Conduite à tenir devant: Une lésion de pontage saphène

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1 Conduite à tenir devant: Une lésion de pontage saphène P. Commeau Ollioules

2 Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale : I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Affiliation/Financial Relationship Company consulting Abbott Boston Sci Stentys Cordis Medtronic Hexacath Biotronik Saint Jude Medical Terumo

3 Je pense que la meilleure stratégie pour prévenir la maladie du greffon veineux et son occlusion. est de laisser la veine saphène dans la jambe! Robert D Safian Cathet CV Interv 2012;79:919

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7 CD

8 Ao-D1

9 Ao-MBG1

10 Thin fibrous cap Foam cells Layered thrombus

11 No Flow RISQUES Resténose

12 LUTTE CONTRE LE NO-FLOW (SYSTÈME DE PROTECTION, SIZING ADAPTÉ, VASODILATATEUR..)

13 Correlation of Necrotic Cores and Doppler Hits Kawamoto et al. J Am Coll Cardiol. 2007; 23: 50:

14 Manipulation de la Plaque = Embolisation TCD Count Guidewire Pre-Dilation Stent Deployed 2 nd Balloon Expansion Distal Balloon Deflation 23 % of control count Al-Mubarak, AHA 2001

15 CK-MB Rise and Related Mortality Rates After Successful SVG Intervention 60% 53% 50% Normal CK-MB 40% 30% 32% P< x CK-MB >5x CK-MB 20% 10% 15% P<0.05 4,8% 6,5% 11,7% 0% Prevalence 1 Year Mortality Hong, et al., Circulation. 1999;100:

16 ESC/EACTS Task Force revascularization guidelines 2010 SAFER FIRE PROXIMAL Wijns et al. EHJ 2010

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18 3-Year Outcomes Associated With Embolic Protection in Saphenous Vein Graft Intervention CathPCIRegistry: 49,325 Medicare beneficiaries who underwent SVG PCI at 1,001 hospitals, ; 21.2% received embolic protection. Use of embolic protection tied to more procedural complications, including no reflow, dissection, perforation, and perioperative MI In-hospital mortality was 1.1% and 30-day MACE was 5.5%, with no between-group differences Embolic protection not associated with lower rates of death, MI, or repeat revascularization by 3 years Conclusion: Embolic protection during SVG intervention increases procedural complications without improving long-term clinical outcomes. Brennan JM, et al. Circ Cardiovasc Interv.2015

19 OVERSIZING Hong et al. Am J Cardiol 2010;105: )

20 Outcome : 30 Day and One Year p = p = NS Hong et al. Am J Cardiol 2010;105: )

21 LUTTE CONTRE LA RESTÉNOSE : DES?

22 Sirolimus-Eluting vs Bare Metal Stents in SVGs Study Limitations -Non-randomized design -Small sample size -Short-term (6 month) follow-up Ge L. J Am Coll Cardiol 2005; 45: 989.

23 Increased Mortality after Sirolimus-Eluting Stenting in Diseased SVGs: The Reduction of Restenosis In Saphenous vein grafts with Cypher* (RRISC) Trial Vermeersch, P. et al. J Am Coll Cardiol 2007;50:

24 Delayed TVR after Sirolimus-Eluting Stenting in Diseased SVGs: The Reduction of Restenosis In Saphenous vein grafts with Cypher (RRISC) Trial Vermeersch, P. et al. J Am Coll Cardiol 2007;50:

25 Summary of DES in SVG Studies Author Study Design N DES Type Follow-up Major Findings Ge Retrospective 150 SES 6 months 15% MACE with SES Tsuchida Retrospective; No control 52 PES 12 months MACE=7.5% Okabe Retrospective 616 SES or PES 12 months No difference Veermesch (RRISC) RCT 96 SES 36 months mortality with SES; No diff TVR

26 Drug-Eluting vs. Bare-Metal Stents in Saphenous Vein Graft (SVG) Lesions ISAR-CABG: Randomized, superiority trial in 610 pts. 1-Year Follow-up DES (n = 303) BMS (n = 307) P Value Death/MI/TLR (Primary Outcome) 15.0% 22.1% 0.02 TLR 6.8% 13.1% 0.01 Stent Thrombosis 0.7% 0.7% 0.99 DES reduced angiographic restenosis at 7 months (15% vs. 29%; P < ). Conclusion: In high-risk SVG lesions, DES cut TLR rates almost in half, leading to an overall decrease in late outcomes. Mehilli J, et al. Lancet

27 DES vs BMS in SVG's % % year Events P=0.46 DES (416) BMS (396) 60% 18.4 Meta Analysis - 4 RCT RRISC (75) BASKET (47) SOS (80) ISAR-CABG (610) MACE Mortality MI Repeat Revasc Alam M., Clin Cardiol 2012;35:291-6

28 Safety and Effectiveness of DES vs BMS in Saphenous Vein Graft PCI Propensity-matched cohort of patients in VA registry who had SVG PCI with BMS (n = 895) or DES (n = 901), Oct Sep DES use increased over time from 50% in 2008 to 69% in 2011 No difference between BMS, DES in procedural complication rate (2.8% vs 2.3%; P =.54) Through more than 2 years of follow-up, mortality risk lower with DES (HR 0.72; 95% CI ); no difference in MI risk (HR 0.94; 95% CI ) Conclusions: DES and BMS appear equally safe for SVG PCI over almost 3 years. Aggarwal V, et al. J Am Coll Cardiol. 2014;64:

29 Safety and Clinical Effectiveness of DES for SVG Intervention in Older Individuals NCDR CathPCI Registry and Medicare data on pts 65 years old with failed SVG lesions who received DES (n = 31,403) or BMS (n = 17,922), Year Outcomes of DES vs BMS: Propensity-Matched Analysis HR 95% CI All-Cause Death MI Urgent Revascularization Conclusion: In older patients, using DES to treat failing SVGs appears safe. Brennan JM, et al. Catheter Cardiovasc Interv

30 En pratique Privilégier le réseau natif Pas de Filtre ( ni même de protection proximale..) Lésion simple sur «beau greffon» (diamètre, aspect ) : DES Lésion de pontage dégénéré dysplasique : BMS (STENTYS?) Si possible sans pré-dilatation ni post-dilatation à haute pression En cas de lésion très longue (>30-40mm), utilisation en pré-dilatation de ballon périphérique jambier ( 220mm) : 1 seule inflation longue (puis DEB?)

31 Conclusions et Recommandations 1. L athérome du greffon veineux est friable, instable et facilement mobilisable et l angioplastie de leurs lésions est associée à un taux élevé de morbi-mortalité 2. Pas d évidence du bénéfice des filtres de protection même si conceptuellement une protection contre l embolisation est logique 3. Le bénéfice à long terme du DES sur le BMS reste à établir 4. L oversizing et les fortes pressions d inflation doivent être évités pour réduire le prolapsus de plaque au travers des mailles du stent et l embolisation de débris 5. L utilisation libérale des vasodilatateurs pourrait être bénéfique

32 SPIDER: Saphenous Vein Graft Protection In a Distal Embolic Protection Randomized Trial 732 pts with SVG lesions 80 clinical sites from Feb 2003-July 2005 Randomization stratified by planned IIbIIIa use ASA & Plavix SPIDER/SpideRX N=375 GuardWire or FilterWire (EX/EZ) N=357 Non-Inferiority Analysis Primary endpoint: MACE at 30-days = Death, MI* (Q-wave and non-q wave), TVR, urgent CABG

33 SPIDER: Primary Endpoint 30 Day Outcomes p=0.79 for superiority p=0.012 for non-inferiority Percent MACE ,1 8,4 Spider (n=375) 8,5 7,6 1,1 0,6 Control (n=357) 7,7 7 0,3 30 Day All Q-wave Non Death MACE MI MI Q-wave MI 0,6 Dixon and O Neill, TCT 2005