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Tehran Heart Center Tehran University of Medical Sciences

PCI VS CABG. M . SALARIFAR , MD. Tehran Heart Center Tehran University of Medical Sciences. PCI VS CABG. From 1987 to 2003 326% increase in PCI Now more than 90% stenting. PCI VS CABG. Factors in patient selection.

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Tehran Heart Center Tehran University of Medical Sciences

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  1. PCI VS CABG M . SALARIFAR , MD Tehran Heart Center Tehran University of Medical Sciences Dr.Salarifar

  2. PCI VS CABG • From 1987 to 2003 326% increase in PCI • Now more than 90% stenting Dr.Salarifar

  3. PCI VS CABG Factors in patient selection • The need for mechanical revascularization as opposed to medical treatment & risk factor modification . • The likelihood of success ( vessel size , calcification , tortuosity , side branches ) • The risk and potential consequences of acute failure of PCI ( Coronary anatomy % viable myocardium , LV function . Dr.Salarifar

  4. 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 basedon the extent of CAD , severity of ischemia , LV function . 6. The presence of comorbid conditions 7. Patient preference Dr.Salarifar

  5. 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% Dr.Salarifar

  6. PCI VS CABG Patients with increased risk for PCI • Advanced age • Female gender • Unstable angina • CHF • LM equivalent disease • Multivessel disease • DM • Renal failure Dr.Salarifar

  7. 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 % Dr.Salarifar

  8. PCI VS CABG PCI and Medical therapy • RCT comparing PCI with medical therapy are few in numberand < 5000 patients , enrolled patients with SVD and priorstenting and enhanced adjunctive pharmaco therapy. • * Results : • Better control of angina • Functional capacity • Quality of life Dr.Salarifar

  9. 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 Dr.Salarifar

  10. 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 . Dr.Salarifar

  11. 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 . Dr.Salarifar

  12. PCI VS CABG PCI in LV dysfunction In hospital & long term mortality was higher in LV dysfunction . EF ≤ 40% 11 % 1 Year Mortality EF 41 – 49% 4.5 % 1 Year Mortality EF ≥ 50% 1.9 % 1 Year Mortality Dr.Salarifar

  13. 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 Dr.Salarifar

  14. 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 Remain stable or improved Dr.Salarifar

  15. 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 % Dr.Salarifar

  16. In THC data base : Dr.Salarifar

  17. CABG Complications PCI VS CABG • 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% Dr.Salarifar

  18. 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 Dr.Salarifar

  19. 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 . Dr.Salarifar

  20. 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 Dr.Salarifar

  21. PCI VS CABG Arterial graft patency IMA graft patency rate 95% 1 y 88% 5 y , 83% 10 y . Dr.Salarifar

  22. 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 dysfunction or high risk non invasive tests Dr.Salarifar

  23. PCI VS CABG Indications for Revascularization PCI : • In patients with SVD the aim of procedure is relief of symptoms or objective evidence of sever ischemia • In patients with angina who are not high risk , medical treatment , PCI & CABG are similar . Dr.Salarifar

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  28. 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 Dr.Salarifar

  29. 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 . Dr.Salarifar

  30. 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 . Dr.Salarifar

  31. PCI VS CABG BARI • Diabetic patients with CABG had better survival at twoyears . Dr.Salarifar

  32. 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 repeat revascularization Dr.Salarifar

  33. 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 Dr.Salarifar

  34. ACC/AHA Guidelines for Revascularization with PCI and CABG in Patients with Stable Angina Dr.Salarifar

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  39. حیرت اندر حیرت است ای یار من این نه کار توست و نه هم کار من Dr.Salarifar

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