1. Nei diabetici con cardiopatia ischemica la rivascolarizzazione con CABG è sempre superiore? Prof. F. Romeo University of Rome“Tor Vergata” Department of Cardiology

2. Atherosclerosis in Diabetes Mellitus: Pathophysiologic Considerations Abnormal platelet function  activation and adhesion in response to shear stress  expression of GpIIb/IIIa receptors   aggregation More diffuse atherosclerosis pattern Impaired coronary flow reserve  reduced tolerance of embolization  plaque burden and more lipid-rich plaques  predisposed to rupture Impaired ability to develop collaterals  larger MIs Increased response to vascular injury  rates of restenosis and reocclusion following both balloon angioplasty and bare stent implantation

3. Diabetes TLR expression patterns can induce distinct types of vascular inflammation as result of selective susceptibility of different regions of the vascular tree to atherosclerosis It has been shown that Apolipoprotein A-I, the major protein component of serum high-density lipoproteins, inhibits DC differentiation and maturation PPAR-a agonists ciglitazone and fenofibrate also inhibit oxLDL-induced maturation and immune functions of DCs in vitro Advanced glycosylation end products can promote atherosclerosis by inducing maturation of

4. Patients with diabetes mellitus  Increased incidence of CAD  More extensive disease at angiography  Worse prognosis than non-diabetic CAD  >20% of all revascularisation procedures

5. Revascularisation in Diabetes Mellitus Heartwire (www.theheart.org) Nov 1999 “Despite stents, diabetic patients undergoing PCI still face higher death rates.” AHA Scientific Statement 1999 “Recent studies indicate that coronary angioplasty is less efficacious for patients with diabetes than for those without; these reports further reveal that CABG is the preferred therapy in patients with diabetes when invasive management is required.”

6. The 1991 Guidelines for CABG state that : “the evidence is complete that the coronary artery bypass operation relieves angina in most patients”. Some caution must be expressed in the use of CABG for relief of symptoms. CABG treats the manifestations of CAD, not the disease of process. The second important recommendation for CABG, after relief of symptoms, is prolongation of life.

7. The explosive growth of PCI in the last decade mandates a careful examination of CABG survival versus PCI survival

8. BARI: Impact of Diabetes on Survival NEJM 1996;335:217-25 CABG PTCA BARI Subgroups Treated diabetic pts only subgroup to show significant survival advantage with CABG 5 year survival CABG 81% PTCA 65% Diabetic subgroup (p=0.006) balloon angioplasty era 5 year survival

9. PCI v CABG Trials - DM Subgroup Analyses ARTS trial - stent era 1205 patients - DM 208 (17%) CABG PCI 1 year mortality 3.1% 6.3% 1 year repeat revasc 12.4% 21.6% 3 year event free 81.3% 52.7%

10. Do Diabetics Have Increased Mortality After Multivessel Stenting? * P<0.05 Yellow = Stent vs. CABG Summary: Stents do not appear to have significantly attenuated the mortality advantage of CABG in multivessel CAD

11. 30 20 10 0 Death/Stroke/MI, % PCI/DES Logrank P=0.005 CABG PCI/DES CABG 5-Year Event Rates: 26.6% vs. 18.7% 0123456 Years post-randomization PRIMARY OUTCOME – DEATH / STROKE / MI FREEDOM Trial

12. PRIMARY ENDPOINT – DEATH / STROKE / MI TREATMENT / SYNTAX INTERACTION - p=0.58 100 90 80 70 60 50 40 30 20 10 0 0.01.02.03.04.05.0 SYNTAX Score  22 (N=669) CABG PCI/DES 5-Year Event Rates: 23.2% 17.2% Freedom from Event (%) Years post-randomization 100 90 80 70 60 50 40 30 20 10 0 0.0 1.0 2.03.04.05.0 SYNTAX Score 23-32 (N=844) CABG PCI/DES Freedom from Event (%) Years post-randomization 5-Year Event Rates: 27.2% 17.7% 100 90 80 70 60 50 40 30 20 10 0 0.01.02.03.04.05.0 SYNTAX Score  33 (N=374) CABG PCI/DES Freedom from Event (%) Years post-randomization 5-Year Event Rates : 30.6% 22.8%

15. PCI in STEMI is Here to Stay!

17. Several studies have compared outcomes for CABG and PCI, but most were done before the availability of stentig, wich has revolutioned the latter approach

18. Stent Availability…

20. Approaches to Improve Late DES Outcomes

22.  Current DES have appreciably improved safety and efficacy profiles in ACS and stable CAD compared to first generation devices, and outcomes are improved by ischemia-guided PCI  By utilizing small amounts of a bioabsorbable polymer, polymer-free systems, or fully bioabsorbable stents, future generation DES will likely further reduce stent thrombosis and improve late outcomes

23. CABG in Patients with Diabetes CABG advantage depends on use of LIMA  rates of procedure related morbidity Renal failure Wound infection Sternal wound failure Possible increased stroke risk ARTS trial - 1 year CVA rate CABG 6.3% PCI 1.8%

24. PCI or CABG?

26. Procedure di rivascolarizzazione miocardica: -PCI -CABG Non devono essere considerate alternative. Bisogna infatti fornire al paziente entrambe le possibilità di rivascolarizzazione. Importanza di un Timing esatto PCI or CABG?

27. Scelta in base a: 1.Anatomia coronarica 2.Età 3.Presentazione Clinica (Angina Cronica Stabile, Sindrome Coronarica Acuta, Presenza di Diabete)

28. Angiographic Patency after CABG: experience from CLEVELAND CLINIC DATABASE (565+511 days) Khot u et al. Circulation 2004

29. Angiographic Patency after CABG: experience from CLEVELAND CLINIC DATABASE (565+511 days) Khot u et al. Circulation 2004

30. Angiographic Patency after CABG: experience from CLEVELAND CLINIC DATABASE (565+511 days) Khot u et al. Circulation 2004

31. MULTIVESSEL DISEASE PCI or CABG? Cardiologists and Cardiac Surgeons should give both opportunities to the patients!

32. Cardiologist must remember… The importance to make a complete revascularization Always let a second surgery chance Think in terms of prognosis in the term of life expectancy rather than immediate success

33. Surgeon must remember… Surgical revascularization can be a path of no return Surgical treatment accelerates the closing of the native circle PCI has to be the first therapeutic choice… … when is possible!!!

34. Both must remember … The two methods must be seen not one the alternative of one another but as a completation to be used in a rational and sequential way

35. The way to think is not as PCI vs CABG but How to make a good PCI… …to have in the future the possibility to make a good CABG

36. CABG performed in 1986

40. Female, 43 years, diabetic

41. One month later