Cath Lab Digest - April 2008 - (Page 30)

30 ASK THE EXPERT APRIL 2008 DRUG-ELUTING STENT SOLUTIONS Use of a New Guidewire: The Tigerwire Cath Lab Digest talks with Prakash Krishnan, MD, Director, Endovascular Intervention, Cardiac Catheterization Laboratory, The Mount Sinai Medical Center, Assistant Professor of Medicine, Mount Sinai School of Medicine, New York about his use of the newly released Tigerwire (St. Jude Medical, St. Paul, MN). Predicting Stent Thrombosis Using A Clinical Risk Score This monthly column in Cath Lab Digest reviews important points of distinction in DES, from characteristics to techniques, so that physicians and cath lab professionals have valuable and relevant information about this revolutionary technology. By Kenneth Baran, MD Dr. Baran is the medical director at John Nasseff Heart Hospital in St. Paul, Minnesota. He is also a partner at the St. Paul Heart Clinic. Q At Transcatheter Cardiovascular Therapeutics (TCT) 2007, you presented an abstract entitled, “A clinical risk score for prediction of stent thrombosis using prospective data from real-world use of the TAXUS Express Paclitaxel-Eluting Stent.” How could your system help physicians improve the quality of patient care? This system could help clinicians better manage antiplatelet therapy in poststent patients. I frequently get questions from referring doctors, including orthopedists and gastroenterologists, about antiplatelet therapy prior to a surgical procedure in their patients with drug-eluting stents (DES). To help answer these questions, I developed a clinically-based scoring method, making it a more predictable approach not only for the other cardiologists in my practice but for clinicians in general. How is the scoring system set up, and what clinical and angiographic factors did you find to be indicators of stent thrombosis? We identified eight clinical and angiographic factors that were the most predictive of stent thrombosis. Then, we weighted each factor according to their hazard ratios (HR). For example, premature discontinuation of Plavix® had an HR of 5.28, which was translated to a score of five. Insulin-treated diabetes had an HR of 4.74, so it was also assigned a five. Interestingly, one of the clinical factors we identified was smoking, which was assigned a score of three. Ultimately, you add up the score of all identified factors present. If you had none, your score would be zero. What role did data from the TAXUS® Stent’s post-market ARRIVE 1 and 2 Registries play in the development of your scoring system? The TAXUS Stent’s ARRIVE data was critical. Since stent thrombosis is a low-frequency event, you need a large database with enough clinical events to extract meaningful causal relationships. Previously published studies have had similar findings but are not supported with a database as strong as ARRIVE (N=7,307). What percentage of DES patients would you classify as low-risk, medium-risk and high-risk for developing stent thrombosis? We went through each of the 7,307 patients in the ARRIVE 1 and 2 Registries and calculated their risk score (as noted above). There seemed to be a natural distribution between the low-risk scores of 0 to 6, moderate-risk scores of 7 to 13, and high-risk scores over 14. Only 1.6 percent of patients fell in the highest risk group for stent thrombosis. The risk for this group was 12.6 percent. Twenty-five percent of patients were classified as medium-risk, with a risk of 3.6 percent. Finally, 73 percent of patients were in the lowestrisk group, meaning they had a stent thrombosis risk of 0.8 percent. continued on next page A Can you tell us about your cath lab? Under the directorship of Samin K. Sharma, MD, FACC, the cardiac catheterization laboratory at Mount Sinai Hospital performed 4,908 interventions in 2007, out of which 400 endovascular interventions were done. The total catheterization volume was >14,500. The catheterization laboratory has 4.5 rooms with 5 full-time interventionalists and 8 part-time interventionalists. The cath lab staff has grown over the last five years, with the current number of employees being over 125 (46 nurses and 8 nurse practitioners). The Tigerwire can function as both. It can be a workhorse wire because it has a safe tip with a stiff body and therefore can be used in most applications in the cath lab. Its unique feature of a gradual transition between a flexible tip to a stiff body makes it ideal to use as a specialty/workhorse wire in endovascular interventions. For example, this gradual transition of the wire enables a rapid iliac cross while working from the contra lateral approach. The stiff body provides ample support to track a sheath and deliver devices to the lesion. The soft Q A Another advantage is the shapeable tip and torquability of this wire. This enables the operator to negotiate the external/internal iliac bifurcation and steer the wire across lesions. I perform all types of endovascular interventions, including renal artery, superficial femoral artery, tibial artery, and subclavian artery interventions. All procedures are performed in one room, which functions as both a coronary room and peripheral room. How long have you been using the Tigerwire? I have been using the Tigerwire for a few months and have done approximately 100 cases with the wire. Is it a specialty wire or a general workhorse wire? tip and gradual transition zone provides safety against dissections or perforations while working on difficult lesions in the superficial femoral artery. Another advantage is the shapeable tip and torquability of this wire. This enables the operator to negotiate the external/internal iliac bifurcation and steer the wire across lesions. These are significant advantages and provide the endovascular specialist with a powerful tool to get the job done. Can you share more about the Tigerwire design? The Tigerwire is a stainless steel, Q A Q A

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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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