Ostial LAD

PCI for Left Anterior Descending Artery Ostial Stenosis
Why Why do do you you hesitate hesitate PCI PCI for for LAD LAD ostial ostial stenosis stenosis ? ?
Limitations of PCI
High elastic recoil Involvement of the distal left main
coronary artery Concern for major side branch occlusion
LAD Ostial Lesion
Cardiovascular Research Foundation
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Is Is it it sate sate to to stent stent in in LAD LAD ostium ostium ? ?

Yes we believe it.
LAD Ostial Lesion
Stenting..
Stenting with precise location

may be a safe and feasible technique with an acceptable clinical outcome.
Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000
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LAD Ostial Lesion
Stenting..
Subjects :
111 patients, 111 Lesions

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In-Hosptial Outcomes
Procedure success Death Stent thrombosis NonQ-MI Emergency CABG
108 (97.5%) 0 (0%) 0 (0%) 4 (3.6%) 1 (0.9%)

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QCA Data
Ref. diameter(mm) Pre-MLD(mm) Post-MLD(mm) Acute gain(mm) Late loss(mm) 3.5 0.6 0.8 0.5 3.6 0.6 2.8 0.7 1.4 1.0

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Angiographic Restenosis
26.1 %
Involvement of LCX ostium (n=6, 5.4%)

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Only Predictor for Restenosis Stenting at LAD Ostial Lesions
Final MLD after Stenting

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Long-term Outcome
Cumulative Percentage
100 90 80 70 60 50 0 12 24 36
Survival
TLR free survival
48
60
Follow-up duration (months)

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Minimal Luminal Diameter

mm 4 3 2 2.2 1 0.8 0 LAD Ostium LCx Ostium
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3.6 3.0 2.6 2.1 Pre-PCI Post-PCI 6 months F/U

Patterns of Restenosis
In-stent restenosis (n=18) Focal type(n=10) Diffuse type(n=8) Involvement of LCX ostium(n=6)

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Which Stent is better ?

LAD Ostial Lesion
High radial force

Good visibility

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Coil vs Tube Stent

Restenosis Rate
80 60 40 20 0
Tube (PS) (n=22) Coil (Tantalum) (n=25) PTCA (n=31)
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(%) 100
*P<0.05
* 67 32
* 62

Is Is side side branch branch occlusion occlusion disastrous disastrous as as expected expected ? ?
Yes, but we have a tips.
LCX LCX Occlusion Occlusion during during PCI PCI
LCX ostial compromise after stenting may be related with clinical recurrence. (20% of restenosis cases) However..
Changes of LCX Ostial Diameter after Stenting

LCX Ostial Diameter(mm)
4 3 2 1 0
Baseline
After Stenting
Follow-up

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Factors associated with the LCX ostial diameter change Variables

Stent jail(>50%)
r value p value
0.47 0.001 0.96 0.07 0.27
LAD-LCX angle(80) 0.005 0.17 LCX ostial diameter Debulking procedure 0.11

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Only Factors Associated with the LCX Ostial Diameter Change
The presence of stent coverage of the LCX ostium>50%

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For the Optimal Positioning of the Stents
Superzooming technique(x 8) RAO caudal or LAD caudal view Stents with visible markers

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Past Strategy
Current recommended Strategy
Precise placement Proximal strut of stent extended into the distal LM

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Conclusions
Stenting of ostial LAD

stenosis may be a safe and feasible technique with an acceptable clinical outcome.

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Can debulking be a useful adjunct to stenting ?
LAD Ostial Lesion
Debulking ..
Aggressive debulking might reduce

the residual plaque burden and subsequently the restenosis.
However, it has limitation to prevent

elastic recoil.
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Debulking and Stenting
LAD Ostial Lesion
Synergistic effect may be expected

to combine removal of plaque and inhibition of elastic recoil.
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Minimal lumen diameter
4
Reference vessel : 3.2 0.5 mm
mm
3
3.2
2
2.3
1
0.8
0
Pre
Post
Follow-up
Bramucci E, et al, Am J Med. 90:1074-1078, 2002

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Restenosis rate : 13.2%
Bramucci E, et al, Am J Med. 90:1074-1078, 2002

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Randomized Comparison of Debulking Followed by Stenting Versus Stenting Alone for LAD Ostial Stenosis
Seung-Jung Park, MD, PhD, FACC
Cardiovascular Center, Asan Medical Center University of Ulsan, Seoul, Korea
SJ Park, et al, J Am Coll Cardiol (In press)
Purpose
Since March 2000 Prospective Randomized Comparison Study of DCA Followed by Stenting and Stenting Alone for LAD Ostial Stenosis

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Inclusions
Ostial stenosis : > 50% diameter Stenosis
arising within 3 mm of the LAD orifice All patients were either symptomatic or ischemic by non-invasive testing De novo lesion

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Procedures
Various types of stents were used Prospective randomized trial Directional Coronary Atherectomy
with Atherocath GTO system
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Methods
Angiographic Analysis IVUS Analysis

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Follow-up
Clinical follow-up was performed by making out patients clinic and telephone interview each 3 month and follow-up coronary angiography was taken at 6 months later.

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Antithrombotic Regimen
Aspirin 200 mg QD indefinitely, Ticlopidine 250 mg BID or Clopidogrel 75 mg QD for 1 month

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LAD Ostial Stenting (n=86)
DCA prior to Stent (n=44)
Stent Alone (n=42)

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Baseline Clinical Findings

D+S (n=44) 59 7 36 / 8 65 8 5 (11%) S (n=42) 57 9 33 / 9 61 11 P 0.305 0.705
Age (years) Men / women Unstable angina (%) LV EF (%) Multivessel ( 2)
33 (75%) 28 (67%) 0.395 0.143
7 (17%) 0.478

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Risk Factors
D+S (n=44) S (n=42)
Current smoker Diabetes mellitus Hypercholesterolmia (> 200 mg/dL) Systemic HTN Previous MI
18 (41%) 23 (55%) 0.199 7 (16%) 9 (21%) 0.511
12 (27%) 14 (33%) 0.541 12 (27%) 15 (36%) 0.399 2 (5%) 2 (5%) 0.962

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Angiographic Findings
D+S (n=44) 23 (52%) S P (n=42) 13 (31%) 0.045
Type B2, C Lesion length (mm) Stent length (mm) Ball to Art ratio Max inf press (atm)
11.9 3.9 12.0 5.2 0.912 15.0 3.5 17.9 6.2 0.008 1.1 0.2 1.1 0.2 0.798
12.8 2.6 14.5 2.9 0.008

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D+S (n=44) 3.6 0.5 S (n=42) 3.6 0.6 P 0.435
Reference size (mm) MLD (mm) Baseline Final Follow-up
1.1 0.4 4.0 0.4 2.3 0.9
1.0 0.5
0.168
3.5 0.5 < 0.001 2.0 0.9 0.187

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Diameter Stenosis (%)

D+S (n=44) 68.6 10.4 -10.0 13.4 37.3 28.5 S P (n=42) 71.9 14.2 0.217 1.5 12.2 < 0.001 44.8 21.8 0.250
Baseline Final Follow-up

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Role of Debulking
Minimal lumen diameter
P<0.001 mm 4
3
Debulking + Stent Stent only
4.0
3.5
P=0.187
2.3 2.0
P=0.168
1.1 1.0
Pre
Post
Follow-up
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Cumulative Percentage of patients (%)

Pre-intervention
100
Follow-up Post-intervention
Cumulative percentage of patients
80
60
40
DCA and Stent Stent alone

DCA and stenting Stenting alone
20
0.0
1.0
2.0
3.0
4.0
5.0
6.0
Minimal Luminal Diameter (mm) M inim al lum ninal diam eter (m m )

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Role of Debulking
Change of lumen diameter
P=0.007 mm 3 2.8
2
2.5
P=0.242
1.7
1
1.5
Acute gain
Late loss
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Role of Debulking Restenosis rate

(%)
40 30 20 10 0
P= 0.47
9 / 32 (28%)
11 / 30 (37%)
Debulking + Stent
Stent only
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Conclusions
Debulking procedure with stenting
gained greater luminal area, but it did not lead to lower restenosis rate due to the tendency of higher late loss.

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IVUS analysis
Serial (pre-intervention, post-DCA,
post-intervention) IVUS evaluation : 67 (78%) patients
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IVUS Findings Reference segment

D+S (n=35) EEM CSA (mm2) Pre-intervention Post-DCA Post-intervention Lumen CSA (mm2) Pre-intervention Post-DCA Post-intervention 15.0 3.0 15.3 3.2 15.5 2.8 9.5 2.1 10.0 2.4 10.3 2.0 9.1 2.4 0.783 S (n=32) 14.9 3.7 15.3 3.6 9.7 2.7 P
0.920 0.851 0.840

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IVUS Findings Lesion segment

D+S (n=35) EEM CSA (mm2) Pre-intervention Post-DCA Post-intervention Lumen CSA (mm2) Pre-intervention Post-DCA Post-intervention
S (n=32) 13.7 3.9 18.2 3.6 1.9 0.3 9.0 2.4
14.2 3.7 16.1 3.9 18.3 3.2 1.9 0.3 7.8 1.7 10.0 1.5
0.576 0.897 0.952 0.075

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Role of Debulking
Reduction of plaque burden
%
100 80 60 40 20 0
P=0.632
Debulking + Stent Stent only P=0.004 51 45 50
86 85
PrePost-DCA Postintervention intervention SJ Park, et al, J Am Coll Cardiol (In press)

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Effect of Residual Plaque

Restenosis rate
Debulking + Stent %
50 40 30
Stent only 13/41 (32%)
P=0.081 0/7 (0%) 8/20 (40%) 5/21 (24%)
20 10 0
0/7 0/2 (0%) (0%) 40 > 40 Residual Plaque burden (%)

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Role of Debulking
Restenosis rate according to remodeling

(%) 70
60 50 40 30 20 10 0
P=0.021
4/6 (67%) 0/7 (0%) Positive remodeling
P=0.929 5/19 4/16 (26%) (25%) Non-Positive remodeling

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Suggestions
The device limitation for substantial reduction of
plaque burden might explain in part the lack of restenosis-reducing effect of DCA prior to stenting.
More effective debulking with new debulking device

might be needed to improve angiographic result.
Debulking might be beneficial in lesions with positive

remodeling.
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Determinants of Angiographic Restenosis
QCA and IVUS predictors associated

with angiograhic restenosis
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Restenosis (n=20) No restenosis (n=42) P
Lesion length (mm) Reference size (mm) MLD (mm) Baseline Final
11.6 5.6 3.7 0.5 1.2 0.4 3.5 0.6
10.7 3.8 3.6 0.6 1.0 0.5 3.8 0.6
0.626 0.853 0.218 0.055

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IVUS Findings Reference Segment

EEM CSA (mm2) Pre-intervention Post-intervention Lumen CSA (mm2) Pre-intervention Post-intervention
13.5 3.8 13.9 3.2 8.8 2.8 9.2 2.4
15.5 3.1 16.0 3.0 9.9 2.2 10.6 2.0
0.078 0.045 0.145 0.053

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IVUS Findings Lesion Segment

EEM CSA (mm2) Pre-intervention Lumen CSA (mm2) Pre-intervention Post-intervention 1.9 0.3 8.4 1.9 1.9 0.3 9.9 1.7 0.773 0.011
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12.8 4.5
14.5 3.4 18.7 3.1
0.173 0.145
Post-intervention 17.1 3.9

Association with Plaque Burden and Restenosis

(%)100
80 60 40 20 0
P=0.061
Restenosis No restenosis
84
86
P=0.089
50
47
Pre-intervention
Post-intervention
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Predictor of Restenosis
-Multivariate Analysis-
Stent CSA after procedure

Odds ratio ; 0.61 95% CI ; 0.41 0.92 P = 0.018
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Stent CSA after Procedure Restenosis rate

(%)
50 40 30 20 10 0
8/18 (44%)
P=0.036
5/30 (17%)
<9
>9
(mm2)
Cross sectional area

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Clinical Follow-up (n=86)

Mean Duration : 19 + 9 months
TLR
DCA + Stenting Stenting alone Death
10 (12%) 5 (11%) 5 (12%) 0 0
Q MI

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Conclusions
We consistently suggest that the final
stent area is the most important determinant for prediction of restenosis.
The final stent area 9 mm2 might be a

good guideline of optimal PCI for LAD ostial stenosis.
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Two Representatives of Future Revascularization

Surgeons View : I like MIDCAB. Interventionists View : I believe DES.
MIDCAB vs. Stent

6 months follow-up
MIDCAB (n=108) % 40
30 20 10 0
Stent (n=108) P=0.02 31 29 15 8
P=0.003
P=0.99 0 2
P=0.68 3 5
Death
AMI
TLR
Combined
Diegeler A, et al, N Engl J Med 2002;347:561

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MIDCAB vs. Stent

200 days FU of death, MI, stroke, and TLR
100 Event free survival (%)
P=0.21
MIDCAB
90 Stent 80
0 50 100 150 200 days
Drenth DJ, et al, J Thorac Cardiovasc Surg 2002;124:130

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Sirolimus Eluting Stent

Sirolimus (n=234) Late loss (mm) In-stent In-segment Restenosis (%) In-stent In-segment TLR (%) MACE (%)
SIRIUS
Control (n=228) 1.04 0.81 41.6 41.6 19.7 22.4
P value
0.20 0.26 2.0 10.1 5.1 8.5
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001
TCT, Oct 2002 ANGIOPLASTY SUMMIT
SIRIUS - TLR Events

Sirolimus Control
Overall Male Female Diabetes No Diabetes LAD Non-LAD 4.1 4.4 3.4 6.9 3.2 5.1 3.4 16.6 16.6 16.5 22.3 14.3 19.8 14.3 18.7 14.8 16.1 17.4 17.7 16.1
P-value
0.0001 0.0001 0.0007 0.0006 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0003 0.0001
# events prevented per 1,000 patients 124 122 130 154 111 147 109 125 128 129 122 131 121
Small Vessel (<2.75) 6.3 Large Vessel Short Lesion 1.9 3.2
Long Lesion (>13.5) 5.2 Overlap No Overlap 4.5 3.9
Hazards Ratio 95% CI
0.1
0.2
0.3
0.4
0.5 0.6 0.7 0.8 0.9 1.0 0.9 0.8 0.7
Sirolimus better
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In the Future .
LAD Ostial Lesion
Randomized comparison studies

about the efficacy of DES, debulking, and MIDCAB are being expected.
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Ostial LAD

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Ostial LAD

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PCI for Left Anterior Descending Artery Ostial Stenosis

LAD Ostial Lesion

Cardiovascular Research Foundation

Is Is it it sate sate to to stent stent in in LAD LAD ostium ostium ? ?

LAD Ostial Lesion

Stenting with precise location

LAD Ostial Lesion

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

108 (97.5%) 0 (0%) 0 (0%) 4 (3.6%) 1 (0.9%)

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

Only Predictor for Restenosis Stenting at LAD Ostial Lesions

Final MLD after Stenting

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

TLR free survival

Follow-up duration (months)

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

Minimal Luminal Diameter

3.6 3.0 2.6 2.1 Pre-PCI Post-PCI 6 months F/U

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

Which Stent is better ?

High radial force

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

Coil vs Tube Stent

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

LCX LCX Occlusion Occlusion during during PCI PCI

Changes of LCX Ostial Diameter after Stenting

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

Factors associated with the LCX ostial diameter change Variables

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

Only Factors Associated with the LCX Ostial Diameter Change

The presence of stent coverage of the LCX ostium>50%

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

For the Optimal Positioning of the Stents

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

Current recommended Strategy

Precise placement Proximal strut of stent extended into the distal LM

Stenting of ostial LAD

Park SJ, et al, Cathet Cardiovasc Intervent. 49:267-271, 2000

Can debulking be a useful adjunct to stenting ?

LAD Ostial Lesion

Aggressive debulking might reduce

However, it has limitation to prevent

Cardiovascular Research Foundation

Debulking and Stenting

LAD Ostial Lesion

Synergistic effect may be expected

Cardiovascular Research Foundation

Debulking and Stenting

Reference vessel : 3.2 0.5 mm

Bramucci E, et al, Am J Med. 90:1074-1078, 2002

Debulking and Stenting

Restenosis rate : 13.2%

Bramucci E, et al, Am J Med. 90:1074-1078, 2002

SJ Park, et al, J Am Coll Cardiol (In press)

SJ Park, et al, J Am Coll Cardiol (In press)

Angiographic Analysis IVUS Analysis

SJ Park, et al, J Am Coll Cardiol (In press)

Aspirin 200 mg QD indefinitely, Ticlopidine 250 mg BID or Clopidogrel 75 mg QD for 1 month

SJ Park, et al, J Am Coll Cardiol (In press)

LAD Ostial Stenting (n=86)

DCA prior to Stent (n=44)