Cath Lab Digest - April 2008 - (Page 28)

28 STEMI INTERVENTIONS APRIL 2008 Direct Stenting 66.0% 92.1% The primary endpoints are italicized and values in bold reached statistical significance with p<0.05. Control 76.3% Treat 60.8 60% 94% - - - - - - - - total ischemic time, infarct-related vessel or segment, TIMI grade or visible thrombus by angiography. From our experience in the Single INdividual Community Experience REgistry for Primary PCI (SINCERE) database, we offer a few additional refinements to the superb work from TAPAS: a. It must be recognized that it may not always be possible to identify thrombus by angiography — it is precisely in dealing with this limitation wherein TAPAS provides rationale for using thrombectomy for all subsets. Yet, not only should every effort be made to demonstrate thrombus, we even suggest trying to determine the thrombus grade. b. Using the thrombus grade (Table 2) as a baseline, we then suggest a strategy to employ either aspiration or mechanical thrombectomy (Table 3). Although we are committed to universally employing thrombectomy for all STEMI interventions and we find the low-profile and trackability of aspiration catheters extremely beneficial, we also recognize the limitations of these catheters in the presence of bulky thrombus and in treating saphenous vein grafts. For these indications, we strongly feel that mechanical thrombectomy with devices such as the AngioJet (Possis Medical, Inc., Minneapolis, MN), provides even more effective treatment of thrombus. c. Finally, we offer a few tips from our experience regarding the use of aspiration catheters: 1. These catheters are most effective with fresh clot. Organized thrombus is more resistant to debulking. 2. Various aspiration catheters have different profiles: a. Different pushability, tractability and aspiration rates. b. All are 6-French compatible. c. It is useful to stock and be familiar with the use of at least one. 3. Flush catheter lumen well before use as it facilitates better tracking over the wire. 4. Avoid kinking the catheter — advance slowly over the initial, softer portion of the catheter. 5. Monitor distal tip of the guidewire as the aspiration Control 24.4% 5.3% 10.0% 15.2% 17.8% 3.1% 19% Distal Emboli 2.1% 4.3% 8.0% Treat 9.3 5% 16.8 - - - - - - - Control 10.8% 12.2% 9.9% No-Reflow 2.2% 3.0% 8.3% Treat 3.3 3% 10.1 15% - - - - - - - - 21.2 ± 18.0% EF: 48.7 ± 0.9 21.2 ± 18.0% EF: 56.8% Control 7.5 - - - - - - - - Infarct Size / EF 13.0 ± 11.6% EF: 51.0 ± 7.7 13.0 ± 11.6% EF: 57.4% Treat 15 - - - - - - - - Listed are all the major trials with various different aspiration catheters in the setting of STEMI and the results of various parameters. Death 6.2% MI: 4.1% CVA: 2.1% Death:6.5% CHF:21.7% MI: 2.2% stroke 0 10.50% Death:0 MI: 0 CVA: 0 Control 1.70% 6.10% 21.0% 30 d:7 2% 4.7 Death:6.5% CHF:10.9% MI: 2.2% stroke 0 Death 6% MI:4% CVA: 2% Death:0 MI:0 CVA:2% 30 d: 9 6.70% 8.60% 6.10% Table 10. Randomized Clinical Trials of Aspiration and Thrombectomy Catheters in STEMI. 14.0% MACE Treat 10.3 EXPIRA14 Export catheter 175 100 97.4 70.3 28.7 80 37.5 2% 5.8 4.5 Reprinted with permission from: Mehta S. Chapter 8: Practical Guidelines for Performing STEMI Interventions. In: Mehta S, ed. Textbook of STEMI Interventions. Malvern, PA: HMP Communications, 2008: 113-138. 52.20% 52.60% 55.30% Control 6.15 ± 6.32 72% 24.5 25% 72% 50% 0 - - 0 - - 37% 39% ST-Resolution 2.78 ± 3.05 82.60% 67.80% 81.60% Treat 90% 46% 68% 90% 68% 44% 40% 36.90% 24.50% Control 13.1% 20.5% 38% 44% 30.4 71.70% 36.8% Treat MBG 46% 54% 88% 46% 31.2 97.70% 18.2 ± 7.7 TIMI Flow Post-PCI 2.96±0.20 93.50% 91.8% 87.5% Treat 69% 89% 90% 89% 2584 100 201 480 258 148 215 355 AngioJet AngioJet Diver CE Diver CE Rescue catheter Rescue catheter Pronto catheter Rescue catheter NON STOP8 Beran et al9 VAMPIRE12 De Luca et al6 Antoniucci et al2 DEAR-MI10 REMEDIA4 Napodano et al1 X-AMINE3 EXPORT13 Dudek et al5 Kaltoftet al11 AIMI7 Trial Export catheter Device X-sizer X-sizer X-sizer TVAC 250 92 99 72 78 61 n 82% - - - 76.90% 2.89±0. 31 Control 97.0% 80.6% 22.5 ± 11.0 51% 80% 84% 78% - - - 73.5 - - - - - 64.8 - - - - - 35.8 - 25.4 - - - NR - - - - - - - - NR - - - - - - - - 2.3% 28.3 34% 82% - - - - - - - -

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Cath Lab Digest - April 2008 Kaiser San Rafael Medical Center Orbital Atherectomy: A New Treatment for Complex Peripheral Arterial Disease Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Contents Clinical Editor’s Corner CEU Education Center The Missing Link in STEMI Interventions — Thrombus Aspiration during Primary Percutaneous Coronary Intervention Predicting Stent Thrombosis Using A Clinical Risk Score Use of a New Guidewire: The Tigerwire Should I Stay or Should I Go? Weighing Options for New Opportunities Navigating Tortuous Coronary Sinus Anatomy Using a Bipolar Lead The National Society of Radiology Practitioner Assistants (NSRPA) Holds 9th Annual Educational Conference For Medical Imaging Physician Extenders and Mid-Level Healthcare Providers Cath Lab & Beyond: A Meeting Update The Ten-Minute Interview with… Dale Hansen RT, CVT Sometimes, You Just Know Twin Circumflex Arteries: A Rare Coronary Artery Anomaly What Do You Think? Meetings Calendar News from the American College of Cardiology (ACC) Scientific Session and the Society of Cardiovascular Angiography & Interventions (SCAI) Annual Scientific Sessions in Partnership with the ACC i2 Summit Clinical & Industry News Cath Laughs Classifieds Advertisers Index

Cath Lab Digest - April 2008

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