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 Complex
PCI |
| The New Concept to approach complex lesions |
| By Dr. Antonio Colombo |
In the era of DES, bypass
surgery should be of historical interest only. However,
PCI needs to overcome four issues prior to take
its significant role over bypass surgery: (1) chronic
total occlusion, (2) left main stenosis, (3) complex
cases too time consuming and difficult for most
operators, expensive procedures in which a large
number of stents will be needed, SVG, and (4) disease
progression, events on non-critical lesions - >
diabetics.
Operator should use appropriate devices from various
tools to enhance procedural success.
Dr. Colombo introduced a technique called STAR (suboptimal
tracking and reentry) to enhance the success rate
of CTO. In this technique, a dissection plane is
created usually with hydrophilic wire “Whisper”
with a loop supported by 1.5mm OTW balloon or monorail.
The wire is advanced keeping the loop configuration
toward the “anatomical” direction of
the vessel. The balloon is used to support the sire
when necessary. By now, STAR technique was performed
to treat 31 patients. Angiographic follow-up was
completed in 21 cases (67.7%). Ten patients (47.6%)
experienced no restenosis while the remaining eleven
patients (52.4%) suffered form restenosis.
Dr. Colombo and his colleagues reported the effectiveness
of Sirolimus eluting stent (SES) in CTO lesions.
At six months follow-up, restenosis rates in the
SES group and in the BMS group were 9.9% (11/111)
and 33.5% (76/227) respectively.
This data demonstrated the effectiveness of drug-eluting
stent in the CTO patients.
Different results were reported in the treatment
of LMT using by the DES. According to the report
from Milan, death was observed in three patients
(3.5%) in DES group, while nine patient s(14.1%)
died in BMS group (p=0.03). However, no significant
difference was observed on TLR. Twelve patients
(14.1%) and fifteen patients (24.2%) experienced
TLR in DES and BMS group respectively (p=0.13).
In general, restenosis in DES group can be easily
treated due to the presence of spot restenosis.
Six months MACE rate indicated a significant difference
between two groups. Seventeen patients (20%) and
23 patients (36%) experienced MACE at 6 months in
DES and BMS groups respectively (P=0.039).
No obvious strategy can be established reducing
a procedural time. Operator should intend to perform
the PCI efficiently. Time is not major factor because
bypass surgery also takes time.
Last issue is the problem of disease progression.
This kind of lesion often leads to restenosis, but
restenosis rarely causes a critical event. According
to Smith SC and his colleagues who studied the severity
f coronary artery stenosis before acute MI, less
than 50% of stenosis caused 70% of AMI. 50 to 70%
stenosis and more than 70% stenosis affected 20%
and 15% of AMI respectively.
Dr. Colombo finally reported the “real-world”
DES data in Milan and Siegburg. In this study, 2229
patients following successful DES implantations
were included. Of those, SES stents were implanted
in 1062 patients while PES stents were placed to
1167 patients. Four patients (0.4%) and nine patients
(0.8%) experienced sub-acute thrombosis in SES group
and PES group respectively (P=0.5). Five patients
(0.5%) in SES group and nine patients (0.8%) in
PES group experienced late stent thrombosis (P=0.3).
Data demonstrated those who received prior brachytherapy
and terminate antiplatelet therapy were commonly
experienced thrombosis.
The success rate of CTO will be increased along
with experiences. Restenosis further declines due
to the introduction of better drug and stent in
near future. Competition will affect the price reduction
of DES. Thus, in the era of DES, bypass surgery
should be of historical interest only. |
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