2. Coronary Artery Disease in Diabetic Patients, Different from Non-diabetics?

3. 울산의대 서울아산병원 흉부외과 이재원 CABG is still better than PCI in DES era

4. Efficacy of PTCA Late Graft Patency Risk of Surgery DiabeticsDiabetics

5. Accelerated intimal hyperplasia & Atherogenesis in diabetics - Potential Mechanisms - Vessel wall  ↑ SMC proliferation  ↑ cholesterol synthesis ← Hyperinsulinemia?  ↑ growth factors ↑ Procoagulant state Vessel wall  ↑ SMC proliferation  ↑ cholesterol synthesis ← Hyperinsulinemia?  ↑ growth factors ↑ Procoagulant state Progression of atherosclerosis

7. BARI Survival – All Patients

8. BARI Survival – Patients without Treated Diabetes

9. BARI Survival – Patients with Treated Diabetes

10. BARI Mortality Influence of DM and IMA

11. Revascularization Strategies How do we decide? Risk Benefit Ratio Patient preference Clinical presentation Anatomy

12. Revolution demands blood!

14. Only 5% Benefit? Revolution?

15. Clinically driven 1yr TLR for BMS

16. Initial DES result in US

17. Stent Usage at Medical City Dallas (n=346)

18. Gold Standard

19. Improving CABG

20. ARTS Study Conclusion although surgery carries a significant risk of cerebrovascular accident.  Diabetic patients showed poor clinical outcome in the stent group when compared to the CABG group. Consequently, surgery may be preferable to stenting in patients with multivessel coronary disease and diabetes, although surgery carries a significant risk of cerebrovascular accident.

21. SOS Trial 3.9 3.49 Hazard Ratio P=0.001 Hazard Ratio P=0.007 For Stent vs. Surgery to have a repeat revascularization For Stent vs. Surgery for 3 year mortality

24. Results of Randomized Trials in Diabetics Diabetics  Increased early and late adverse events after both PTCA/CABG  Both approaches-suboptimal But CABG superior to PTCA ↑ restenosis ↓ complete revascularization ↑ disease progression Therapy directed to lesion vs. vessel

26. PTCA or CABG for Multivessel Disease ; Considerations  Need for revascularization  Need for complete revascularization  LV function  Technical/anatomic factors  Individual patient circumstances

27. Revascularization in Patients with Multivessel Disease CABGPCI Triple vessel disease LV dysfunction LMCA disease Diffuse disease Double vessel disease ※ Preserved LV function ※ Suitable anatomy ※ Advanced age “Salvage”procedure Diabetics? ※ Majority of pt in randomized trials

28. STS Database CABG Mortality 1990 ~ 2001

29. Restenosis Rates in Diabetics

30. DES in Diabetics Late Loss (mm)

31. SIRIUS-Diabetic subgroup (279 pts)

32. Sirolimus-eluting stents Binary restenosis according the different type of diabetes

33. In-segment Restenosis Relationship diameter & lesion length (from SIRIUS)

34. SIRIUS – Diabetic subgroup

35. Choosing Interventional Therapy

36. DES: Lesion & Patients

37. Introduction

38. Patients profile Period : 2000. 7 ~ 2003. 12 Patients 329 consecutive patients isolated OPCAB first time elective operation no exclusion criteria for OPCAB

39. Preoperative Data Age (years) 61.6  8.1 (40~85) Men/Women 219/110 (66.6%) Diabetes 100 (30.4%) Ejection fraction 58.1  9.8 (25~75)

40. Postoperative Data Mechanical ventilation (hr)7.5  6.0 Chest drainage (cc) 912  458 ICU stay (day)2.0  1.8 LOS (day) 8.0  11.7

41. Postoperative Events Operative mortality3 (0.9) Reoperation9 (2.7) Perioperative MI3 (0.9) Deep wound infection7 (2.1) N(%)

42. Postoperative Events Arrhythmia11 (3.4) Pulmonary complications6 (1.8) Postop IABP3 (0.9) Postop Inotropics35 (10.6) Renal failure0 CVA0 N(%)

43. Mortality N 0.9%3/334 1.7%7/407 1.5%7/458 1.5%8/542 (101)(173)(148)(141) 12110201013

44. Target Coronary Vessels Total distal anastomoses : 1,184 Total distal anastomoses : 1,184 Anastomoses/Pt : 3.6  1.1(1~7) ( 1.7, 1.2, 0.8 ) Anastomoses/Pt : 3.6  1.1(1~7) ( 1.7, 1.2, 0.8 )

45. Early Graft Patency LAD97.6%(285/292) Other vessels98.6%(704/714) Revascularization(1year):2.12%(7/329)

46. LITA & RA composite graft & In situ RITA anastomosis to LAD

47. 97.9% Reintervention free survival

48. 99.1% Cumulative Survival

50. Goals of Therapy  Improve survival  Avoid CNS complications  Preserve/Improve LV function  Relieve symptoms  Prevent infarction  Decrease need for subsequent procedures