rate at 6 Months
7.9
0
0
2
4
6
8
10
%
0/21 3/38Covering
LMCAPrecise Location
P=0.546
Cardiovascular Research Foundation ANGIOPLASTY SUMMIT
• Sirolimus-Eluting Stentings appear more effective in reducing restenosis and target lesion revascularization for ostial left anterior descending lesions, compared to bare metal stentimplantations.
• New strategy covering the distal left main coronary artery across left circumflex artery which was applied to the cases having insignificant mild narrowing at the distal left main coronary artery was safe and may lead to favorable clinical outcomes with complete lesion coverage.