1. LM strategy Interventional cardiology dpt Cardiovascular Hospital - Lyon - France Gilles Rioufol MD PhD INSERM U1060 High Tech Marseille, 26 Janvier 2012

2. ACS high risk Troponin + Unstable distal LM Rapid revascularization Thrombotic event Bifurcation management Type of stent Cx management stratification

3. Immediate or urgent revascularization? No pain Hemodynamic instability? Loading dose clopidogrel P2Y12 measurement 12h later Compliance evaluation Bleeding risk evaluation Patient’s choice Technical strategy Close watching – ICU

4. The angiogram showed a marked decrease in the thrombus burden. Thrombus management Bifurcation PCI = multiple balloons inflations = high embolization risk

5. 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?

6. Soulis et al. J of Biomechanics 2006;39:742. Vessel dimensions 3 Main vessel Side branch 4.44 ± 0.84 mm 3.65 ± 0.77 mm 3.04 ± 0.58 mm ∆D = 0.79 ± 0.36 mm Range [0.23 - 1.42 mm] Murray CD. Proc. Natl Acad. Sci. USA, 1926 Finet G. et al. EuroIntervention 2007 Motreff P., Finet G. et al. Eurointervention 2009 D 0 3 = D 1 3 + D 2 3 Murray’s law D 0 = 0.678 x (D 1 + D 2 ) Linear law Unprotected LMCA IVUS-guided PCI 4.51 mm3.45 mm

7. Distribution of low shear stress and localization of atherosclerosis lesion Nakazawa et al. JACC 2010;55:1679 Plaque thickness (mm), n=36

8. LM PCI : type of stent? Park et al. Circ cardiovasc Interv 2009;2:167

9. Guidelines on myocardial revascularization ESC 2010

10. 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)

11. 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)

12. Guidelines on myocardial revascularization ESC 2010

13. Area (mm 2 ) 9,722,325,084,76 Diameter (mm) 3,531,752,572,49 LM PCI : why IVUS helps (I)

14. CIRCX LM LAD (1) Ref LM 16,2mm 2 (2) LM stenosis 4,9mm 2 (3)Ostial LAD 8,06mm 2 DES 16x3.5 – kissing 3.5/3.0 LM PCI : why IVUS helps (II)

15. CIRCX LAD LM MLA 9,8 mm2 malapposition DES 16x3.5 – kissing 3.5/3.0 CIRCX LADLM Postdilatation 4.5 mm

16. Conclusion Proposal strategy DES – IVUS guided length diameter apposition SB SB Provisional stenting Final kissing Thienopyridin response Compliance Technical feasability Thrombus management