Technical approach 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 Augusto Pichard, MD PCI in Small Vessels: A Comprehensive Approach

Technical approach PCI in Small Vessels Definition A true small vessel: A Vessel that Perfuses Small Amount of Myocardium

Technical approach PCI in Small Vessels First Conclusion: True small vessels do not need PCI Conclusion (1)

Technical approach PCI in Small Vessels Is this proximal LAD a small vessel ? No a large vessel with diffuse disease IVUS: 4 mm Insights From IVUS

Technical approach PCI in Small Vessels Patient Referred for ISRS of a 2.5 mm stent in the LAD. Vessel size ? RAO cranial IVUS 4 mm 2.5 mm Insights From IVUS

Technical approach PCI in Small Vessels Insights From IVUS WHC IVUS Core Lab Laborgne, Cheneau et al LAD size assessment by IVUS

Technical approach PCI in Small Vessels Vessel size: Angiography vs IVUS Insights From IVUS

Technical approach 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)

Technical approach PCI in Small Vessels PCI of Small Vessels Which 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

Technical approach PCI in Small Vessels PCI of Small Vessels Stents

Technical approach PCI in Small Vessels Stent vs. Balloon in Small Vessels Kastrati et al. JACC 38:1604 Final Diameter Stenosis in the Balloon Arm Percent Difference in Restenosis between Balloon and Stent Stent vs Balloon

Technical approach PCI in Small Vessels Provisional Stenting in Vessels <2.7 mm WHC: Abizaid, Pichard et al. ACC lesions with provisional stenting under IVUS guidance. 45% crossed-over to stent. 453 control lesions with elective stenting. Results

Technical approach PCI in Small Vessels Why are Stents Less Effective in Small Vessels ? IVUS Core LAB. Washington Hospital Center ISRS is highest in small vessels Small vessels develop the same amount of intimal hyperplasia as large vessels WHC: Mintz et al. 1997WHC: Hoffmann AJC 1998;82: Limitations

Technical approach PCI in Small Vessels Mean IH thickness vs Stent CSA at 6-month follow up in N on-Polymeric Paclitaxel-coated Stents. Mintz et al. TCT 2003 Control High dose Low dose 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

Technical approach PCI in Small Vessels Small Vessel PCI Any benefit with specialized approach ? Rotablator Cutting balloon Special coatings Specialized Approach

Technical approach PCI in Small Vessels Rotablator vs. Balloon for Small Vessels. DART Trial. Mauri et al. AHJ 2003; 145: 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

Technical approach PCI in Small Vessels Cutting Balloon vs. Balloon in Small Vessels Cutting balloon

Technical approach PCI in Small Vessels Cutting Balloon vs. Stent in Small Vessels 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

Technical approach PCI in Small Vessels TENAX Stent (Silicon Carbide Coated Stent). SVS Trial (Small Vessel Study). Bonnier et al. CRT patients with Small Vessels ( mm) randomized SiC coating

Technical approach PCI in Small Vessels Heparin-Coated Stent in Small Vessels. COAST Trial. Haude et al. Circulation. 2003;107: 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

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

Technical approach PCI in Small Vessels ISAR SMART-II: Randomized vessels <2.5 mm BiodivYsio PC Coating Kastrati; TCT 2003 PC Coating

Technical approach 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)

Technical approach PCI in Small Vessels ISAR SMART-II: Randomized vessels <2.5 mm Abciximab Anti- GPIIb/IIIa

Technical approach PCI in Small Vessels Restenosis with Cilostazol in PCI. CREST Trial Diabetic restenosis p= Small vessel restenosis p= Diabetics >2.75mm p=ns Diabetics <2.75mm p=ns CP CPCPCP C=Cilostazol P=Placebo Devireddy. Circulation 2004;110:III-489 Drug

Technical approach PCI in Small Vessels Drug Eluting Stents in Small Vessels

Technical approach PCI in Small Vessels DES vs BMS in Small Vessels. Randomized Trials % RS DES

Technical approach PCI in Small Vessels Late Loss in Small Vessels. BMS vs DES Randomized Trials mm DES

Technical approach PCI in Small Vessels Oct 04 DES Diameters

Technical approach PCI in Small Vessels SES diameters used (n=16251) 30% SES Diameters

Technical approach PCI in Small Vessels Fourth conclusion Drug Eluting Stent is clearly the device of choice for small vessels. Conclusion (4)

Technical approach PCI in Small Vessels Is the “Bigger is Better” Stent Strategy Necessary when Stenting Small Vessels?

Technical approach PCI in Small Vessels MACE in Small Vessels and Stent Lumen Area Iakovou et al. AJC 2003;92: 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

Technical approach PCI in Small Vessels How Big is Better in Small Vessels ? Moussa et al. AJC 1999;83: IVUS

Technical approach PCI in Small Vessels Final Stent Area and Restenosis. SIRIUS IVUS sub study. 72 SES and 50 BMS. Sonoda, et al. JACC 2004;43: Drug Eluting Stents IVUS

Technical approach 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: IVUS

Technical approach PCI in Small Vessels Stent area and Outcome at 6 months N=209 patients, N= 319 lesions treated with Cypher TLR MACE P=0.068P= % 0% 4.4% 2.2% % <66-7.5>7.5<66-7.5>7.5 Minimal stent CSA (mm 2 ) by Ivus Follow up

Technical approach PCI in Small Vessels IVUS Findings in SAT. Cheneau et al. Circulation. 2003;108: 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

Technical approach PCI in Small Vessels Summary 1.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