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Cath Conference. 7/9/08 Priya Pillutla, M.D. History. HPI 58 y/o M presented in May ‘08 w/escalating chest pressure at rest and with exertion Symptoms relieved with NTG; exertional chest pain better with rest - PowerPoint PPT Presentation

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  • 7/9/08Priya Pillutla, M.D.Cath Conference

    Priya Pillutla, MD

  • HistoryPriya Pillutla, MDHPI 58 y/o M presented in May 08 w/escalating chest pressure at rest and with exertion Symptoms relieved with NTG; exertional chest pain better with restCath planned but patient eloped; referred back from clinic for persistent chest painPMH CAD, DJDNSTEMI 11/07. Cath showed R dominant system, 90% proximal LAD stenosis s/p PCI (3.5x12mm taxus and 4x18mm driver)

    Priya Pillutla, MD

  • HistoryPriya Pillutla, MDMeds Metoprolol, clopidigrel, simvastatin, lisinopril, NTG as needed, adderal

    Allergies - ?iodine (no complications 11/07)

    Social hx - Marginally housed, denies substance abuse Utox + meth, cannabis

    Family hx - noncontributory

    Priya Pillutla, MD

  • Physical ExamPriya Pillutla, MDVS BP 128/65, HR 60, RR 13, 98% RADisheveled JVP 7 cm H20. Neck supple, normal carotid upstrokesPMI nonsustained, nondisplaced. RRR nl s1/s2. No s3/s4. No murmurs.Lungs clearAbdomen soft, nontenderNo edema2+ radial, femoral and dorsalis pedis pulses

    Priya Pillutla, MD

  • Laboratory DataPriya Pillutla, MDElectrolytes - K 4.5, Cr 0.8Hematocrit - 40.8Platelets - 230KINR - 1Cardiac biomarkers - Troponin neg, CKMB normal x 3

    Priya Pillutla, MD

  • Priya Pillutla, MD

    Priya Pillutla, MD

  • Cardiac CatheterizationPriya Pillutla, MD

    Priya Pillutla, MD

  • SummaryPriya Pillutla, MDHigh-grade (95-99%) in-stent restenosis of the proximal LAD and proximal stent 40% stenosis PCI of proximal LAD using cutting balloon (4x10mm)Probable compliance issues given living situation and +utoxExcellent angiographic result with TIMI 3 flow and resolution of chest painPatient observed overnight and discharged the following day without complicationsMissed cath f/u appointment

    Priya Pillutla, MD

  • In-stent restenosisPriya Pillutla, MDCan be seen in 5-35%1 of patients after PCI Somewhat lower after DESMechanisms include:Negative remodelingElastic recoilNeointimal hyperplasia

    1Stone et al, JAMA, 2005

    Priya Pillutla, MD

  • Treatment optionsPriya Pillutla, MDAngioplasty (PTCA, cutting balloon)High rates of restenosis1 (39-67%)Mechanical debulking (rotational, laser)Repeat stenting (BMS, DES)Intracoronary radiation (brachytherapy)

    1Scheller et al, NEJM, 2006

    Priya Pillutla, MD

  • Priya Pillutla, MDDauerman, JACC, 2006(Not shown - TAXUS V, showing that PES is better than brachytherapy)

    Priya Pillutla, MD

  • Current effective treatments BrachytherapyWorks well but considerable safety, logistical and technical issuesRisk of stent-edge restenosis and thrombosisDESRecurrence rates 13-22%1DES + DES = higher rate of restenosis2 (43%)Very small but serious risk of stent thrombosis

    1Scheller et al, NEJM, 20062Lemos et al, Circulation, 2004Priya Pillutla, MD

    Priya Pillutla, MD

  • Whats special about DES?Drug-elution is keyCan drug be delivered for a shorter time?Can lower levels of drug still attain antiproliferative effects?Data (cell-culture and swine experiments) suggest that both of the above are true!

    Priya Pillutla, MD

    Priya Pillutla, MD

  • Paclitaxel-Coated Balloon Angioplasty PACCOCATH ISR NEJM, 2006 (Scheller et al)Hypothesis - Angioplasty using paclitaxel-coated balloons will prevent in-stent restenosisBalloon delivers all of the drug at once and is then withdrawn

    Priya Pillutla, MD

    Priya Pillutla, MD

  • Study designDouble-blind, randomized pilot studyInclusionAngina or +functional studySingle restenotic lesion

    ExclusionRecent MI, CKD, allergySick or noncompliantLong (>30mm) or small (

  • Study DesignPatients randomized toConventional PTCA PTCA with paclitaxel-coated balloon (3 ug/mm2)Angiography before, after and at 6 months using QCA (quantitative coronary angiography)ASA, plavix x 1 month then ASA aloneEndpointsPrimary late luminal loss (lumen at 6 months vs after PTCA)Secondary restenosis, combined clinical events Priya Pillutla, MD

    Priya Pillutla, MD

  • Results52 patients26 patients in each groupSimilar baseline and procedural characteristicsMean age 64 years71% menMost patients had multi-vessel disease with diffuse ISRPriya Pillutla, MD

    Priya Pillutla, MD

  • Angiographic findings 6 monthsMLD = minimal lumen diameter; LLL = late lumen lossPriya Pillutla, MD

    UncoatedCoatedp valueMLD (in-stent)1.6 mm2.3 mm0.004LLL (in-segment)** primary endpoint0.74 mm0.03 mm0.002Restenosis (%)4350.002

    Priya Pillutla, MD

  • Priya Pillutla, MD

    Priya Pillutla, MD

  • Priya Pillutla, MD

    Priya Pillutla, MD

  • Priya Pillutla, MD

    Priya Pillutla, MD

  • Adverse events related or possibly related to procedureUncoated group2 small groin hematomas 6 revascularizations, 1 unstable anginaCoated group3 small groin hematomas1 MI (possibly related)** Second MI noted in a patient randomized to uncoated balloon who erroneously received coated balloon, possibly related to balloon

    Priya Pillutla, MD

    Priya Pillutla, MD

  • LimitationsExtremely smallNot truly blinded coated balloons had distinct appearanceShould be studied in comparison with standard of care (DES)Anti-platelet agents only given for 1 monthWas LLL an appropriate parameter?DES trials show that early LLL may not correlate well with restenosisNevertheless results are encouragingPriya Pillutla, MD

    Priya Pillutla, MD

  • SummaryIn-stent restenosis continues to complicate PCIsNeoproliferation, negative remodeling and elastic recoil are causative factorsTherapyData most strongly supports DES at this timeDrug-coated balloon PTCA is likely to be an emerging modalityPriya Pillutla, MD

    Priya Pillutla, MD

    NSR 57 bpm with APCsNormal axisNormal intervalsBorderline R wave progressionNo ST-T changes

    Suggests reduction in neointimal proliferation. For comparison, LLL for conventional drug-eluting stents is around 0.32 mm.?lose this slide*