1. Complex Lesion Subsets: Indications for DES Andreas Baumbach, MD, FRCP, FESC Bristol Heart Institute

2. MY CONFLICTS OF INTEREST ARE Advisory Board Boston Scientific Advisory Board Abbott Vascular Educational Grants Cordis Educational Grants Boston Scientific

3. Complex Lesion Subsets What is complex ? What is a B2/C lesion ?

4. Type B2/C Lesions % of lesions Type B2/C Stent length

5. 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. 1990;82:1193–1202

6. 10-20mm length Eccentric Mod tortuosity Mod angulation 45-90º Irregular contour Mod/heavy calcification Ostial location Bifurcation requiring double wires Thrombus Total occlusion <3months Complex: B2/C >20mm length Excessive tortuosity Extremely angulated >90º Inability to protect major branch Degenerated vein graft Total occlusion > 3months BC

7. 10-20mm length Eccentric Mod tortuosity Mod angulation 45-90º Irregular contour Mod/heavy calcification Ostial location Bifurcation requiring double wires Thrombus Total occlusion <3months Complex: B2/C >20mm length Excessive tortuosity Extremely angulated >90º Inability to protect major branch Degenerated vein graft Total occlusion > 3months BC

8. Complex Lesion Subsets Type B2/C Long Lesions Small Vessels CTO Vein Grafts Bifurcation Lesions LMS In-Stent Restenosis

9. Data Randomised Trial Randomised Trials Subgroup Analyses Published

10. Complexity in DES Trials multi-vessel disease bifurcated lesions ISR diabetes long lesions small vessels work -horse CTO left main disease TRIAL: randomized, multicenter, blinded, actively controlled trial involving an independent core lab and CEC TRIAL : feasibility studies involving only 1 to 3 centers often not using an independent core lab or CEC TAXUS V ISR SYNTAX TAXUS IV TAXUS V REALITY -TAXUS TAXUS VI SYNTAX TAXUS VI TAXUS V TAXUS IV TAXUS V REALITY -TAXUS Park LL2CORPAL-BIF SISR ISAR -DESIRE FREEDOM ISAR -DIABETES RIBS II RAVEL SES-SMART SIRIUS ISAR -SMART PRISON II REALITY -CYPHER DIABETES CARDIA Increasing complexity Data currently all 1 st generation DES

11. High Proportion of Type B2/C Lesions

12. Complex Lesions SCANDSTENT: Stenting in non-stress/benestent disease CTO (36%) /Bifurcation (34%)/Ostial (22%) /Angulated % N: 322, randomised Kelbaek et al. JACC 2006; 47:449 P<0.001 p<0.001 6 months outcome

13. Long Lesions

14. TAXUS VI : 3 yr Target Lesion Revascularisation

15. 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 C Sirius Investigators JACC 2004; 43: 1110 p<0.001 9 months outcome

16. 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 <3mm % N: 352, randomised Schofer et al. Lancet 2003; 362: 1093 p<0.001 p<0.0001 8 months outcome p<0.002

17. Small Vessels SES Smart Single lesion <2.75mm native coronary % N: 257, randomised Ardissino et al. JAMA 2004; 292: 2727 p<0.002 P<0.001 p<0.001 p<0.04 8 months outcome

18. Small Vessels

19. Chronic Total Occlusion PRISON II Single CTO >2 weeks, crossed and predilated % N: 200, randomised Suttorp et al. Circulation 2006;114:921 p<0.001 P<0.001 p<0.001 6 months outcome

20. Chronic Total Occlusion SCANDSTENT Subgroup analysis CTO, crossed and predilated % N: 127, randomised Kelbaek et al; Am Heart J 2006: 152:882 P<0.001 p<0.001 6 months outcome

21. Saphenous Vein Grafts RRISC Trial Lesions in SVG Grafts % N:75pts, 96 lesions, randomised Vermeersch et al JACC 2006; 48:2423 P=0.012 P=0.024 6 months outcome

22. Bifurcation Lesions SCANDSTENT subgroup Bifurcations: 126 pts randomised % Thuesen et al. Am Heart J 2006: 152:1140 P<0.001 6 months outcome P<0.001 p=0.01

23. 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