New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
CONFLICT OF INTEREST:
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Case as Presented by
Dr. Antonio Serra
Hospital de Sant Pau,
Hospital del Mar
Barcelona
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Clinical presentation
Patient A
64-yr old male patient
Risk factors:
Hypertension
Ex-smoker
Hypercholesterolemia
CAD clinical presentation :
Inferior AMI 4 hrs of evolution.
Non complicated
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Coronary angiography
Ostial LM + LAD disease
Occlusion mid RCA
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Primary PCI
Patient A
TIMI 0 flow after
wire crossing.
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Clinical presentation
Patient B
60-yr old male patient
Risk factors:
Hypertension
Active smoker
CAD clinical presentation :
Angina Class II in the last 3 months
Acute anterior MI of 3 hours of
evolution, uncomplicated.
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Coronary angiography
Normal RCA
Occlusion mid LAD
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Coronary angiography
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Coronary angiography
Patient B
TIMI 0 flow after
wire crossing.
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Coronary angiography
Patient A
Patient B
Both patients with TIMI 0 flow after wire crossing
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
How would you treat ?
•A:
Balloon dilatation
•B:
Direct Stenting
•C:
Aspiration
•D:
Other alternatives
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
How did I treat ?
Dr. Antonio Serra
Hospital de Sant Pau,
Hospital del Mar
Barcelona
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Option A : Balloon
When does distal embolization occur in primary PCI?
400 consecutive patients with primary PCI:
Distal embolization
64 / 400 (16%)
54.7
60
50
40
23.4
30
17.1
20
10
4.7
0
Basal
Guide wire
Balloon
Stent
Napodano M et al. TCT, 2005
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Option A : Balloon
Impact of distal embolization during primary PCI
Distal embolization
No embolization
70
27 / 194 (14%)
Embolization
57
60
44
42
50
40
30
20
9
10
0
5-yr mortality
LVEF
Henriques JP et al. The Zwolle Group. Eur Heart J 2002;23:1112-1117
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Option B : Direct Stenting
How to choose the stent?
TIMI 0-1 flow after
crossing the occlusion with
the guide wire
Stent choice ? :
Lenght…………… ?
Diameter………… ?
Guidance
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Option C: Aspiration
Since the publication of the
TAPAS trial, Aspiration in all
acute MI became a Gold
Standard in primary PCI.
However, is aspiration
useful in all patients with
acute MI?
Spanish TAPAS
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
TAPAS trial
EXPORT 1071 Pts with acute MI + Abciximab
Catheter
Export (n=502)
Balloon (n=503)
• No visible thrombus on angiogram: 51%
• EXPORT Catheter did not cross: 11%
• No material in the aspirate: 27%
• Amongst those with material in aspirate,
67.7% were platelet thrombi
• Size of aspirated material < 0.5mm in the
majority of cases
Svilaas T et al. N Engl J Med 2008;358:557-567
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
TAPAS trial : Aspiration arm (n=502)
EXPORT
Not able to cross (n=54)
Nothing in the
aspirate (n=123)
11%
24.5%
Thrombus > 2.0 mm : 61 / 331 pts = 18.4%
28.8%
35.7%
Thrombus > 0.5 mm (n=146)
Thrombus < 0.5 mm (n=179)
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Spanish Registry
100 consecutive pts with acute MI < 12 h
and TIMI flow 0-1 after wire crossing
AMICath crossed the occlusion : 95%
TIMI 2-3 flow after AMICath : 85%
Angiographically visible thrombus : 49%
Thrombus aspiration : 18%
Stent implant without pre-dilatation : 83%
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Option C: Always aspiration first
Should we routinely aspirate in all primary PCI cases ?
In 60.2% of Cases
-No aspirate
OR
-´Mini´
thrombus
NO
Catheter big profile
- Plaque rupture
- Spasm
- Distal emboli
When should we aspirate in primary PCI ?
When thrombus is visible on angiography
“SELECTIVE ASPIRATION”
Guidance
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Option D: Other alternatives
Tip profile : 0.017”, like standard
PTCA balloon
The profile increases
up to 1.5 mm
4 Radiopaque markers separated
by 10 mm
“High flow” distal holes
Monorail system
Hypotube design for max push
Very flexible
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Patient A
AMI Cath advanced distal to the oclusion. Adenosine 1-2 mg
injected distally to the occlusion to prevent reperfusion injury
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Patient A
Dye injection
through “high flow”
distal holes of the
AMI Cath allows
anatomic
characterization of
the distal vessel.
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Patient A
TIMI 3 flow is restored by “Dotter effect” with the AMI Cath. Absence of
distal embolization.
Time to recanalize the artery: 3 minutes
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Patient A
Thrombus ?
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Patient A
Thrombus aspiration with the HUNTER Catheter
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Patient A
BMS (Apolo Bionert)
3.0 x 19 mm
Final result
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Patient A
 TIMI 3 flow
 Blush grade 2-3
 > 70% ST segment
resolution
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Patient B
AMI Cath advanced distal to the oclusion.
Adenosine 2-4 mg distally to prevent reperfusion injury
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Patient B
Dye injection
through “high
flow” distal holes
of the AMI Cath
allows anatomic
characterization of
the distal vessel.
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Patient B
TIMI 3 flow is obtained in < 3 minutes since the
insertion of the AMI Cath.
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Patient B
Thrombus ?
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Patient B
Second GW in D1
“Direct” BMS 3.0 x 23 mm
Final result
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Patient B
 TIMI 3 flow
 Blush grade 2-3
 > 70% ST segment
resolution
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
Summary
Patients of similar age, risk factors
Acute uncomplicated MI of < 6 hrs,
TIMI 0-1 flow after wire crossing.
AMI Cath Strategy
TIMI 3 flow restored in < 3 minutes
- Adenosine distal to the occlusion
(prevention of reperfusion injury)
- Assessment of the distal vessel
A
Thrombus
B
NO Thrombus
Manual aspiration
Manual aspiration
“Direct” stenting
“Direct” stenting
TIMI 3, Blush 2-3, > 70% STR
G
U
I
D
A
N
C
E
New strategies and perfusion/aspiration devices for primary PCI
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager
THANK YOU
Sandra Garcia Cruset, PhD.
Cordynamic B.U. Marketing Manager