对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术verghes英课件

PercutaneousorSurgicalRevascularizationforMultivesselCoronaryArteryDisease VergheseMathew MD FACCConsultant DivisionofCardiovascularDiseasesandDepartmentofRadiologyProfessorofMedicine MayoClinicCollegeofMedicine RevascularizationStrategies Howdowedecide AnatomyClinicalPatientpresentationpreference Riskvs Benefit InvasiveTherapies LowRiskPatient HighRiskPatient Someacuterisk Lesslong termriskreduction Greateracuterisk Greaterlong termriskreduction 12 YearSurvivalinPatientswithCAD 5035 49 35 EmondMetal Circ90 2645 1994 23 467Medically TreatedPatientsinCASSRegistry LVEF CP1203018 2 12 YearSurvivalinPatientswithCAD NoCAD1vessel2vessel3vessel EmondMetal Circ90 2645 1994 23 467Medically TreatedPatientsinCASSRegistry CP1203018 1 ClinicalPresentation AgeAcuteischemicsyndromeversuschronicstableanginaPriorcardiachistory MI CABG intervention Co morbidconditions diabetes cerebrovasculardisease renaldisease lungdisease FunctionalimpairmentIschemicburden ExtensionofSurvivalwithCABGvsMedicalTherapyAfter10Years CP1203018 14 Extensionofsurvival mo YusufSetal Lancet344 563 1994 Overall Vesseldisease1 2vessels3vesselsLeftmain LVfunctionNormalAbnormal ExercisetestNormalAbnormal AnginaClass0 I IIClassIII IV LowModerateHigh LowModerateHigh VAriskscore Stepwiseriskscore CABGvsStentingforMVDMeta AnalysisofARTS ERACI II MASS IIandSOS Circ118 2008 Days Event FreeSurvivalAnalysisofDeath 1 5181 4721 4561 4401 4061 3471 5331 4791 4571 4391 4121 349 Overallsurvival P 0 78 Days RepeatRevascularization 1 5181 2047727407076651 5331 428927911882855 P 0 0001 Overallsurvival Days Death StrokeorMI 1 5181 3819138968728461 5331 377908891868845 Overallsurvival P 0 64 Days MajorAdverseCardiacandCerebrovascularEvents 1 5181 1537296916576161 5331 332867846812785 P 0 0001 Overallsurvival PCI91 5 CABG91 8 PCI71 0 CABG92 1 PCI83 3 CABG83 1 PCI60 8 CABG77 0 IncreasedLikelihoodofRestenosisLesion PatientSubsets SmallvesselsBifurcationsOstialCTOBaremetalISRSVGAMI thrombus Diabetesmellitus Hazardratio95 CI CP1045415 3 SIRIUS ClinicalRestenosis TLR at1Year SirolimusControlOverall4 920 0Male5 220 5Female4 119 0Diabetes8 426 4Nodiabetes3 717 6LAD6 023 0Non LAD4 118 0Smallvessel 13 5 6 021 9Overlap5 723 2Nooverlap4 518 6 P0 00010 00010 00020 00020 00010 00010 00010 00010 00010 00010 00010 00010 0001 Eventsprevented 1 000pt152153149180138170140157151146158175141 Oddsratio CABGvsDrug ElutingStentsinMultivesselCoronaryDiseaseAMeta Analysison24 268Patients Benedettoetal EJCTS6958 2009 FavorsDES PCI FavorsCABG 0 010 1110100 HRand95 CI StudynameParkHannanBriguoriYangJHLeeYangZKJavaidVaraniTarantini LeftMainDisease isolated 1 2or 3vessels 3VesselDisease revascall3vascularterritories SYNTAXEligiblePatients Denovodisease LimitedExclusionCriteriaPreviousinterventionsAcuteMIwithCPK 2xConcomitantcardiacsurgery SYNTAXInclusionCriteria 3 vesseldiseaseand orleftmaindiseaseTotalocclusionwithouttimelimitationPreviousstroke 1monthRenalandrespiratoryinsufficiencyDecreasedpumpfunctionMyocardialischemia unstable silent stable Patientswithcomorbidity Realworldpatientpopulation PCIn 198 TAXUS n 903 CABGn 897 vs CABGn 1077 nof un 428 5yrf un 649 TwoRegistryArmsN 1275 RandomizedArmsN 1800 HeartTeam surgeon interventionalist Amenableforonlyonetreatmentapproach Amenableforbothtreatmentoptions Stratification LMandDiabetes LM33 7 3VD66 3 LM34 6 3VD65 4 23USSites 62EUSites SYNTAXTrialDesign TAXUSExpress Cumulativerate SYNTAX Outcomes NEJM360 10 2009 Cumulativerate DeathfromAnyCause DeathfromAnyCause Stroke orMI RepeatRevascularization MajorAdverseCardiacorCerebrovascularEvent Monthssincerandomization Cumulativerate Cumulativerate Monthssincerandomization P 0 37 P 0 99 3 5 P 0 001 P 0 002 Monthssincerandomization Monthssincerandomization PCI CABG 4 4 PCI 7 7 7 6 CABG PCI CABG 13 5 5 9 17 8 12 4 PCI CABG SYNTAXCABG PCIRegistries SYNTAXappendix NEJM 2009 ReasonsforCABG Complexanatomy70 9 Untreatablechronic22 0 totalocclusionUnabletotake0 9 anti plateletmedicationsPatientrefusedPCI0 5 Other5 7 ReasonsforPCI Comorbidity70 7 Nograftmaterial9 1 PatientrefusedCABG5 6 Smallorpoorquality1 5 ofdistalvesselOther13 1 n 644 n 192 SYNTAXScore Number locationoflesions Tortuosity Thrombus Bifurcation TotalOcclusion Diffuse LeftMain Dominance SYNTAXScore Calcification EuroInterv2005 1 219 227 OutcomesStratifiedbySYNTAXScore NEJM360 970 2009 Cumulativerateofmajoradversecardiacorcerebrovascularevents P 0 71 Cumulativerateofmajoradversecardiacorcerebrovascularevents P 0 10 Monthssincerandomization Monthssincerandomization Cumulativerateofmajoradversecardiacorcerebrovascularevents P 0 001 Monthssincerandomization LowSYNTAXScore 0 22 IntermediateSYNTAXScore 22 32 HighSYNTAXScore 33 14 7 13 6 CABG PCI 16 7 12 0 CABG PCI 23 4 10 9 PCI CABG ProceduralDifferencesBetweenSYNTAXCABGRandomizedvsRegistry CABGRCTCABGregistryVariablen 897n 644Completerevasc 63 2 550 870 74 7 481 644 Graftrevascularization Atleast1arterialgraft97 3 831 854 96 7 623 644 ArterialgrafttoLAD95 6 816 854 94 7 610 644 DoubleLIMA RIMA27 6 236 854 16 1 104 644 Completearterial18 9 161 854 11 2 72 644 revascularizationVenousgraftsonly2 6 22 854 3 3 21 644 SerruysPetal NEnglJMed2009 10 1056 NEJMoa0804626 ProceduralDifferencesBetweenSYNTAXPCIRandomizedCohortandthePCIRegistry PCIRCTPCIregistryVariablen 903n 192Completerevasc 56 7 508 896 36 5 70 192 Lesions no mean SD 4 4 1 84 5 1 8Stentsimplanted4 6 2 33 1 1 8 mean SD Totallengthimplanted 86 1 47 958 5 41 2mean SD mm Range mm 8 0 324 08 0 252 0Longstenting33 2 291 877 12 2 23 188 100mm SYNTAXStentThrombosisandSymptomaticGraftOcclusion CP1294833 1 StentThrombosis SymptomaticGraftOcclusion TFeldmanEuroPCR2009 PercutaneousorSurgicalRevascularizationforMultivesselCoronaryArteryDisease Spectrumofrisk anatomic clinical inpatientswithstablemultivesselCADPatientswithmoreextensive diffuseCAD higherSYNTAXscore farebetterwithCABGthanPCIduetorepeatrevascularizationratesLowerSYNTAXscorepatientsdowellwithPCITherearesomepatientstoohighriskforCABG LimitationsofPCI TLRremainshigherwithPCIthanCABGLongsegmentsofstentsPost dilation IVUSDualantiplatelettherapyStentthrombosisPCIstillhasasignificantacutefailurerateinspecificlesionsubsets CTOBifurcationSVGSeverecalcification tortuosity LimitationsofCA