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PCI VS CABG
M . SALARIFAR , MD
Tehran Heart Center
Tehran University of Medical Sciences
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PCI VS CABG
From 1987 to 2003 326% increase in PCI
Now more than 90% stenting
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PCI VS CABG
Factors in patient selection
1. The need for mechanical revascularization as opposed
to medical treatment & risk factor modification .
2. The likelihood of success ( vessel size , calcification ,
tortuosity , side branches )
3. The risk and potential consequences of acute failure of
PCI ( Coronary anatomy % viable myocardium , LV
function .
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PCI VS CABG
4.The likelihood of restenosis ( diabetes , prior restenosis
,
small vessel , long lesion , Total
occlusion , SVG disease) .
5. The need for complete revascularization based on
the
extent of CAD , severity of ischemia ,
LV function .
6. The presence of comorbid conditions
7. Patient preference
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PCI VS CABG
Ideal cases of PCI
Significant symptoms despite intensive
medical
therapy
Low risk for complications
Technical success rate
No history of CHF
EF > 40%
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PCI VS CABG
Patients with increased risk for PCI
Advanced age
Female gender
Unstable angina
CHF
LM equivalent disease
Multivessel disease
DM
Renal failure
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PCI VS CABG
Current expectations for PCI
Procedural success at least 90%
Mortality < 1%
Q ware MI < 1.5%
Emergency by pass surgery 1 – 2 %
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PCI VS CABG
PCI and Medical therapy
RCT comparing PCI with medical therapy are few
in
number and < 5000 patients , enrolled patients with
SVD
and prior stenting and enhanced
adjunctive
pharmaco therapy.
* Results :
Better control of angina
Functional capacity
Quality of life
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PCI VS CABG
No RCT to date has demonsrated a reduction in
death or MI with PCI compared with medical
thraphy for patient with chronic stable angina
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PCI VS CABG
PCI and Medical therapy
RITA – 2 showel excess of death and MI
62% Patients multivessed disease
COURAGE TRIAL :
2287 patients
PCI did not reduce the risk of death or MI over a
medium
4.6 years follow up .
TIMe Trial : similar results in elderly patients .
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PCI VS CABG
PCI and Medical therapy
Conclusion
Most patients with chronic stable angina and class I –
II
symptoms
Medical treatment .
PCI for patients with severe symptoms despite medical
therapy or patients with high risk criteria on Noninvasive
tests .
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PCI VS CABG
PCI in LV dysfunction
In hospital & long term mortality was higher in LV
dysfunction .
EF ≤ 40%
11 %
EF 41 – 49%
4.5 % 1 Year Mortality
EF ≥ 50%
1.9 % 1 Year Mortality
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1 Year Mortality
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PCI VS CABG
CABG
Garrett , Dennis , DeBakey : Bailoat CABG in 1964
Fovoloro : late 1960 s
Kolessov : use of IMA 1967
Green : 1970
% 26 in CABG since 1997
In 2004 : 20% off – PUMP CABG
Minimally Invasive
Hybrid procedure
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PCI VS CABG
CABG
Surgical outcomes
Patient population of CABG
Higher risk
( older , 3VD , History of Revascularization , LV
dysfunction
Diabetes , Peripheral vascular disease )
Out comes with CABG
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Remain stable or improved
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PCI VS CABG
CABG
Operative Mortality
Mortaliy of 503 , 478 CABG - only in the s td data
base 1997 – 1999: 3.05 %
2005 : 2 . 2 %
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In THC data base :
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PCI VS CABG
CABG Complications
Mojor morbidity ( death , stroke , Renal failure sternal
infection : 13.4% in 30 days
MI : 3.9%
Respiratory complications
Bleeding : 2-6 % reparation for bleeding
Wound infection
Post operative HTN
Cerebrovascular complication
Stroke 2.6%
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PCI VS CABG
CABG Complications
AF : One of the most frequent complications of CABG
up to 40%
Risk of stroke
Use of beta blockers reoluces post operative AF
Brady arrhythmia : 0.8% need for permanent pacemaker
Renal dysfunction
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PCI VS CABG
Return to Employment
80% who were employed prior to CABG
Return
to work
Patient undergoing CABG return to work 6
W
later than PCI
But long term employment is similar .
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PCI VS CABG
SVG Patency
Early occlusion : 8 – 12 %
1 year occlusion : 15 – 30 %
occlusion
1 – 6 y occlusion : 2%
Annually
6 – 10 occlusion : 4%
Annually
At 10 y
:50% SVG occlusion and 20 -40%
significant stenosis in Remaining
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PCI VS CABG
Arterial graft patency
IMA graft patency rate 95% 1 y 88% 5 y ,
83% 10 y .
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PCI VS CABG
Indications for Revascularization
CABG :
Significant left main disease : Regardless of the
severity
of symptoms or LV dysfunction
Patients with 3 VD that Includes LAD proximal lesion
&
LV dysfunction
Patients with 2 VD with LAD proximal lesion &
LV
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dysfunction or high risk non invasive tests
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PCI VS CABG
Indications for Revascularization
PCI :
In patients with SVD the aim of procedure
is
of sever
relief of symptoms or objective evidence
ischemia
In patients with angina who are not high risk
,
similar .
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medical treatment , PCI & CABG are
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PCI VS CABG
PCI or CABG witch strategy ?
SVD : PCI
2VD
Multivessel disease : PCI as initial strategy especially in
patients with good LV function , suitable anatomy and
patient preference .
CABG : Severe LAD proximal lesion , DM LV dysfunction ,
LM lesion , Diffuse disease .
Advanced age and comorbidity : PCI is better
Younger patient < 50 y : PCI is initial strategy
CASS Registry : Impaired survivial in young patients
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PCI VS CABG
PCI VS CABG
Observational studies:
Recent studies after stenting 60/000 patients with
multivessel disease treated with stenting or CABG
in the newyork state Registry (1997 – 2000 ) :
Higher survival with CABG after adjustment for
medical comorbidities .
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PCI VS CABG
PCI VS CABG
Randomized trials :
ARTS trial ;
Death , MI , CVA and one – year mortality were similar .
CK – MB more than twice in CABG and was a predictor
of
poor outcome .
In PCI groupe DM was the main factor for poor out come
PCI was associated with a greater need for
Repeat
Revascularization .
TVR was Higher in stenting groupe .
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PCI VS CABG
BARI
Diabetic patients with CABG had better
survival at two years .
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PCI VS CABG
Recent Publications
NENGLJMED 358 : 4 January 2008
* DES VS . CABG in multivessel disease
Newyork state Registry ( oct 2003 – Dec 2004 )
More than 17000 patients ( 9963 DES , 7437 CABG )
CABG was associated with lower mortality , MI
and
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repeat revascularization
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PCI VS CABG
The – MAIN – COMPARE Registry
Stenting VS . CAGB for LM
1102 stenting & 1138 CABG in Korea 2000 -2006
No significant difference in Death , MI , stroke
Higher Rate of TVR in stenting
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ACC/AHA Guidelines for Revascularization with PCI
and CABG in Patients with Stable Angina
Class
I (indicated)
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Indication
Evidence
1. CABG for patients with significant left main coronary disease
A
2. CABG for patients with triple-vessel disease. The survival benefit is
A
greater in patients with abnormal LV function (ejection fraction <0.50)
3. CABG for patients with double-vessel disease with significant
A
proximal LADCAD and either abnormal LV function
(ejection fraction <50%) or demonstrable ischemia on noninvasive testing
4. PCI for patients with double- or triple-vessel disease with significant
B
proximal LAD CAD, who have anatomy suitable for catheter-based therapy
and normal LV function and who do not have treated diabetes
5. PCI or CABG for patients with single- or double-vessel CAD without
B
significant proximal LAD CAD but with a large area of viable myocardium and
high-risk criteria on noninvasive testing
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Class
I (indicated)
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Indication
Evidence
6. CABG for patients with single- or double-vessel CAD without
C
significant proximal LAD CAD who have survived sudden cardiac
death or sustained ventricular tachycardia
7. In patients with prior PCI, CABG or PCI for recurrent stenosis
C
associated with a large area of viable myocardium or high-risk criteria on
noninvasive testing
8. PCI or CABG for patients who have not been successfully treated
B
by medical therapy and can undergo revascularization with acceptable risk
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Class
Indication
Evidence*
1. Repeat CABG for patients with multiple saphenous
C
vein graft stenoses, especially when there is significant
(good
supportive stenosis of a graft supplying the LAD; it may be appropriate
to use PCI for focal saphenous vein graft lesions or multiple
evidence) stenoses in poor candidates for reoperative surgery
2. Use of PCI or CABG for patients with single- or double- B
vessel CAD without significant proximal LAD disease but
with a moderate area of viable myocardium and
demonstrable ischemia on noninvasive testing
3. Use of PCI or CABG for patients with single-vessel
B
disease with significant proximal LAD disease
IIa
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Class
Indication
Evidence*
1.Compared with CABG, PCI for patients with doubleB
or triple-vessel disease with significant proximal LAD
(weak
supportive CAD,who have anatomy suitable for catheter-based therapy
and who have treated diabetes or abnormal LV function
C
evidence) 2. Use of PCI for patients with significant left main
coronary disease who are not candidates for CABG
3. PCI for patients with single- or double-vessel CAD
C
without significant proximal LAD CAD who have survived
sudden cardiac death or sustained ventricular tachycardia
IIb
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Class
Indication
Evidence*
III
1. Use of PCI or CABG for patients with single- or
C
(not
double-vessel CAD without significant proximal LAD
indicated) CAD, who have mild symptoms that are unlikely due to
myocardial ischemia, or who have not received and adequate
trial of medical therapy and
a. have only a small area of viable myocardium
Or
b. have no demonstrable ischemia on noninvasive testing
2. Use of PCI or CABG for patients with borderline
C
coronary stenoses (50-60% diameter in locations other
than the left main coronary artery) and no demonstrable
ischemia on noninvasive testing
3. Use of PCI or CABG for patients with insignificant
C
coronary stenosis (<50% diameter)
4. Use of PCI in patients with significant left main
B
coronary artery disease who are candidates for CABG
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Dr.Salarifar
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