SKS in LM stentingSKS in LM stenting

Sheffield experience in 100Sheffield experience in 100 consecutive ULMCA bifurcation

stenosesstenoses

Dr. Julian GunnDr. Julian Gunn

Senior Lecturer/ Hon ConsultantSenior Lecturer/ Hon. Consultant Cardiologist, University of

Sheffield Sheffield TeachingSheffield, Sheffield Teaching Hospitals, UK

SKS: technique/ tipsSKS: technique/ tipsSKS: technique/ tipsSKS: technique/ tips•8F catheter•Predilatation•Taxus stents•Cover all disease•1:1 diameter LAD/ Cx•Balloon for length•Back beyond ostium•Spider and LAO CranialIVUS/ b i i b/ IABP•IVUS/ abciximab/ IABP

if necessary

60y MElective*Cathet Cardiovasc Interv 2007; 69:209-15 ElectiveCathet Cardiovasc Interv 2007; 69:209 15

SKS for ULMCA bifurcation: SKS for ULMCA bifurcation: aftercareaftercare

• Dual antiplatelet therapy for life• Clinical followup 3 12 months• Clinical followup 3,12 months• 1st 30: 6/12 angiography

• 2nd 70: no routine angio• ETT when possible: 4/12 and 8/12• ETT when possible: 4/12 and 8/12

SKS for UMLCA bifurcation: S ff

SKS for UMLCA bifurcation: S ffSheffield resultsSheffield results

N 100• N= 100• All-comers (shock/ AMI/ v elderly/ frail)

• 1 PCI turndown• 35 % unsuitable for CABG35 % unsuitable for CABG• Mean age 66 (45-88)

76% male• 76% male• 8% emergency, 23% acute, 69% elective• 2.0 vessel disease (+ULMCA)• 1.8 vessels treated1.8 vessels treated

SKS for UMLCA bifurcation: Sh ffi ld lt

SKS for UMLCA bifurcation: Sh ffi ld ltSheffield resultsSheffield results

100% SKS technical success• 100% SKS technical success • 96% DES, 4% BMS

3% IVUS• 3% IVUS• 17% IABP

F ll di 20• Followup: median 20m• Death in hospital 4 (3 emerg, 1 urgent, 0 routine)

D th l t 6 (0 2 t 4 ti )• Death long term 6 (0 emerg, 2 urgent, 4 routine)

SKS for UMLCA bifurcation: SheffieldThe deaths

SKS for UMLCA bifurcation: SheffieldThe deathsThe deathsThe deaths

3 emergency cases. All cardiogenic shocks; had s ccessf l PCI b t died s bseq entlsuccessful PCI but died subsequently.

3 t 1 d th f ll i LMS t 1 h d l3 urgent cases. 1 death following LMS rupture. 1 had renal failure at time of PCI and died 7m later. 1 died after 4m.

4 routines. Died at 2, 4, 7 and 10m.

SKS for UMLCA bifurcation: Risk scoresSKS for UMLCA bifurcation: Risk scoresSKS for UMLCA bifurcation: Risk scoresSKS for UMLCA bifurcation: Risk scores

Number Deaths (20m)

Euroscore risk death(20m) risk death

Elective 69 4 (6%) 2%

Urgent 23 3 (13%) 18%

Emergency 8 3 (38%) 44%

Total 100 10 (10%) 9%

SKS for UMLCA bifurcation: survivalSKS for UMLCA bifurcation: survivalSKS for UMLCA bifurcation: survivalSKS for UMLCA bifurcation: survival

80

90

100

Elective and urgent patients (n=92)

50

60

70

viva

l (%

)

Emergency patients (n=8)

(p=0.03)

20

30

40Surv

0

10

20

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

No deaths beyond 10 m

Time (months)

SKS for ULMCA bifurcation: TVRSKS for ULMCA bifurcation: TVRSKS for ULMCA bifurcation: TVRSKS for ULMCA bifurcation: TVR

6%• 6%• Symptom-driveny p• 5 re-PCI (3 repeat SKS; 2 SKB/S)

1 CABG• 1 CABG

SKS:SKS:RestenosisRestenosisRestenosis,Restenosis,Thrombosis,Thrombosis,ReRe PCIPCI

HP

ReRe--PCIPCI

SKS HP3.0/ 3.0Kissing

SKS8/12 ago

3 5/3 5 BalloonsPre-dil

3.5/3.5Taxus

STEMI t Repeat SKS:Taxus3 5x24

STEMI atDGH

3.5x243.5x24Lysis

Successful

Immediatetransfer

SKS: SKS: IVUS preIVUS preIVUS preIVUS pre

77y F, El iElective

SKS: SKS: IVUS postIVUS postIVUS postIVUS post

SKS: reSKS: re--endothelialisationendothelialisation

Septum

6/12, M

SKS: SKS: Animal studiesAnimal studies

3/12, pig3/ , p g

*Cathet Cardiovasc Interv 2007; 69:209-15

SKS: in emergencySKS: in emergency

79y MCardiogenicshock

SKS for ULMCA bifurcation: SKS for ULMCA bifurcation: SKS for ULMCA bifurcation: SKS for ULMCA bifurcation: ConclusionsConclusionsConclusionsConclusions

• Easy• Easy• Quick

Eff ti• Effective • Excellent in extremis• Mortality 4% in hospital (incl shocks/ turndowns)

• Mortality 10 % at 20m (incl shocks/ turndowns)y– Electives (69%) 8% (incl turndowns)– Urgents (23%) 14% (incl turndowns)

Emergencies (8%) 38% (incl shocks and turndowns)– Emergencies (8%) 38% (incl shocks and turndowns)

• [CABG 3% in hospital (no shocks/ turndowns)7% at 20m (all LMSs]]% ( ]]

• TVR 6%

AcknowledgmentsAcknowledgmentsAcknowledgmentsAcknowledgments

D A j Si ti• Dr Anjan Siotia• Dr Allison Morton• Dr Jiun Tuan

D N di A ld• Dr Nadine Arnold• Dr Peter KorgulDr Peter Korgul• Jim Heppenstall• John Bowles