Coronary Artery Coronary Artery Disease in Diabetic Disease in Diabetic Patients, Different Patients, Different

from Non-from Non-diabetics? diabetics?

Coronary Artery Coronary Artery Disease in Diabetic Disease in Diabetic Patients, Different Patients, Different

from Non-from Non-diabetics? diabetics?

울산의대울산의대서울아산병원 흉부외과서울아산병원 흉부외과

이재원이재원

CABG is still better CABG is still better than PCI in DES erathan PCI in DES era

Efficacy of PTCA

Late Graft Patency

Risk of Surgery

DiabeticsDiabeticsDiabeticsDiabetics

Accelerated intimal hyperplasia & Atherogenesis in diabetics - Potential Mechanisms -

Accelerated intimal hyperplasia & Atherogenesis in diabetics - Potential Mechanisms -

Vessel wall

↑SMC proliferation

↑cholesterol synthesis ← Hyperinsulinemia?

↑growth factors

↑ Procoagulant state

Vessel wall

↑SMC proliferation

↑cholesterol synthesis ← Hyperinsulinemia?

↑growth factors

↑ Procoagulant state

Progression of Progression of atherosclerosisatherosclerosis

BARIBARISurvival – All PatientsSurvival – All Patients

BARIBARISurvival – All PatientsSurvival – All Patients

BARI BARI Survival – Patients without Treated Survival – Patients without Treated

DiabetesDiabetes

BARI BARI Survival – Patients without Treated Survival – Patients without Treated

DiabetesDiabetes

BARI BARI Survival – Patients with Treated DiabetesSurvival – Patients with Treated Diabetes

BARI BARI Survival – Patients with Treated DiabetesSurvival – Patients with Treated Diabetes

BARIBARIBARIBARI

Mortality Influence of DM and IMAMortality Influence of DM and IMA

21

18

34.6 5.4 4.8

0

5

10

15

20

25

DM Non-DM

PTCA SVG I MA

21

18

34.6 5.4 4.8

0

5

10

15

20

25

DM Non-DM

PTCA SVG I MA

Revascularization Revascularization StrategiesStrategies

Revascularization Revascularization StrategiesStrategies

How do we decide?How do we decide?

Risk Benefit RatioRisk Benefit Ratio

Patient Patient preferencpreferencee

Clinical Clinical presentatiopresentationn

AnatomyAnatomy

Revolution demands blood!Revolution demands blood!Revolution demands blood!Revolution demands blood!

Only 5% Benefit? Only 5% Benefit? Revolution?Revolution?

Only 5% Benefit? Only 5% Benefit? Revolution?Revolution?

Clinically driven 1yr TLR for Clinically driven 1yr TLR for BMSBMS

Clinically driven 1yr TLR for Clinically driven 1yr TLR for BMSBMS

Initial DES result in USInitial DES result in USInitial DES result in USInitial DES result in US

Stent Usage at Medical City Dallas Stent Usage at Medical City Dallas (n=34(n=346)6)

Stent Usage at Medical City Dallas Stent Usage at Medical City Dallas (n=34(n=346)6)

Gold StandardGold StandardGold StandardGold Standard

Improving CABGImproving CABGImproving CABGImproving CABG

ARTS Study ConclusionARTS Study ConclusionARTS Study ConclusionARTS Study Conclusion

Diabetic patients showed poor clinical outcome in the stent group when compared to the CABG group. Consequently, surgery may be preferable to stenting in patients with multivessel coronary disease and diabetes, although surgery carries a sialthough surgery carries a significant risk of cerebrovascular accident.gnificant risk of cerebrovascular accident.

SOS TrialSOS TrialSOS TrialSOS Trial

3.9

3.49

Hazard Ratio

P=0.001

Hazard Ratio

P=0.007

For Stent vs. Surgery to have a repeat revascularization

For Stent vs. Surgery for 3 year mortality

Results of Randomized Trials in Results of Randomized Trials in DiabeticsDiabetics

Results of Randomized Trials in Results of Randomized Trials in DiabeticsDiabetics

Diabetics Increased early and late adverse events after both P

TCA/CABG Both approaches-suboptimal

ButCABG superior to PTCA

↑restenosis ↓complete revascularization↑disease progression

Therapy directed to Therapy directed to lesion vs. vessellesion vs. vessel

PTCA or CABG for Multivessel DiseasePTCA or CABG for Multivessel Disease ; Considerations; Considerations

PTCA or CABG for Multivessel DiseasePTCA or CABG for Multivessel Disease ; Considerations; Considerations

Need for revascularization Need for complete

revascularization LV function Technical/anatomic factors Individual patient circumstances

Revascularization in Patients with Multivessel Revascularization in Patients with Multivessel DiseaseDisease

Revascularization in Patients with Multivessel Revascularization in Patients with Multivessel DiseaseDisease

CABG PCI

Triple vessel disease

LV dysfunction

LMCA disease

Diffuse disease

Double vessel disease※

Preserved LV function※

Suitable anatomy※

Advanced age

“Salvage”procedure

Diabetics? ※ Majority of pt in randomized trials

STS Database CABG STS Database CABG MortalityMortality

1990 ~ 20011990 ~ 2001

STS Database CABG STS Database CABG MortalityMortality

1990 ~ 20011990 ~ 2001

Restenosis Rates in DiabeticsRestenosis Rates in DiabeticsRestenosis Rates in DiabeticsRestenosis Rates in Diabetics

DES in DiabeticsDES in DiabeticsDES in DiabeticsDES in Diabetics

Late Loss (mm)Late Loss (mm)

SIRIUS-Diabetic subgroup SIRIUS-Diabetic subgroup (279 pts)(279 pts)

SIRIUS-Diabetic subgroup SIRIUS-Diabetic subgroup (279 pts)(279 pts)

Sirolimus-eluting stentsSirolimus-eluting stentsSirolimus-eluting stentsSirolimus-eluting stents

Binary restenosis according the different type of diabetesBinary restenosis according the different type of diabetes

In-segment RestenosisIn-segment RestenosisIn-segment RestenosisIn-segment Restenosis

Relationship diameter & lesion length (from Relationship diameter & lesion length (from SIRIUS)SIRIUS)

SIRIUS – Diabetic subgroupSIRIUS – Diabetic subgroupSIRIUS – Diabetic subgroupSIRIUS – Diabetic subgroup

Choosing Interventional Choosing Interventional TherapyTherapy

Choosing Interventional Choosing Interventional TherapyTherapy

                                                                    

DES: Lesion & PatientsDES: Lesion & PatientsDES: Lesion & PatientsDES: Lesion & Patients

                                                                    

IntroductionIntroductionIntroductionIntroduction

                                                                    

Patients profilePatients profilePatients profilePatients profile

Period : 2000. 7 ~ 2003. 12

Patients

329 consecutive patients

isolated OPCAB

first time elective operation

no exclusion criteria for OPCAB

Preoperative DataPreoperative DataPreoperative DataPreoperative Data

Age (years) 61.6 8.1 (40~85)

Men/Women 219/110 (66.6%)

Diabetes 100 (30.4%)

Ejection fraction 58.1 9.8 (25~75)

Postoperative DataPostoperative DataPostoperative DataPostoperative Data

Mechanical ventilation (hr) 7.56.0

Chest drainage (cc) 912458

ICU stay (day) 2.01.8

LOS (day) 8.011.7

Postoperative EventsPostoperative EventsPostoperative EventsPostoperative Events

Operative mortality 3 (0.9)

Reoperation 9 (2.7)

Perioperative MI 3 (0.9)

Deep wound infection 7 (2.1)

N(%)

Postoperative EventsPostoperative EventsPostoperative EventsPostoperative Events

Arrhythmia 11 (3.4) Pulmonary complications 6 (1.8) Postop IABP 3 (0.9) Postop Inotropics 35 (10.6) Renal failure 0 CVA 0

N(%)

Mortality Mortality Mortality Mortality

40

61

145

24

4

114

11

23

100

13

28

0

20

40

60

80

100

120

140

160

2000 2001 2002 2003

OPCAB CABG on pump beating CABG

40

61

145

24

4

114

11

23

100

13

28

0

20

40

60

80

100

120

140

160

2000 2001 2002 2003

OPCAB CABG on pump beating CABG

NN

0.9%0.9%3/3343/334

1.7%1.7%7/4077/407

1.5%1.5%7/4587/458

1.5%1.5%8/5428/542

(101(101))

(173(173))

(148(148))

(141(141))

11 22 11 11 00 22 00 11 00 11 33

Target Coronary VesselsTarget Coronary VesselsTarget Coronary VesselsTarget Coronary Vessels

RCA

2%(19)

RI

1%(11)

PDA

15%(176) Dx

18%(212)

LAD

28%(338)

OM

29%(345)

PL

7%(83)

Total distal anastomoses : 1,184 Total distal anastomoses : 1,184 Anastomoses/Pt : 3.6Anastomoses/Pt : 3.61.1(1~7) 1.1(1~7) ( 1.7, 1.2, 0.8 )( 1.7, 1.2, 0.8 )

Early Graft PatencyEarly Graft PatencyEarly Graft PatencyEarly Graft Patency

LAD 97.6%(285/292)

Other vessels 98.6%(704/714)

Revascularization(1year):2.12%(7/329)

LITA & RA composite graft &LITA & RA composite graft &In situ RITA anastomosis to LADIn situ RITA anastomosis to LAD

LITA & RA composite graft &LITA & RA composite graft &In situ RITA anastomosis to LADIn situ RITA anastomosis to LAD

97.9%

Reintervention free survivalReintervention free survivalReintervention free survivalReintervention free survival

years

3210

%100

90

80

70

60

50

years

3210

%100

90

80

70

60

50

99.1%

Cumulative SurvivalCumulative SurvivalCumulative SurvivalCumulative Survival

Goals of TherapyGoals of TherapyGoals of TherapyGoals of Therapy

Improve survival

Avoid CNS complications

Preserve/Improve LV function

Relieve symptoms

Prevent infarction

Decrease need for subsequent procedures