Our activities at EuroPCR 2017 celebrated the combined strength and passion of Abbott and St. Jude Medical, and showcased the innovation, education and services that together we offer to help make a difference to patients’ lives. Over 7000 healthcare professionals got involved, through our booth, innovation pavilion, training village and scientific sessions.
Read on for a flavour of some of those sessions.
EuroPCR 2017 Hotline - What is the best strategy for intervention in patients with STEMI or multivessel disease?
Speakers: D. Capodanno, D. Dudek, J. Fajadet, V. Kocka, T. Lefevre, A.S. Petronio, A. Serra, N.E.J. West
In this case-based session covering primary percutaneous coronary intervention, long lesions, chronic total occlusion and bifurcation lesions, a panel of experts offered their perspectives on when best to use a scaffold or a stent.
The first case involved a 42-year-old woman with a single vessel lesion who underwent primary percutaneous coronary intervention. Dr Capodanno suggested using a stent because it is less thrombogenic and is supported by more robust clinical data, but Dr Kocka chose to implant a bioresorbable scaffold. His choice was driven by the patient’s age, the simple pathology and the likelihood that the plaque was soft.
In the case of a 55-year-old male with a long lesion, Dr Petronio and Dr West agreed that a bioresorbable scaffold was the most appropriate option because of the length of the lesion (5 cm), the patient’s young age, and the low risk of problems with dual antiplatelet therapy. This choice was also supported by the Italian data from the It-Disappear study, focussing on long lesions and MVD o nly. Tips for good results included using imaging guidance to minimise scaffold overlap, and following the ‘prepare, size, post-dilate’ (PSP) strategy.
In the complex case of a 36-year-old woman with three-vessel disease, including two chronic total occlusions, Dr Capodanno favoured coronary artery bypass grafting because of the complex anatomy and high SYNTAX score. For him, stents would be preferable to scaffolds because they are supported by stronger outcome data and are easier and quicker to implant. However, Dr Serra opted for complete revascularisation in stages, using a total of nine bioresorbable scaffolds and extensive imaging. He concluded that scaffolds in multivessel disease can offer good outcomes, especially in young patients with soft, non-calcified plaques; effective pre-dilation is key to success. Long term imaging outcome was excellent in this patient with several ‘golden tubes’ on OCT.
The experts agreed that main branch stenting with provisional side branch stenting is the most appropriate strategy for treating complex bifurcation lesions. However, a bioresorbable scaffold is an option for simple bifurcation lesions that can be treated with a single scaffold. It was noted that bioresorbable scaffolds are feasible for treating drug-eluting stent restenosis, but supporting data are lacking.
The panel concluded that indications for using a scaffold include young age, primary percutaneous coronary intervention and long lesions. Scaffolds can also offer good results in chronic total occlusions, but for complex bifurcation lesions a metallic stent is better.
Speakers: J. Diaz Fernandez, A. Finn, T. Palmerini, B. Ratner, R. Virmani, W. Wijns
When materials are placed in blood, they are quickly coated with proteins, such as albumin and fibrinogen. Platelets attach to these proteins, which leads to thrombosis. Far fewer platelets attach to albumin than fibrinogen, so ideally stents should have a high albumin-to-fibrinogen ratio on their surface once inserted into the blood vessel.
Opening this session, Dr Ratner explained that poly(vinylidene fluoride-hexafluoropropylene) (PVDF-HFP) – the fluoropolymer which coats the XIENCE family of stents – binds more albumin, and thus fewer platelets, than other stent materials. Dr Finn reviewed preclinical studies comparing Xience with other commercially available drug-eluting stents, and Dr Palmerini reviewed the clinical studies. Both preclinical and clinical studies demonstrated that not all drug-eluting stents are equal: Xience has consistently a lower rate of early and late stent thrombosis than other drug-eluting stents (and also bare metal stents).
To illustrate the low rate of stent thrombosis in highly complex patients, Dr Diaz Fernandez presented the complex case of a 56-year-old man who was diagnosed with bladder cancer 3 months after being implanted with two Xience stents. Optical coherence tomography at 3 months showed that the stent struts were completely covered, inspiring confidence that thrombosis was unlikely. Antiplatelet therapy was reduced to aspirin only, enabling cancer surgery to take place. Two months post-surgery, the patient is doing well, with no signs of thrombosis despite not restarting ticagrelor antiplatelet therapy.
This well-attended introduction to polymer technology generated considerable discussion, demonstrating cardiologists’ interest in the science behind polymer-coated stents and its translation to better outcomes in the clinic.
Speakers: E. Barbato, P. MacCarthy, P. Smits
This lunchtime symposium focused on how fractional flow reserve (FFR) can guide percutaneous coronary intervention (PCI) strategy in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease. It opened with Dr Smits’ review of three treatment strategies – aggressive, intermediate and conservative – followed by Professor MacCarthy’s summary of recent clinical trial data that support FFR-guided PCI of non-culprit lesions. The session ended with Dr Barbato’s presentation of two STEMI cases: 1) a 77-year-old male with occlusion of the mid-left anterior descending artery (LAD) and left circumflex stenosis, and 2) a 63-year-old male with an occlusion of the marginal branch and a long lesion on the proximal LAD. In both cases, Dr Barbato stented the culprit lesions. The audience and panel discussed the range of strategies for treating the non-culprit lesions. In the second case, the panel agreed that FFR-guided PCI should be attempted at the time of primary PCI because the patient was stable and the procedure was low risk and easy. The greater complexity of the first case generated varying opinions about whether FFR should be performed acutely or staged. Dr Barbato opted for acute FFR with staged PCI 4 days later to avoid jeopardising the last remaining vessel during the acute phase.
While the panel agreed that; based on Compare Acute, FFR can aid decision-making in multivessel PCI, it is yet unclear whether FFR guidance leads to better outcomes than angiographic guidance. More data on the benefits of complete versus culprit-only revascularisation are also required. As such, the results of the COMPLETE1, FULL REVASC2 and FLOWER-MI3 trials are eagerly awaited.
1. clinicaltrials.gov/ct2/show/NCT01740479 [Accessed 17 May 2017]
2. clinicaltrials.gov/ct2/show/NCT02862119 [Accessed 17 May 2017]
3. clinicaltrials.gov/ct2/show/NCT02943954 [Accessed 17 May 2017]
Speakers: Z. Ali, T Johnson, U Landmesser
ILUMIEN III: OPTIMIZE PCI trial introduced a new optical coherence tomography (OCT) method for stent sizing, based on measuring the external elastic lamina in proximal and distal reference segments of the vessel before intervention. Using this method, the trial showed that the minimum stent area after OCT-guided percutaneous coronary intervention (PCI) was similar to that after intravascular ultrasound (IVUS)-guided PCI. This addressed concerns that OCT-guided PCI leads to smaller luminal diameters after stent implantation than IVUS-guided PCI. In addition, OCT-guided PCI led to better stent expansion than angiography-guided PCI, and less major malapposition than both angiography-guided and IVUS-guided PCI.
Three cases demonstrated how to translate the ILUMIEN III optimisation criteria into clinical routine: two case studies described by Dr Johnson and a live case from the Cardiovascular Centre at OLV Aalst in Belgium. While the panel stressed that perfection is not always possible, the cases showed that OCT guidance following ILUMIEN III criteria can produce better imaging results than angiographic guidance alone. For example, in the live case the vessel tapered from the proximal to the distal area, so the cardiologists determined the stent size by measuring the mean external elastic lamina in the distal reference site. They pre-dilated with a non-compliant balloon, then further modified the proximal side with a larger cutting balloon. After insertion, the proximal side of the stent was underexpanded according to ILUMIEN III criteria, so the cardiologists post-dilated it with a larger non-compliant balloon, which also corrected sections of malapposition.
Tips for successful OCT-guided PCI included switching on the bifurcation mode to automatically highlight bifurcation points; using angiographic co-registration, which marks the distal and proximal references on the angiogram, to guide stent placement; and combining angiographic and OCT acquisition to minimise contrast volumes.
While these cases and the ILUMIEN III results are encouraging, the panel agreed that more data are needed to show that clinical outcomes are better after OCT-guided PCI than angiography-guided PCI. The ILUMIEN IV trial, described by Dr Landmesser, will compare the long-term outcomes of angiography-guided PCI alone versus angiography and OCT-guided PCI, and will enrol its first patient later this year.