Technicalapproach

PCI in Small Vessels

Washington Cardiology Center

Augusto Pichard, L. Satler, K. Kent, R. Waksman,

J. Laird, W. Suddath, J. Sharretts, S. Epstein, N. Weissman,

A. Fuisz, G. Weigold, J. Lindsay

AugustoPichard, MD

PCI in Small Vessels: A Comprehensive ApproachPCI in Small Vessels: A Comprehensive Approach

Technicalapproach

PCI in Small Vessels

Definition

A true small vessel: A Vessel that PerfusesSmall Amount of Myocardium

Technicalapproach

PCI in Small Vessels

First Conclusion:

True small vessels do not need

PCIConclusion(1)

Technicalapproach

PCI in Small Vessels

Is this proximal LAD a small vessel ?

No a large vessel with diffuse disease

IVUS: 4 mm

InsightsFrom IVUS

Technicalapproach

PCI in Small Vessels

Patient Referred for ISRS of a 2.5 mm stent in the LAD.

Vessel size ?

RAO cranialIVUS

4 mm

2.5 mm

InsightsFrom IVUS

Technicalapproach

PCI in Small Vessels

InsightsFrom IVUS

WHC IVUSCore Lab

Laborgne,Cheneau et al.2002

LAD size assessment by IVUS

Technicalapproach

PCI in Small Vessels

Vessel size: Angiography vs IVUS

InsightsFrom IVUS

Technicalapproach

PCI in Small Vessels

Second Conclusion:

The proximal LAD is almost never a small vessel.

(The same is often true for the proximal RCA and CX).

Conclusion(2)

Technicalapproach

PCI in Small Vessels

PCI of Small VesselsWhich one is the best tool ?

1. Balloon?

2. Cutting Balloon ?3. Stent ?4. Specialized Stents (PC

coating, Pixel, Silicon Carbide coating, etc.)?

5. Drug eluting stents ?

Materials

Technicalapproach

PCI in Small Vessels

PCI of Small Vessels

Stents

Technicalapproach

PCI in Small Vessels

Stent vs. Balloon in Small VesselsKastrati et al. JACC 38:1604

Final Diameter Stenosis in the Balloon Arm

Percent Difference in Restenosis between Balloon and Stent

Stent vs

Balloon

Technicalapproach

PCI in Small Vessels

Provisional Stenting in Vessels <2.7 mm WHC: Abizaid, Pichard et al. ACC 2001

2.28

26.1

7.8

33.5

2.29

27.5

8.1

34.9

2.35

26.9

6.1

33

0

5

10

15

20

25

30

35

40

Ref Diam 1 yr TVR D-MI MACE

Balloon

Cross-over

Elect. Stent

286 lesions with provisional stenting under IVUS guidance. 45% crossed-over to stent. 453 control lesions with elective stenting.

Results

Technicalapproach

PCI in Small Vessels

Why are Stents Less Effective in Small Vessels ?IVUS Core LAB. Washington Hospital Center

ISRS is highest in small vesselsSmall vessels develop the same amount of intimal hyperplasia as large vessels

WHC: Mintz et al. 1997WHC: Hoffmann AJC 1998;82:1168-72

Limitations

Technicalapproach

PCI in Small Vessels

Mean IH thickness vs Stent CSA at 6-month follow upin Non-Polymeric Paclitaxel-coated Stents.

Mintz et al. TCT 2003

Control High dose Low dose

-.2

0

.2

.4

.6

.8

1

1.2

1.4

1.6

2 3 4 5 6 7 8 9 10 11 12-.2

0

.2

.4

.6

.8

1

1.2

1.4

1.6

2 3 4 5 6 7 8 9 10 11 12

-.2

0

.2

.4

.6

.8

1

1.2

1.4

1.6

2 3 4 5 6 7 8 9 10 11 12

Per slice bases

R=0.009

P=0.87

R=0.126

P=0.01

R=0.002

P=0.96

Stent CSA (mm²)DES

Technicalapproach

PCI in Small Vessels

Small Vessel PCI

Any benefit with specialized approach ?

• Rotablator

• Cutting balloon

• Special coatings

Specialized

Approach

Technicalapproach

PCI in Small Vessels

Rotablator vs. Balloon for Small Vessels. DART Trial.

Mauri et al. AHJ 2003; 145:847-54

• 446 patients randomized• Vessel diameter (mean 2.46).• Lesion length: 10±6 mm.• Procedural success: 92% (R) vs 94% (B).• 12 months follow up:

– angio restenosis: 50.5% in both.– late loss: 0.49 (R) vs 0.56 (B).

Conclusion: no benefit of Rotablator in Small Vessels

Rotablator

Technicalapproach

PCI in Small Vessels

Cutting Balloon vs. Balloon in Small Vessels

0

5

10

15

20

25

30

35

40

45

50

Ergene Tamaki CAPAS

BalloonCutting Balloon

Cutting balloon

Technicalapproach

PCI in Small Vessels

Cutting Balloon vs. Stentin Small Vessels

0

5

10

15

20

25

30

35

40

45

1 2 3 4

CBStentCB+St

Refer. Vess. Diam: 2.2 mm 2.3 mm 2.2 mm 2.4 mm

n= 86 pts. 310 lesions 48 pts. 174 pts.

1: Kawaguchi. JACC 2002;39:48a; 2: Kawaguchi JACC 2002;39:7A; 3: Kinoshita AJC 2003; 92:170L; 4:Umeda JACC 2002;39:52 A

Cutting balloon

Technicalapproach

PCI in Small Vessels

TENAX Stent (Silicon Carbide Coated Stent).SVS Trial (Small Vessel Study).

Bonnier et al. CRT 2003

495 patients with Small Vessels (2.5-3.0 mm) randomized

SiC coating

Technicalapproach

PCI in Small Vessels

Heparin-Coated Stent in Small Vessels. COAST Trial. Haude et al. Circulation. 2003;107:1265-70

Restenosis: 32.2% after PTCA with provisional stenting, 24.8% after bare stenting,

and 29.6% after heparin-coated stenting. (P=0.34).

588 pts. randomized to angioplasty with provisional stent (n=195), bare stenting (n=196), or Corline heparin-coated stenting (n=197). (JomedFlex Stent)

Heparin

Technicalapproach

PCI in Small Vessels

BiodivYsio PC Coating Stent in Small Vessels. Lasmal Trial. Rodriguez et al. Buenos Aires

PC Coating

Technicalapproach

PCI in Small Vessels

ISAR SMART-II: Randomized vessels <2.5 mm

39

26,9

34,2

21,3

0

5

10

15

20

25

30

35

40

45

Angio restenosis TVR

Stent

Balloon

BiodivYsio PC Coating

Kastrati; TCT 2003

PC Coating

Technicalapproach

PCI in Small Vessels

Third conclusion• Bare metal stents have the same restenosis

rate as optimal balloon angioplasty.

• Cutting balloon seems to offer a restenosis benefit in small vessels.

• Stents with special coatings offer no detectable advantage.

Conclusion(3)

Technicalapproach

PCI in Small Vessels

ISAR SMART-II: Randomized vessels <2.5 mm

39,3

19,9

34,3

22,3

0

5

10

15

20

25

30

35

40

45

Angio restenosis TVR

Abciximab

Placebo

Abciximab

Anti-GPIIb/IIIa

Technicalapproach

PCI in Small Vessels

Restenosis with Cilostazol in PCI.CREST Trial

17,0%

22,0% 22,0%

14,0%

37,0%34,0%

36,0%39,0%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Diabeticrestenosisp=0.0108

Small vessel

restenosisp=0.0038

Diabetics >2.75mm

p=ns

Diabetics<2.75mm

p=ns

C P C P C P C PC=CilostazolP=Placebo

Devireddy. Circulation 2004;110:III-489

Drug

Technicalapproach

PCI in Small Vessels

Drug Eluting Stents

in

Small Vessels

Technicalapproach

PCI in Small Vessels

DES vs BMS in Small Vessels. Randomized Trials

37

43 42 42

26

39 4038

0

18,6

6

02,5

107

3,90

5

10

15

20

25

30

35

40

45

50

Ravel Sirius E Sirius C Sirius Taxus 2 Taxus 4 Taxus 6 Svelte

BMSDES

% RS

DES

Technicalapproach

PCI in Small Vessels

Late Loss in Small Vessels. BMS vs DES Randomized Trials

0,85

0,97

0,79

0,69

0,84

0,53

0,97

0,03

0,16 0,18 0,16

0,32

0,03

0,22

0

0,2

0,4

0,6

0,8

1

1,2

Ravel Sirius Sm NewSirius

SESSmart

Taxus 2 Taxus 4 Svelte

BMSDES

mm

DES

Technicalapproach

PCI in Small Vessels

DES: Stent diameter (mm)n = 5616

Washington Hospital Center

28%42%

9%

21%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

2.5 2.75 3 3.5Oct 04

DES Diameters

Technicalapproach

PCI in Small Vessels

SES diameters used (n=16251)

655

8521

2307

3939

829

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

2.25 2.50 2.75 3.00 3.50

mm

nb. o

f ste

nts

30%

SESDiameters

Technicalapproach

PCI in Small Vessels

Fourth conclusion

Drug Eluting Stent is clearly the device of choice

for small vessels.Conclusion

(4)

Technicalapproach

PCI in Small Vessels

Is the “Bigger is Better”

Stent Strategy Necessary when Stenting

Small Vessels?

Technicalapproach

PCI in Small Vessels

MACE in Small Vessels and Stent Lumen Area Iakovou et al. AJC 2003;92:1171-6

423 pts with 446 stents in vessels <2.75mm.

Group 1: 308 pts with final CSA <6 mm2.

Group 2: 115 pts with final CSA > 6mm2.

1 year f/u

IVUS

Technicalapproach

PCI in Small Vessels

How Big is Better in Small Vessels ?Moussa et al. AJC 1999;83:1012-1017

IVUS

Technicalapproach

PCI in Small Vessels

Final Stent Area and Restenosis.SIRIUS IVUS sub study. 72 SES and 50 BMS.

Sonoda, et al. JACC 2004;43: 1959-63

Drug Eluting Stents

IVUS

Technicalapproach

PCI in Small Vessels

Final Stent Area and Follow up Lumen Area SIRIUS IVUS sub study. 72 SES and 50 BMS.

Sonoda, et al. JACC 2004;43: 1959-63

IVUS

Technicalapproach

PCI in Small Vessels

Stent area and Outcome at 6 monthsN=209 patients, N= 319 lesions treated with Cypher

0

2

4

6

8

10TLR MACE

P=0.068 P=0.54

2.9%

0% 0%

4.4%

2.2% 2.2%

%

<6 6-7.5 >7.5 <6 6-7.5 >7.5

Minimal stent CSA (mm2) by Ivus

Follow up

Technicalapproach

PCI in Small Vessels

IVUS Findings in SAT.Cheneau et al. Circulation. 2003;108:43.

7484 PCI’s with IVUS: 27 SAT (0.36%)

Inadequate Stent Expansion 18 (78%)

Stent malappostition 2 (5%)

Dissection 4 (17%)

Tissue protrusion 1 (4%)

Thrombus post PCI 1 (4%) IVUS

Technicalapproach

PCI in Small Vessels

Summary1. True small vessels do not need PCI.2. The proximal LAD is almost never a small

vessel.3. Bare metal stent has same restenosis as

optimal balloon angioplasty. Cutting balloon seems to offer a restenosis benefit.

4. Drug Eluting Stent is the device of choice for small vessels.

5. Adequate expansion in DES seems important

(final stent area >6 mm2).

Summary