C.H.T Dr.Salarifar 1 Tehran Heart Center Tehran University of Medical Sciences PCI VS CABG M....

C.H.TC.H.T Dr.SalarifarDr.Salarifar 11

Tehran Heart Center Tehran University of Medical Sciences

PCI VS CABG

M . SALARIFAR , MD


PCI VS CABG

From 1987 to 2003 326% increase in PCI

Now more than 90% stenting


Factors in patient selection

1. The need for mechanical revascularization as opposed to medical treatment & risk factor modification .

2. The likelihood of success ( vessel size , calcification , tortuosity , side branches )

3. The risk and potential consequences of acute failure of PCI ( Coronary anatomy % viable myocardium , LV function .

PCI VS CABG


4.The likelihood of restenosis ( diabetes , prior restenosis , small vessel , long lesion , Total occlusion , SVG disease) .

5. The need for complete revascularization based on the extent of CAD , severity of ischemia ,

LV function .

6. The presence of comorbid conditions

7. Patient preference

PCI VS CABG


Ideal cases of PCI

Significant symptoms despite intensive medical therapy

Low risk for complications

Technical success rate

No history of CHF

EF > 40%

PCI VS CABG


Patients with increased risk for PCI

Advanced age

Female gender

Unstable angina

CHF

LM equivalent disease

Multivessel disease

DM

Renal failure

PCI VS CABG


Current expectations for PCI

Procedural success at least 90%

Mortality < 1%

Q ware MI < 1.5%

Emergency by pass surgery 1 – 2 %

PCI VS CABG


PCI and Medical therapy

RCT comparing PCI with medical therapy are few in number and < 5000 patients , enrolled patients with SVD and prior stenting and enhanced adjunctive pharmaco therapy.

* Results :

Better control of angina

Functional capacity

Quality of life

PCI VS CABG


No RCT to date has demonsrated a reduction in death or MI with PCI compared with medical

thraphy for patient with chronic stable angina

PCI VS CABG


RITA – 2 showel excess of death and MI

62% Patients multivessed disease

COURAGE TRIAL :

2287 patients

PCI did not reduce the risk of death or MI over a medium 4.6 years follow up .

TIMe Trial : similar results in elderly patients .

PCI and Medical therapy PCI VS CABG


Most patients with chronic stable angina and class I – II symptoms Medical treatment .

PCI for patients with severe symptoms despite medical

therapy or patients with high risk criteria on Noninvasive

tests .

PCI and Medical therapy Conclusion

PCI VS CABG


PCI in LV dysfunction

In hospital & long term mortality was higher in LV dysfunction .

EF ≤ 40% 11 % 1 Year Mortality

EF 41 – 49% 4.5 % 1 Year Mortality

EF ≥ 50% 1.9 % 1 Year Mortality

PCI VS CABG


CABG

Garrett , Dennis , DeBakey : Bailoat CABG in 1964

Fovoloro : late 1960 s

Kolessov : use of IMA 1967

Green : 1970

% 26 in CABG since 1997

In 2004 : 20% off – PUMP CABG

Minimally Invasive

Hybrid procedure

PCI VS CABG


Surgical outcomes

CABG

Patient population of CABG Higher risk

( older , 3VD , History of Revascularization , LV dysfunction Diabetes , Peripheral vascular disease )

Out comes with CABG Remain stable or improved

PCI VS CABG


Operative Mortality

Mortaliy of 503 , 478 CABG - only in the s td data

base 1997 – 1999: 3.05 %

2005 : 2 . 2 %

CABG PCI VS CABG


In THC data base:


CABG Complications

Mojor morbidity ( death , stroke , Renal failure sternal

infection : 13.4% in 30 days

MI : 3.9%

Respiratory complications

Bleeding : 2-6 % reparation for bleeding

Wound infection

Post operative HTN

Cerebrovascular complication

Stroke 2.6%

PCI VS CABG


CABG Complications

AF : One of the most frequent complications of CABG up to 40% Risk of stroke Use of beta blockers reoluces post operative AF

Brady arrhythmia : 0.8% need for permanent pacemaker Renal dysfunction

PCI VS CABG


Return to Employment

80% who were employed prior to CABG Return to work

Patient undergoing CABG return to work 6 W later than PCI

But long term employment is similar .

PCI VS CABG


SVG Patency

Early occlusion : 8 – 12 %

1 year occlusion : 15 – 30 % occlusion

1 – 6 y occlusion : 2% Annually

6 – 10 occlusion : 4% Annually

At 10 y :50% SVG occlusion and 20 -40%

significant stenosis in Remaining

PCI VS CABG


Arterial graft patency

IMA graft patency rate 95% 1 y 88% 5 y ,

83% 10 y .

PCI VS CABG


Indications for Revascularization CABG:

Significant left main disease : Regardless of the severity of symptoms or LV dysfunction

Patients with 3 VD that Includes LAD proximal lesion & LV dysfunction

Patients with 2 VD with LAD proximal lesion & LV dysfunction or high risk non invasive tests

PCI VS CABG


Indications for Revascularization

PCI:

In patients with SVD the aim of procedure is relief of symptoms or objective evidence of sever ischemia

In patients with angina who are not high risk , medical treatment , PCI & CABG are similar .

PCI VS CABG


PCI or CABG witch strategy ?

SVD : PCI

2VD

Multivessel disease : PCI as initial strategy especially in patients with good LV function , suitable anatomy and patient preference .

CABG : Severe LAD proximal lesion , DM LV dysfunction , LM lesion , Diffuse disease .

Advanced age and comorbidity : PCI is better

Younger patient < 50 y : PCI is initial strategy

CASS Registry : Impaired survivial in young patients

PCI VS CABG


PCI VS CABG

Observational studies :

Recent studies after stenting 60/000 patients with

multivessel disease treated with stenting or CABG

in the newyork state Registry (1997 – 2000 ) :

Higher survival with CABG after adjustment for

medical comorbidities .

PCI VS CABG


PCI VS CABG

Randomized trials :

ARTS trial ;

Death , MI , CVA and one – year mortality were similar .

CK – MB more than twice in CABG and was a predictor of poor outcome .

In PCI groupe DM was the main factor for poor out come

PCI was associated with a greater need for Repeat Revascularization .

TVR was Higher in stenting groupe .

PCI VS CABG


BARI

Diabetic patients with CABG had better

survival at two years .

PCI VS CABG


PCI VS CABG

Recent Publications

NENGLJMED 358 : 4 January 2008

* DES VS . CABG in multivessel disease

Newyork state Registry ( oct 2003 – Dec 2004 )

More than 17000 patients ( 9963 DES , 7437 CABG )

CABG was associated with lower mortality , MI and repeat revascularization


The – MAIN – COMPARE Registry

PCI VS CABG

Stenting VS . CAGB for LM

1102 stenting & 1138 CABG in Korea 2000 -2006

No significant difference in Death , MI , stroke

Higher Rate of TVR in stenting


ACC/AHA Guidelines for Revascularization with PCI and CABG in Patients with Stable Angina

Class Indication Evidence

I (indicated) 1 .CABG for patients with significant left main coronary disease A2. CABG for patients with triple-vessel disease. The survival benefit is A greater in patients with abnormal LV function (ejection fraction <0.50) 3. CABG for patients with double-vessel disease with significant Aproximal LADCAD and either abnormal LV function(ejection fraction <50%) or demonstrable ischemia on noninvasive testing 4. PCI for patients with double- or triple-vessel disease with significant B proximal LAD CAD, who have anatomy suitable for catheter-based therapy and normal LV function and who do not have treated diabetes 5. PCI or CABG for patients with single- or double-vessel CAD without Bsignificant proximal LAD CAD but with a large area of viable myocardium and high-risk criteria on noninvasive testing


Class Indication Evidence

I (indicated) 6 .CABG for patients with single- or double-vessel CAD without C significant proximal LAD CAD who have survived sudden cardiacdeath or sustained ventricular tachycardia

7. In patients with prior PCI, CABG or PCI for recurrent stenosis Cassociated with a large area of viable myocardium or high-risk criteria on noninvasive testing 8. PCI or CABG for patients who have not been successfully treated Bby medical therapy and can undergo revascularization with acceptable risk


IIa ) good

supportive evidence)

1. Repeat CABG for patients with multiple saphenous Cvein graft stenoses, especially when there is significant stenosis of a graft supplying the LAD; it may be appropriate to use PCI for focal saphenous vein graft lesions or multiple stenoses in poor candidates for reoperative surgery 2. Use of PCI or CABG for patients with single- or double- Bvessel CAD without significant proximal LAD disease but with a moderate area of viable myocardium and demonstrable ischemia on noninvasive testing 3. Use of PCI or CABG for patients with single-vessel B disease with significant proximal LAD disease

Class Indication Evidence*


IIb )weak

supportive evidence)

1.Compared with CABG, PCI for patients with double- B or triple-vessel disease with significant proximal LADCAD,who have anatomy suitable for catheter-based therapy and who have treated diabetes or abnormal LV function 2. Use of PCI for patients with significant left main C coronary disease who are not candidates for CABG 3. PCI for patients with single- or double-vessel CAD Cwithout significant proximal LAD CAD who have survivedsudden cardiac death or sustained ventricular tachycardia



III ) not

indicated (

1. Use of PCI or CABG for patients with single- or C double-vessel CAD without significant proximal LAD CAD, who have mild symptoms that are unlikely due to myocardial ischemia, or who have not received and adequate trial of medical therapy and a. have only a small area of viable myocardium Or b. have no demonstrable ischemia on noninvasive testing 2. Use of PCI or CABG for patients with borderline Ccoronary stenoses (50-60% diameter in locations other than the left main coronary artery) and no demonstrable ischemia on noninvasive testing 3. Use of PCI or CABG for patients with insignificant C coronary stenosis (<50% diameter) 4. Use of PCI in patients with significant left main Bcoronary artery disease who are candidates for CABG



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C.H.T Dr.Salarifar 1 Tehran Heart Center Tehran University of Medical Sciences PCI VS CABG M....

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