Complex Lesion Subsets: Indications for DES Andreas Baumbach, MD, FRCP, FESC Bristol Heart...

Complex Lesion Subsets:Indications for DES

Andreas Baumbach, MD, FRCP, FESC

Bristol Heart Institute

MY CONFLICTSOF INTEREST ARE

Advisory Board Boston Scientific

Advisory Board Abbott Vascular

Educational Grants Cordis

Educational Grants Boston Scientific

Complex Lesion Subsets

What is complex ?

What is a B2/C lesion ?

Type B2/C Lesions%

of l

esio

ns T

ype

B2/

C

Stent length

Lesion Complexity

Ellis SG, Vandormael MG, Cowley MJ, DiSciascio G, Deligonul U, Topol EJ, Bulle TM. Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease: implications for patient selection. Circulation. 1990;82:1193–1202

• 10-20mm length

• Eccentric

• Mod tortuosity

• Mod angulation 45-90º

• Irregular contour

• Mod/heavy calcification

• Ostial location

• Bifurcation requiring double wires

• Thrombus

• Total occlusion <3months

Complex: B2/C

• >20mm length

• Excessive tortuosity

• Extremely angulated >90º

• Inability to protect major branch

• Degenerated vein graft

• Total occlusion > 3months

B C

Complex Lesion Subsets

• Type B2/C

• Long Lesions

• Small Vessels

• CTO

• Vein Grafts

• Bifurcation Lesions • LMS

• In-Stent Restenosis

Data

• Randomised Trial

• Randomised Trials Subgroup Analyses

• Published

Complexity in DES Trialsmulti-vessel

diseasebifurcated

lesions

ISR

diabeteslong

lesionssmall

vesselswork

-horse

CTO

left maindisease

TRIAL: randomized, multicenter, blinded, actively controlled trial involving an independent core lab and CEC

TRIAL: feasibility studies involving only 1 to 3 centers often not using an independent core lab or CEC

TAXUS V ISR

SYNTAX

TAXUS IV

TAXUS V

REALITY-TAXUS

TAXUS VI

SYNTAX

SYNTAX

SYNTAX

TAXUS VI

TAXUS V

TAXUS V

TAXUS IV

TAXUS V

REALITY-TAXUS

Park LL2

CORPAL-BIF

SISR

ISAR-DESIRE

FREEDOM

ISAR-DIABETES

RIBS II

RAVEL

SES-SMART

SIRIUS

ISAR-SMART

PRISON II

REALITY-CYPHER

DIABETES

CARDIA

Increasing complexity

Data currently all 1st generation DES

High Proportion of Type B2/C Lesions

Complex LesionsSCANDSTENT: Stenting in non-stress/benestent disease

CTO (36%) /Bifurcation (34%)/Ostial (22%) /Angulated

2

31.9

4.3

29.3

0.63.1

0

5

10

15

20

25

30

35

Restenosis MACE SAT

Cypher

BMS

%N: 322, randomised

Kelbaek et al. JACC 2006; 47:449

P<0.001

p<0.001

6 months outcome

Long Lesions

Long LesionsTAXUS VI: 3 yr Target Lesion Revascularisation

Long LesionsC-Sirius (Sirolimus eluting stent in the treatment of long de-novo lesions)

• Single de novo lesion 15-32mm length

2

52

49

4

18

2 0 2 40

10

20

30

40

50

60

Restenosis TLR MACE CABG MI

Cypher

BMS%

N: 100, randomised

C Sirius Investigators JACC 2004; 43: 1110

p<0.001

p<0.001

9 months outcome

Long LesionsE-Sirius (Sirolimus eluting stents for the treatment of patients with long

atherosclerotic lesions in small coronary arteries)

• Single de novo lesion 15-32mm length, Vessel <3mm

5.9

42.3

4

20.9

8

22.6

1.1 0.64.6

2.30

5

10

15

20

25

30

35

40

45

Restenosis TLR MACE Death MI

Cypher

Bx Velocity%

N: 352, randomised

Schofer et al. Lancet 2003; 362: 1093

p<0.001

p<0.0001

8 months outcome

p<0.002

Small VesselsSES Smart• Single lesion <2.75mm native coronary

12

60

7

21.1

9.3

31.3

0 1.6 1.6

7.8

0

10

20

30

40

50

60

Restenosis TLR MACE Death MI

Cypher

BX Velocity

% N: 257, randomised

Ardissino et al. JAMA 2004; 292: 2727

p<0.002

P<0.001 p<0.001

p<0.04

8 months outcome

Small Vessels

Chronic Total Occlusion

PRISON II• Single CTO >2 weeks, crossed and predilated

7

36

4

19

4

20

20

2 3

0

5

10

15

20

25

30

35

40

Restenosis TLR MACE SAT MI

Cypher

BX Velocity

% N: 200, randomised

Suttorp et al. Circulation 2006;114:921

p<0.001

P<0.001 p<0.001

6 months outcome

Chronic Total OcclusionSCANDSTENT Subgroup analysis• CTO, crossed and predilated

0

38

5

35

01.8

0

5

10

15

20

25

30

35

40

Restenosis TVF SAT

Cypher

BMS

%N: 127, randomised

Kelbaek et al; Am Heart J 2006: 152:882

P<0.001 p<0.001 6 months outcome

Saphenous Vein Grafts

RRISC Trial• Lesions in SVG Grafts

11.3

30.6

5.3

21.6

15.8

29.7

2.7

7.9

0

5

10

15

20

25

30

35

Restenosis TLR MACE MI

Cypher

BX Velocity

%N:75pts, 96 lesions, randomised

Vermeersch et al JACC 2006; 48:2423

P=0.012

P=0.024

6 months outcome

Bifurcation Lesions

SCANDSTENT subgroup• Bifurcations: 126 pts randomised

4.9

28.3

14.8

43.4

9

28

0

9

0

5

10

15

20

25

30

35

40

45

Restenosis Restenosis SB MACE SAT

Cypher

BX Velocity

%

Thuesen et al. Am Heart J 2006: 152:1140

P<0.001

6 months outcome

P<0.001 p=0.01

Conclusion

• In the complex lesion subsets

presented, use of DES significantly

reduces the incidence of restenosis and

the need for repeat revascularisation,

when compared to bare metal stents

Complex Lesion Subsets: Indications for DES Andreas Baumbach, MD, FRCP, FESC Bristol Heart...

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