1. Unprotected Left Main Intervention How To Perform A Safe PCI
Ian T. Meredith
MBBS, PhD, FRACP, FACC, FCSANZ, FSCAI, FAPSIC
Director of Monash HEART, Southern Health
Professor of Cardiology and Medicine,
Monash University, Melbourne, Australia

2. Ian T Meredith, MD, PhD Honoraria: Abbott Vascular
Boston Scientific Corporation
Medtronic, Inc.

3. “SAFE” PCI
S Selection criteria, Scores, Syntax A Access, Adjunctive therapies, Angiographic angles, Approach F Finesse – techniques, tips and tricks E Evaluation - In real time, immediately post procedure (angiographic, IVUS/OCT and longer term

4. “SAFE” PCI
S Selection criteria, Scores, Syntax A Access, Adjunctive therapies, Angiographic angles, Approach F Finesse – techniques, tips and tricks E Evaluation - In real time, immediately post procedure (angiographic, IVUS/OCT and longer term

5. Selection for “SAFE” L Main PCI
Is the lesion functionally significant Is PCI the appropriate strategy? (Heart team forum, Evidence, Appropriateness criteria) What are the peri procedural MACE risks? (Syntax, NCDR, CIN, Bleeding Risk scores) What are the anatomic subtleties/complexities that may preclude a safe and successful procedure? (CTA, coronary angiography) Surgical Back up

6. Capodanno et al, JACC 2011;58:1426-32
PCI vs. CABG for Left Main Disease Meta-analysis of 4 RCTs, 1,611 Patients 1-Year Death
PCI CABG OR (95%CI) p-Value
LEMANS 1/52 4/ ( ) 0.21
SYNTAX left main 15/355 15/ ( ) 0.88
Boudriot et al. 2/100 5/ ( ) 0.27
PRECOMBAT 6/300 8/ ( ) 0.59
Fixed effects estimate 3.0% 4.1% ( ) 0.29
Random effects estimate ( ) 0.29
I2=0%
OR (95%CI )
(24/807)
(32/790)
0.01
0.1 1 10
100
Favors PCI
Favors CABG
Capodanno et al, JACC 2011;58:

7. Capodanno et al, JACC 2011;58:1426-32
PCI vs. CABG for Left Main Disease Meta-analysis of 4 RCTs, 1,611 Patients 1-Year MACCE
PCI CABG OR (95%CI) p-Value
LEMANS 16/52 13/ ( ) 0.48
SYNTAX left main 56/355 46/ ( ) 0.44
Boudriot et al. 19/100 14/ ( ) 0.33
PRECOMBAT 26/300 20/ ( ) 0.36
Fixed effects estiamate 14.5% 11.8% ( ) 0.11
Random effects estimate ( ) 0.11
I2=0%
OR (95%CI )
(117/807)
(93/790)
0.01
0.1 1 10
100
Favors PCI
Favors CABG
Capodanno et al, JACC 2011;58:

8. All-Cause Death to 4 Years Left Main Subset
TAXUS (N=357)
CABG (N=348)
Before 1 year*
4.5% vs 4.2%
P=0.88
1-2 years*
1.9% vs 1.5%
P=0.68
2-3 years*
2.3% vs 1.8%
P=0.67
3-4 years*
3.0% vs 4.3%
P=0.39 25 50
P=0.94
Cumulative Event Rate (%)
1 yr data From SYNTAX_CSR_randomized_Unblinded_2008Oct10.doc exhibit 52
2-Year_Randomized_ doc Exhibits 21
SYNTAX 3-Year Report_Randomized_12JUL10.doc exhibits 21 (KM overall rate), 22 (year 2-3)
SYNTAX 4-Year Report_Randomized_15JUN11.doc exhibits 20 (KM rate on right sidea) and exhibit 22 (binary interval rate in white box)
11.4%
11.2% 12 48 24 36
Months Since Allocation
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
ITT population 8

9. MACCE to 4 Years Left Main Subset
TAXUS (N=357)
CABG (N=348)
Before 1 year*
13.7% vs 15.8%
P=0.44
1-2 years*
7.5% vs 10.3%
P=0.22
2-3 years*
5.2% vs 5.7%
P=0.78
3-4 years*
6.4% vs 8.3%
P=0.35 25 50
P=0.14
33.2%
Cumulative Event Rate (%)
1 yr data From SYNTAX_CSR_randomized_Unblinded_2008Oct10.doc exhibit 52
2-Year_Randomized_ doc Exhibits 21
SYNTAX 3-Year Report_Randomized_12JUL10.doc exhibits 21 (KM overall rate), 22 (year 2-3)
SYNTAX 4-Year Report_Randomized_15JUN11.doc exhibits 20 (KM rate on right sidea) and exhibit 22 (binary interval rate in white box)
27.8% 12 48 24 36
Months Since Allocation
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
ITT population 9

10. MACCE to 4 Years by SYNTAX Score Tercile Low Scores (0-22)
TAXUS (N=118)
CABG (N=104)
CABG
PCI
P value
Death
9.2%
7.1%
0.54
CVA
4.1%
1.8%
0.28 MI
3.1%
4.3%
0.64
Death, CVA or MI
14.2%
12.3%
0.60
Revasc.
16.8%
18.2%
Left Main
>
Months Since Allocation
Cumulative Event Rate (%) 12 24 50 25 48 36
>
28.4%
P=0.60
<
4-Year_Randomized_SX0-22(Core)-LM(Site)_18JUL11.doc exhibit 1
26.0%
>
<
Cumulative KM Event Rate ± 1.5 SE; log-rank P value
Site-reported Data; ITT population

11. MACCE to 4 Years by SYNTAX Score Tercile High Scores (33)
TAXUS (N=135)
CABG (N=149)
CABG
PCI
P value
Death
10.5%
17.9%
0.06
CVA
4.9%
1.6%
0.14 MI
6.1%
10.9%
0.18
Death, CVA or MI
18.5%
23.1%
0.33
Revasc.
11.8%
31.3%
<0.001
Left Main
<
42.6%
Months Since Allocation
Cumulative Event Rate (%) 12 24 50 25 48 36
P<0.003
>
<
4-Year_Randomized_SX 33+(Core)-3VD(Site)_18JUL11.doc exhibit 1
26.3%
<
<
Cumulative KM Event Rate ± 1.5 SE; log-rank P value
Site-reported Data; ITT population

12. Vessel Distribution in LM Population According to Syntax Score Terciles
LM Lesion Locations by SX Tertile 17SEP09.rtf
\\Natfile06\depts\Clinical\Clinical Communications\Projects\IC\TAXUS\SYNTAX\Data Tables\LM and LM subgroups
35%
61% 4%
59%
29%
11%
66%
27% 7%
Distal
Nondistal
Both
0-22
23-32
33+

13. Appropriateness Criteria for PCI
JACC Vol. 53, No. 6, 2009

14. “SAFE” PCI L Main
S Selection criteria, Scores, Syntax A Access, Adjunctive therapies, Angiographic angles, Approach F Finesse – techniques, tips and tricks E Evaluation - In real time, immediately post procedure (angiographic, IVUS/OCT and longer term

15. Access Site Selection – Radial vs Femoral

16. Adjunctive Therapy

17. Bleeding Risk
Distribution of the Integer Risk Score and Consequent Probability of a Major Non–CABG-Related Bleed Within 30 Days
JACC Vol. 55, No. 23, 2010 Mehran et al. 2561
June 8, 2010:2556–66

18. Angiographic Projections (General Principles)
RAO Cau/ PA Cra or RAO Cra
AP Caud/LAO Cra
LAO/LAO Cau
LAO Cra/RAO Cra
Left Main stem
RAO Caud/LAO Caud
RAO Caud
LAO/RAO
or Lateral
RAO Cra/LAO Cra
Grossman 7th Edn

19. “SAFE” PCI L Main
S Selection criteria, Scores, Syntax A Access, Adjunctive therapies, Angiographic angles, Approach F Finesse – techniques, tips and tricks E Evaluation - In real time, immediately post procedure (angiographic, IVUS/OCT and longer term

20. Left Main Techniques

21. Finesse

22. Finesse Use shallow AP Caudal and RAO AP Cranial Views
Type of guide depends on position of L Main lesion but short tip & larger guides.
With ostial and prox lesion engage and disengage by gentle rotation rather than advancing and retracting.
Use IVUS to assess vessel size, lesion length, LAD and LCx ostial involvement and mal-apposition once stented.
Use two wires if the adjacent ostium is compromised and crossover is necessary.
USE an appropriately sized DES with good radial strength and side branch access if needed
Avoid excessive aortic stent overhang

23. Tip 1 Not all left main lesions are actually left main lesions
Particularly ostial lesions

24. Ostial Left Main

25. Tip 2
The Left Main Coronary is frequently much larger than you think

26. L Main Identifying Normal Ref Vessel

27. Tip 3
Ostial L Main Coronary lesions are often eccentric even when they appear concentric.
Ostial lesions often distort and displace the true ostium.
The degree of aortic plaque extension is a key factor in determining the suitability for stenting
Stenting large ostial “lip” protruding into the L coronary Cusp will result in free stent overhang
Eccentric plaques with minimal protrusion into the aorta are favourable targets for stenting
Concentric ostial lesions with symmetrical aortic protrusion are the best and safest targets.

28. Eccentric Ostial L Main

29. Eccentric Ostial L Main Stent Protusion
Distal LM
L Cor Cusp

30. Concentric Ostial L Main Stenting

31. Tip 4
Distal L Main lesions invariably involve the ostium of LAD and or LCx.
The extent of Ostial LAD and LCX determines the need for cross-over stenting or bifurcation stenting.
Cross-over stenting rarely compromises the adjacent vessel if its ostium is disease free and > 3mm
The choice of 2 stent bifurcation technique depends on anatomy

32. L Main-LAD Lesion Cross-over Stenting to LAD

33. Tip 5 Malapposition is very common in L Main stenting.
Underestimate vessel size
Reluctance to use large balloons
Malapposition is difficult to avoid with L Main crossover or bifurcational techniques due to size mismatch.
IVUS plays a pivotal role in detecting and resolving this problem

34. Most Useful Tip for L Main PCI
DES are not a replacement for perfect technique

35. “SAFE” PCI L Main
S Selection criteria, Scores, Syntax A Access, Adjunctive therapies, Angiographic angles, Approach F Finesse – techniques, tips and tricks E Evaluation - In real time, immediately post procedure (angiographic, IVUS/OCT and longer term

36. Selection for “SAFE” L Main PCI
Is PCI the appropriate strategy? (Heart team forum,
Appropriateness criteria)
What are the peri procedural MACE risks? (Syntax NCDR
Risk score)
Step 3: What are the anatomical subtleties/complexities
in angiography that preclude a safe and successful
procedure? (CTA, coronary angiography)
Step 4: What are the procedural strategies that will help in
keeping the procedure simple, safe and elegant?
Step 5: What are the post procedural risks for
bleeding and contrast induced kidney injury?