Complex Lesion Subsets: Indications for DES

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Complex Lesion SubsetsIndications for DES

• Andreas Baumbach, MD, FRCP, FESC
• Bristol Heart Institute

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MY CONFLICTS OF INTEREST ARE Advisory Board
Boston Scientific Advisory Board Abbott
Vascular Educational Grants Cordis Educational
Grants Boston Scientific
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Complex Lesion Subsets

• What is complex ?
• What is a B2/C lesion ?

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Type B2/C Lesions
of lesions Type B2/C
Stent length
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Lesion Complexity
Ellis SG, Vandormael MG, Cowley MJ, DiSciascio G,
Deligonul U, Topol EJ, Bulle TM. Coronary
morphologic and clinical determinants of
procedural outcome with angioplasty for
multivessel coronary disease implications for
patient selection. Circulation. 19908211931202
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Complex B2/C

• 10-20mm length
• Eccentric
• Mod tortuosity
• Mod angulation 45-90º
• Irregular contour
• Mod/heavy calcification
• Ostial location
• Bifurcation requiring double wires
• Thrombus
• Total occlusion lt3months

• gt20mm length
• Excessive tortuosity
• Extremely angulated gt90º
• Inability to protect major branch
• Degenerated vein graft
• Total occlusion gt 3months

B
C
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Complex B2/C

• 10-20mm length
• Eccentric
• Mod tortuosity
• Mod angulation 45-90º
• Irregular contour
• Mod/heavy calcification
• Ostial location
• Bifurcation requiring double wires
• Thrombus
• Total occlusion lt3months

• gt20mm length
• Excessive tortuosity
• Extremely angulated gt90º
• Inability to protect major branch
• Degenerated vein graft
• Total occlusion gt 3months

B
C
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Complex Lesion Subsets

• Type B2/C
• Long Lesions
• Small Vessels
• CTO
• Vein Grafts
• Bifurcation Lesions
• LMS
• In-Stent Restenosis

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Data

• Randomised Trial
• Randomised Trials Subgroup Analyses
• Published

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Complexity in DES Trials
left maindisease
multi-vesseldisease
Data currently all 1st generation DES
bifurcated lesions
CTO
ISR
diabetes
long lesions
smallvessels
work-horse
Increasing complexity
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High Proportion of Type B2/C Lesions
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Complex Lesions

• SCANDSTENT Stenting in non-stress/benestent
  disease
• CTO (36) /Bifurcation (34)/Ostial (22)
  /Angulated

N 322, randomised

Plt0.001
6 months outcome
plt0.001
Kelbaek et al. JACC 2006 47449
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Long Lesions
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Long Lesions
TAXUS VI 3 yr Target Lesion Revascularisation
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Long Lesions

• C-Sirius (Sirolimus eluting stent in the
  treatment of long de-novo lesions)
• Single de novo lesion 15-32mm length

N 100, randomised

9 months outcome
plt0.001
plt0.001
C Sirius Investigators JACC 2004 43 1110
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Long Lesions

• E-Sirius (Sirolimus eluting stents for the
  treatment of patients with long atherosclerotic
  lesions in small coronary arteries)
• Single de novo lesion 15-32mm length, Vessel lt3mm

N 352, randomised
8 months outcome

plt0.001
plt0.002
plt0.0001
Schofer et al. Lancet 2003 362 1093
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Small Vessels

• SES Smart
• Single lesion lt2.75mm native coronary

N 257, randomised

8 months outcome
plt0.001
Plt0.001
plt0.002
plt0.04
Ardissino et al. JAMA 2004 292 2727
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Small Vessels
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Chronic Total Occlusion

• PRISON II
• Single CTO gt2 weeks, crossed and predilated

N 200, randomised

6 months outcome
plt0.001
Plt0.001
plt0.001
Suttorp et al. Circulation 2006114921
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Chronic Total Occlusion

• SCANDSTENT Subgroup analysis
• CTO, crossed and predilated

N 127, randomised

plt0.001
6 months outcome
Plt0.001
Kelbaek et al Am Heart J 2006 152882
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Saphenous Vein Grafts

• RRISC Trial
• Lesions in SVG Grafts

N75pts, 96 lesions, randomised

6 months outcome
P0.024
P0.012
Vermeersch et al JACC 2006 482423
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Bifurcation Lesions

• SCANDSTENT subgroup
• Bifurcations 126 pts randomised

Plt0.001
Plt0.001
p0.01
6 months outcome
Thuesen et al. Am Heart J 2006 1521140
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Conclusion

• In the complex lesion subsets presented, use of
  DES significantly reduces the incidence of
  restenosis and the need for repeat
  revascularisation, when compared to bare metal
  stents