Direct Stenting is Better (Debate Session) 동아의대 김 무 현

Direct Stenting(without pre-dilatation) Direct PTCA = Primary PTCA Direct Stenting ≠ Primary stenting Direct Stenting = Stenting without pre-dilation

Possible Advantage of Direct Stenting Reduce cost Reduce procedure time Reduce radiation exposure Reduce injury to the vessel wall Reduce distal embolization in SVG Improve coronary flow in AMI patient

Randomized Trial of Direct Stenting PREDICT Trial – Baim DS et al, JACC 2001 BET Trial – Carrie D et al, AJC 2001 DIRECT Trial – Brito FS et al, AJC 2002 AMI Patient – Loubeyre C et al, JACC 2002

PRE-Dilatation vs Direct Stenting In Coronary Treatment 399 patients with S670 stents Modest (10%) saving of fluoroscopic time, contrast use and a decrease in use of balloob use No reduction in late restenosis PREDICT Trial Baim DS et al, Am J Cardiol 2001;88:1364-9

Procedure time(min)33.2± ±16.5 Fluoroscopy time(min)9.2 ± ±8.1 Contrast use(ml)154 ±86169 ±82 Balloon use0.56 ± ±0.62 * Stent/lesion1.20 ± ±0.42 Single stent84%(168/201)84%(170/203) Acute Procedural Results (PREDICT) * P < 0.001

Direct Pre-dilatation Available for analysis162/201(81%)163/203(80%) Reference vessel2.85± ±0.46 In-stent Minimal lumen diameter1.95 ± ±0.73 Diameter stenosis31.6 ± ±22 Binary restenosis20.4(33/162)20.9(34/163) Loss index0.51 ± ±0.32 Angiographic Follow-up (PREDICT)

Event Free Survival (DIRECT Study) Brito FS et al, Am J Cardiol 2002;89: (P=0.0002) N=411

Direct Stenting in AMI (n=206) Reduce the incidence of no-reflow or distal embolization Early ST-segment elevation resolution >>> Direct stenting in AMI can prevents microvascular damage and may improve myocardial perfusion. Loubeyre C et al, JACC 2002;39:15-21

In-hospital Clinical Outcome(AMI) p=0.36p=0.89 p=0.28p=0.99 p=0.55 Loubeyre C et al, JACC 2002;39:15-21

Comparison of Randomized Trial No SR PT Contrast Cost RR AE Flow PREDICT 40091%--+-- * DIRECT 41197%--+*- * BET 33886% + ++*- * AMI(Loubeyre)20692% **+*- +

Months from discharge Event-free survival(%) (death/MI/revascularization) Immediate and Late Outcomes after Direct Stenting Wilson SH et al, JACC 2000;35:937-43

Potential Direct Stenting Exclusion Extensive calcification Total or subtotal occlusion Severe lesion angulation Proximal vessel tortuosity Ostial or bifurcation lesion Suboptimal guide support

Possible Disadvantages May increase cost and procedure time Failure to deliver stent Failure to remove undelivered stent Stent selection difficulty : Size and length Unpredictable undilatable lesion

Direct Stenting in SVG Shorter duration of procedure Lower radiation exposure Similar clinical outcome May decrease distal embolization

IVUS guided DS in Native Coronary Artery CS DS p Procedural Success, % In-Hospital MACE, % One Year TLR, % One Year MACE, % Ahmed JM, et al, Eur Heart J 2001(supp)

DS P & S p Procedural success(%) In-hospital MACE(%) Non-Q wave MI (%) one year (%) one year (%) IVUS guided DS in SVG Ahamed JM et al, Eur H J(supp) 2001

DS B & S p Angiographic Complication(%) No. of Stent NS CK-MB Elevation Final IVUS Lumen CSA Final IVUS Lumen diameter one year (%) IVUS guided DS in SVG Abizaid AS et al, JACC(supp) 2002

Should every eligible lesion undergo direct stenting ? It can reduce cost, contrast and procedure time It has same restenosis, dissection and acute complication rate. >>> Why not if we select appropriate lesion. ( Not in Korea !!!! )

But we have to be careful !!! When angiograpically overlooked fibrotic or calcific lesion is present When vessel is tortuous When a 5 Fr guiding catheter is used