LM strategy

Interventional cardiology dptCardiovascular Hospital - Lyon - France

Gilles Rioufol MD PhD

INSERM U1060

High TechMarseille, 26 Janvier 2012

ACS high riskTroponin +Unstable distal LM

Rapid revascularizationThrombotic eventBifurcation management

Type of stentCx management

stratification

Immediate or urgent revascularization?

No painHemodynamic instability?Loading dose clopidogrel

P2Y12 measurement 12h laterCompliance evaluationBleeding risk evaluationPatient’s choiceTechnical strategy

Close watching – ICU

The angiogram showed a marked decrease in the thrombus burden.

Thrombus management

Bifurcation PCI = multiple balloons inflations = high embolization risk

Technical strategy

Medina 1.0.0 ?

Cx ostia Cx #3.5 mm diameter – 90° takeoff – ostium free/contralateral plaque

Medina 1.1.0 ?

LM diameter # 0.678*(3.5+3) # 4.5 mm ? Stent design allowing 1.5 mm step?

Vessel dimensions3

Main vessel

Side branch

4.44 ± 0.84 mm

3.65 ± 0.77 mm

3.04 ± 0.58 mm

∆D = 0.79 ± 0.36 mmRange [0.23 - 1.42 mm]

Murray CD. Proc. Natl Acad. Sci. USA, 1926Finet G. et al. EuroIntervention 2007

Motreff P., Finet G. et al. Eurointervention 2009

D03 = D1

3 + D23

Murray’s law

D0 = 0.678 x (D1 + D2) Linear law

Unprotected LMCA IVUS-guided PCI

4.51 mm 3.45 mm

Distribution of low shear stress and localization of atherosclerosis lesion

Nakazawa et al. JACC 2010;55:1679

Plaque thickness (mm), n=36

LM PCI : type of stent?

Park et al. Circ cardiovasc Interv 2009;2:167

Guidelines on myocardial revascularization ESC 2010

Stent underexpansion are related to stent thrombosis after SES implantation

Fujii et al. JACC 2005

Procedural characteristics, angiographic and IVUS findings

IntraVascularUltraSound help – EBM (I)

Propensy-matched paired-patients analysis

Park et al. Circ cardiovasc Interv 2009;2:167

MAIN COMPARE registry

DES (sirolimus) n=145

IntraVascularUltraSound help – EBM (II)

Guidelines on myocardial revascularization ESC 2010

Area(mm2)

9,72 2,32 5,08 4,76

Diameter (mm)

3,53 1,75 2,57 2,49

LM PCI : why IVUS helps (I)

CIRCX

LM LAD

(1) Ref LM 16,2mm2 (2) LM stenosis 4,9mm2 (3)Ostial LAD 8,06mm2

DES 16x3.5 – kissing 3.5/3.0

LM PCI : why IVUS helps (II)

CIRCX

LADLM

MLA 9,8 mm2

malapposition

DES 16x3.5 – kissing 3.5/3.0

CIRCX

LADLM

Postdilatation 4.5 mm

Conclusion

Proposal strategy

DES – IVUS guidedlengthdiameterappositionSB

SB Provisional stentingFinal kissing

Thienopyridin responseCompliance

Technical feasability

Thrombus management