1. Technical approach PCI in Small Vessels Washington Cardiology Center Augusto Pichard, L. Satler, K. Kent, R. Waksman, J. Laird, W. Suddath, J. Sharretts, S. Epstein, N. Weissman, A. Fuisz, G. Weigold, J. Lindsay Augusto Pichard, MD PCI in Small Vessels: A Comprehensive Approach

2. Technical approach PCI in Small Vessels Definition A true small vessel: A Vessel that Perfuses Small Amount of Myocardium

3. Technical approach PCI in Small Vessels First Conclusion: True small vessels do not need PCI Conclusion (1)

4. Technical approach PCI in Small Vessels Is this proximal LAD a small vessel ? No a large vessel with diffuse disease IVUS: 4 mm Insights From IVUS

5. Technical approach PCI in Small Vessels Patient Referred for ISRS of a 2.5 mm stent in the LAD. Vessel size ? RAO cranial IVUS 4 mm 2.5 mm Insights From IVUS

6. Technical approach PCI in Small Vessels Insights From IVUS WHC IVUS Core Lab Laborgne, Cheneau et al. 2002 LAD size assessment by IVUS

7. Technical approach PCI in Small Vessels Vessel size: Angiography vs IVUS Insights From IVUS

8. Technical approach PCI in Small Vessels Second Conclusion: The proximal LAD is almost never a small vessel. (The same is often true for the proximal RCA and CX). Conclusion (2)

9. Technical approach PCI in Small Vessels PCI of Small Vessels Which one is the best tool ? 1. Balloon? 2. Cutting Balloon ? 3. Stent ? 4. Specialized Stents (PC coating, Pixel, Silicon Carbide coating, etc.)? 5. Drug eluting stents ? Materials

10. Technical approach PCI in Small Vessels PCI of Small Vessels Stents

11. Technical approach PCI in Small Vessels Stent vs. Balloon in Small Vessels Kastrati et al. JACC 38:1604 Final Diameter Stenosis in the Balloon Arm Percent Difference in Restenosis between Balloon and Stent Stent vs Balloon

12. Technical approach PCI in Small Vessels Provisional Stenting in Vessels <2.7 mm WHC: Abizaid, Pichard et al. ACC 2001 286 lesions with provisional stenting under IVUS guidance. 45% crossed-over to stent. 453 control lesions with elective stenting. Results

13. Technical approach PCI in Small Vessels Why are Stents Less Effective in Small Vessels ? IVUS Core LAB. Washington Hospital Center ISRS is highest in small vessels Small vessels develop the same amount of intimal hyperplasia as large vessels WHC: Mintz et al. 1997WHC: Hoffmann AJC 1998;82:1168-72 Limitations

14. Technical approach PCI in Small Vessels Mean IH thickness vs Stent CSA at 6-month follow up in N on-Polymeric Paclitaxel-coated Stents. Mintz et al. TCT 2003 Control High dose Low dose Per slice bases R=0.009 P=0.87 R=0.126 P=0.01 R=0.002 P=0.96 Stent CSA (mm²) DES

15. Technical approach PCI in Small Vessels Small Vessel PCI Any benefit with specialized approach ? Rotablator Cutting balloon Special coatings Specialized Approach

16. Technical approach PCI in Small Vessels Rotablator vs. Balloon for Small Vessels. DART Trial. Mauri et al. AHJ 2003; 145:847-54 446 patients randomized Vessel diameter (mean 2.46). Lesion length: 10±6 mm. Procedural success: 92% (R) vs 94% (B). 12 months follow up: – angio restenosis: 50.5% in both. – late loss: 0.49 (R) vs 0.56 (B). Conclusion: no benefit of Rotablator in Small Vessels Rotablator

17. Technical approach PCI in Small Vessels Cutting Balloon vs. Balloon in Small Vessels Cutting balloon

18. Technical approach PCI in Small Vessels Cutting Balloon vs. Stent in Small Vessels Refer. Vess. Diam: 2.2 mm 2.3 mm 2.2 mm 2.4 mm n= 86 pts. 310 lesions 48 pts. 174 pts. 1: Kawaguchi. JACC 2002;39:48a; 2: Kawaguchi JACC 2002;39:7A; 3: Kinoshita AJC 2003; 92:170L; 4:Umeda JACC 2002;39:52 A Cutting balloon

19. Technical approach PCI in Small Vessels TENAX Stent (Silicon Carbide Coated Stent). SVS Trial (Small Vessel Study). Bonnier et al. CRT 2003 495 patients with Small Vessels (2.5-3.0 mm) randomized SiC coating

20. Technical approach PCI in Small Vessels Heparin-Coated Stent in Small Vessels. COAST Trial. Haude et al. Circulation. 2003;107:1265-70 Restenosis: 32.2% after PTCA with provisional stenting, 24.8% after bare stenting, and 29.6% after heparin-coated stenting. (P=0.34). 588 pts. randomized to angioplasty with provisional stent (n=195), bare stenting (n=196), or Corline heparin-coated stenting (n=197). (JomedFlex Stent) Heparin

21. Technical approach PCI in Small Vessels BiodivYsio PC Coating Stent in Small Vessels. Lasmal Trial. Rodriguez et al. Buenos Aires PC Coating

22. Technical approach PCI in Small Vessels ISAR SMART-II: Randomized vessels <2.5 mm BiodivYsio PC Coating Kastrati; TCT 2003 PC Coating

23. Technical approach PCI in Small Vessels Third conclusion Bare metal stents have the same restenosis rate as optimal balloon angioplasty. Cutting balloon seems to offer a restenosis benefit in small vessels. Stents with special coatings offer no detectable advantage. Conclusion (3)

24. Technical approach PCI in Small Vessels ISAR SMART-II: Randomized vessels <2.5 mm Abciximab Anti- GPIIb/IIIa

25. Technical approach PCI in Small Vessels Restenosis with Cilostazol in PCI. CREST Trial Diabetic restenosis p=0.0108 Small vessel restenosis p=0.0038 Diabetics >2.75mm p=ns Diabetics <2.75mm p=ns CP CPCPCP C=Cilostazol P=Placebo Devireddy. Circulation 2004;110:III-489 Drug

26. Technical approach PCI in Small Vessels Drug Eluting Stents in Small Vessels

27. Technical approach PCI in Small Vessels DES vs BMS in Small Vessels. Randomized Trials % RS DES

28. Technical approach PCI in Small Vessels Late Loss in Small Vessels. BMS vs DES Randomized Trials mm DES

29. Technical approach PCI in Small Vessels Oct 04 DES Diameters

30. Technical approach PCI in Small Vessels SES diameters used (n=16251) 30% SES Diameters

31. Technical approach PCI in Small Vessels Fourth conclusion Drug Eluting Stent is clearly the device of choice for small vessels. Conclusion (4)

32. Technical approach PCI in Small Vessels Is the “Bigger is Better” Stent Strategy Necessary when Stenting Small Vessels?

33. Technical approach PCI in Small Vessels MACE in Small Vessels and Stent Lumen Area Iakovou et al. AJC 2003;92:1171-6 423 pts with 446 stents in vessels <2.75mm. Group 1: 308 pts with final CSA <6 mm2. Group 2: 115 pts with final CSA > 6mm2. 1 year f/u IVUS

34. Technical approach PCI in Small Vessels How Big is Better in Small Vessels ? Moussa et al. AJC 1999;83:1012-1017 IVUS

35. Technical approach PCI in Small Vessels Final Stent Area and Restenosis. SIRIUS IVUS sub study. 72 SES and 50 BMS. Sonoda, et al. JACC 2004;43: 1959-63 Drug Eluting Stents IVUS

36. Technical approach PCI in Small Vessels Final Stent Area and Follow up Lumen Area SIRIUS IVUS sub study. 72 SES and 50 BMS. Sonoda, et al. JACC 2004;43: 1959-63 IVUS

37. Technical approach PCI in Small Vessels Stent area and Outcome at 6 months N=209 patients, N= 319 lesions treated with Cypher TLR MACE P=0.068P=0.54 2.9% 0% 4.4% 2.2% % <66-7.5>7.5<66-7.5>7.5 Minimal stent CSA (mm 2 ) by Ivus Follow up

38. Technical approach PCI in Small Vessels IVUS Findings in SAT. Cheneau et al. Circulation. 2003;108:43. 7484 PCI’s with IVUS: 27 SAT (0.36%) Inadequate Stent Expansion 18 (78%) Stent malappostition 2 (5%) Dissection 4 (17%) Tissue protrusion 1 (4%) Thrombus post PCI 1 (4%) IVUS

39. Technical approach PCI in Small Vessels Summary 1.True small vessels do not need PCI. 2.The proximal LAD is almost never a small vessel. 3.Bare metal stent has same restenosis as optimal balloon angioplasty. Cutting balloon seems to offer a restenosis benefit. 4.Drug Eluting Stent is the device of choice for small vessels. 5.Adequate expansion in DES seems important (final stent area >6 mm2). Summary