PercutaneousorSurgicalRevascularizationforMultivesselCoronaryArteryDisease?VergheseMathew,MD,FACCConsultant,DivisionofCardiovascularDiseasesandDepartmentofRadiologyProfessorofMedicine,MayoClinicCollegeofMedicine第一頁，共三十八頁。編輯課件RevascularizationStrategiesHowdowedecide?Anatomy Clinical Patient presentationpreferenceRiskvs.Benefit第二頁，共三十八頁。編輯課件InvasiveTherapiesLowRiskPatientHighRiskPatientSomeacuteriskLesslong-termriskreductionGreateracuteriskGreaterlong-termriskreduction第三頁，共三十八頁。編輯課件12-YearSurvivalinPatientswithCAD >50 35-49 <35 EmondMetal:Circ90:2645,199423,467Medically-TreatedPatientsinCASSRegistryLVEFCP1203018-2第四頁，共三十八頁。編輯課件12-YearSurvivalinPatientswithCAD NoCAD 1vessel 2vessel 3vesselEmondMetal:Circ90:2645,199423,467Medically-TreatedPatientsinCASSRegistryCP1203018-1第五頁，共三十八頁。編輯課件ClinicalPresentationAgeAcuteischemicsyndromeversuschronicstableanginaPriorcardiachistory(MI,CABG,intervention)Co-morbidconditions(diabetes,cerebrovasculardisease,renaldisease,lungdisease)FunctionalimpairmentIschemicburden第六頁，共三十八頁。編輯課件ExtensionofSurvivalwithCABGvsMedicalTherapyAfter10YearsCP1203018-14Extensionofsurvival(mo)YusufSetal:

Lancet344:563,1994OverallVesseldisease1/2vessels3vesselsLeftmainLVfunctionNormal

AbnormalExercisetestNormal

AbnormalAnginaClass0,I,IIClassIII,IVLowModerateHighLowModerateHighVAriskscoreStepwise

riskscore第七頁，共三十八頁。編輯課件CABGvsStentingforMVDMeta-AnalysisofARTS,ERACI-II,MASS-IIandSOSCirc118,2008DaysEvent-FreeSurvivalAnalysis

ofDeath

1,518 1,472 1,456 1,440 1,406 1,347

1,533 1,479 1,457 1,439 1,412 1,349Overallsurvival(%)P=0.78DaysRepeatRevascularization

1,518 1,204 772 740 707 665

1,533 1,428 927 911 882 855P<0.0001Overallsurvival(%)DaysDeath,StrokeorMI

1,518 1,381 913 896 872 846

1,533 1,377 908 891 868 845Overallsurvival(%)P=0.64DaysMajorAdverseCardiacandCerebrovascularEvents

1,518 1,153 729 691 657 616

1,533 1,332 867 846 812 785P<0.0001Overallsurvival(%)PCI91.5%CABG91.8%PCI71.0%CABG92.1%PCI83.3%CABG83.1%PCI60.8%CABG77.0%第八頁，共三十八頁。IncreasedLikelihoodofRestenosisLesion/PatientSubsetsSmallvesselsBifurcationsOstialCTOBaremetalISRSVGAMI(thrombus)Diabetesmellitus第九頁，共三十八頁。編輯課件Hazardratio95%CICP1045415-3SIRIUS–ClinicalRestenosis(TLR)at1Year Sirolimus ControlOverall 4.9 20.0Male 5.2 20.5Female 4.1 19.0Diabetes 8.4 26.4Nodiabetes 3.7 17.6LAD 6.0 23.0Non-LAD 4.1 18.0Smallvessel(<2.75) 6.6 22.3Largevessel 3.1 18.2Shortlesion 4.0 18.6Longlesion(>13.5) 6.0 21.9Overlap 5.7 23.2Nooverlap 4.5 18.6P0.00010.00010.00020.00020.00010.00010.00010.00010.00010.00010.00010.00010.0001Events

prevented/

1,000pt152153149180138170140157151146158175141Oddsratio第十頁，共三十八頁。編輯課件CABGvsDrug-ElutingStentsinMultivesselCoronaryDisease

AMeta-Analysison24,268PatientsBenedettoetal:EJCTS6958,2009FavorsDES-PCIFavorsCABG 0.01 0.1 1 10 100HRand95%CIStudynameParkHannanBriguoriYangJHLeeYangZKJavaidVaraniTarantini第十一頁，共三十八頁。編輯課件LeftMainDisease(isolated,+1,+2or+3vessels)3VesselDisease(revascall3vascularterritories)SYNTAXEligiblePatientsDenovodiseaseLimitedExclusionCriteriaPreviousinterventionsAcuteMIwithCPK>2xConcomitantcardiacsurgery第十二頁，共三十八頁。編輯課件SYNTAXInclusionCriteria3-vesseldiseaseand/orleftmaindiseaseTotalocclusionwithouttimelimitationPreviousstroke>1monthRenalandrespiratoryinsufficiencyDecreasedpumpfunctionMyocardialischemia(unstable-silent-stable)PatientswithcomorbidityRealworldpatientpopulation第十三頁，共三十八頁。編輯課件PCIn=198TAXUS*n=903

CABGn=897vsCABGn=1077nof/un=4285yrf/un=649TwoRegistryArmsN=1275RandomizedArmsN=1800HeartTeam(surgeon&interventionalist)AmenableforonlyonetreatmentapproachAmenableforbothtreatmentoptionsStratification:

LMandDiabetesLM33.7%3VD66.3%LM34.6%3VD65.4%23USSites62EUSites+SYNTAXTrialDesign*TAXUSExpress第十四頁，共三十八頁。編輯課件Cumulative

rate(%)SYNTAX:OutcomesNEJM360(10),2009Cumulativerate(%)DeathfromAnyCauseDeathfromAnyCause,

Stroke,orMIRepeatRevascularizationMajorAdverseCardiacorCerebrovascularEventMonthssincerandomizationCumulative

rate(%)Cumulative

rate(%)MonthssincerandomizationP=0.37P=0.993.5P<0.001P=0.002MonthssincerandomizationMonthssincerandomizationPCICABG4.4PCI7.77.6CABGPCICABG13.55.917.812.4PCICABG第十五頁，共三十八頁。SYNTAXCABG/PCIRegistriesSYNTAXappendix:NEJM,2009ReasonsforCABGComplexanatomy 70.9%Untreatablechronic 22.0%

totalocclusionUnabletotake 0.9%

anti-plateletmedicationsPatientrefusedPCI 0.5%Other 5.7%ReasonsforPCIComorbidity 70.7%Nograftmaterial 9.1%PatientrefusedCABG 5.6%Smallorpoorquality 1.5%

ofdistalvesselOther 13.1%n=644n=192第十六頁，共三十八頁。SYNTAXScoreNumber&locationoflesionsTortuosityThrombusBifurcationTotalOcclusionDiffuseLeftMainDominanceSYNTAXScoreCalcificationEuroInterv2005;1:219-227第十七頁，共三十八頁。編輯課件OutcomesStratifiedbySYNTAXScoreNEJM360:970,2009CumulativerateofmajoradversecardiacorcerebrovasculareventsP=0.71CumulativerateofmajoradversecardiacorcerebrovasculareventsP=0.10MonthssincerandomizationMonthssincerandomizationCumulativerateofmajoradversecardiacorcerebrovasculareventsP<0.001MonthssincerandomizationLowSYNTAXScore(0-22)IntermediateSYNTAXScore(22-32)HighSYNTAXScore(>33)14.713.6CABGPCI16.712.0CABGPCI23.410.9PCICABG第十八頁，共三十八頁。編輯課件第十九頁，共三十八頁。編輯課件第二十頁，共三十八頁。編輯課件第二十一頁，共三十八頁。編輯課件第二十二頁，共三十八頁。編輯課件第二十三頁，共三十八頁。編輯課件第二十四頁，共三十八頁。編輯課件第二十五頁，共三十八頁。編輯課件第二十六頁，共三十八頁。編輯課件ProceduralDifferencesBetween

SYNTAXCABGRandomizedvsRegistry CABGRCT CABGregistryVariable n=897 n=644Completerevasc(%) 63.2(550/870) 74.7(481/644)Graftrevascularization(%) Atleast1arterialgraft 97.3(831/854) 96.7(623/644) ArterialgrafttoLAD 95.6(816/854) 94.7(610/644) DoubleLIMA/RIMA 27.6(236/854) 16.1(104/644) Completearterial 18.9(161/854) 11.2(72/644)

revascularization Venousgraftsonly 2.6(22/854) 3.3(21/644)第二十七頁，共三十八頁。Cardiac-RelatedMedicationsGivenaftertheStudyProcedure*

MedicationPCICABGpValue

percentAny98.998.60.62AspirinAtdischarge96.388.5<0.0016moafterrandomization93.282.7<0.001ThienopyridineAtdischarge96.819.5<0.0016moafterrandomization91.316.1<0.001AnyantiplateletdrugAtdischarge9723.7<0.0016moafterrandomization91.418.4<0.001Warfarinderivative2.67.1<0.001Statin86.774.5<0.001Beta-blocker81.378.60.17ACEinhibitor55.144.6<0.001AngiotensinII–receptorantagonist13.37<0.001*Percentagesarefromtheintention-to-treatanalysis.ACEdenotesangiotensin-convertingenzyme,CABGcoronary-arterybypassgrafting,andPCIpercutaneouscoronaryintervention.SerruysPetal.NEnglJMed2009;10.1056/NEJMoa0804626第二十八頁，共三十八頁。編輯課件ProceduralDifferencesBetweenSYNTAXPCIRandomizedCohortandthePCIRegistry PCIRCT PCIregistryVariable n=903 n=192Completerevasc(%) 56.7(508/896) 36.5(70/192)Lesions,no.(mean±SD) 4.4±1.8 4.5±1.8Stentsimplanted 4.6±2.3 3.1±1.8

(mean±SD)Totallengthimplanted, 86.1±47.9 58.5±41.2

mean±SD(mm)Longstenting 33.2(291/877) 12.2(23/188)

(>100mm)(%)第二十九頁，共三十八頁。SYNTAX

StentThrombosisandSymptomaticGraftOcclusionCP1294833-1StentThrombosisSymptomaticGraftOcclusionIncidence MortalityTFeldmanEuroPCR2009第三十頁，共三十八頁。編輯課件PercutaneousorSurgicalRevascularizationforMultivesselCoronaryArteryDisease?Spectrumofrisk(anatomic,clinical)inpatientswithstablemultivesselCADPatientswithmoreextensive,diffuseCAD(higherSYNTAXscore)farebetterwithCABGthanPCIduetorepeatrevascularizationratesLowerSYNTAXscorepatientsdowellwithPCITherearesomepatientstoohighriskforCABG第三十一頁，共三十八頁。編輯課件LimitationsofPCITLRremainshigherwithPCIthanCABGLongsegmentsofstentsPost-dilation,IVUSDualantiplatelettherapyStentthrombosisPCIstillhasasignificantacutefailurerateinspecificlesionsubsets:CTOBifurcationSVGSeverecalcification/tortuosity第三十二頁，共三十八頁。編輯課件LimitationsofCABGLong-termgraftattrition;totalarterialrevascularizationstilluncommonNativevesselprogressionCABGnotcurativePCIfrequentlyutilizedf