Stent Roundtable: Patient Volumes, DES vs. BMS, Transradial Approach and the Bottom Line

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 - Stent Roundtable

Cardiovascular Business invited five luminaries in the field of interventional cardiology to engage in a discussion about stents, including the choice to use PCI over CABG, DES versus BMS, a specific stent over contracting and the radial approach versus the femoral approach—always with an eye toward running a better practice.

Listen to highlights from the interview

Participants of the discussion are:

  • Gregory J. Mishkel, MD, interventionalist at Prairie Cardiovascular in Springfield, Ill.
  • Jeffrey J. Popma, MD, director of innovations in interventional cardiology at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School in Boston.
  • Gregg W. Stone, MD, director of cardiovascular research and education and an interventionalist at New York-Presbyterian Hospital/Columbia University Medical Center in New York City. Vice chairman of the Cardiovascular Research Foundation, which conducts the Transcatheter Cardiovascular Therapeutics annual meeting.
  • Christopher J. White, MD, chairman of the department of cardiovascular diseases at Ochsner Clinic Foundation in New Orleans, Editor-in-Chief of Catheterization and Cardiovascular Intervention.
  • Alan C. Yeung, MD, division chief and director of interventional cardiology at Stanford University Medical Center in Stanford, Calif.
  • Moderator: Justine Cadet, News & Features Editor, Cardiovascular Business

What is the decision-making process to stratify patients with coronary artery disease (CAD) to receive either PCI or CABG at your facility?

White: At Ochsner, six interventionalists perform about 4,000 caths per year and 1,500 interventions. We make individual choices about how to manage our patients, and do not have an algorithm or a structured decision-making model. We occasionally use the SYNTAX Score to help stratify patients for risk. Generally, we use bypass surgery in patients who have extensive vascular disease—three-vessel complex lesions or chronic total occlusions (CTOs). However, multivessel disease, in which each vessel would be a straightforward single-vessel intervention, is routinely handled with PCI. We average about 2.1 to 2.2 stents per patient which averages high, refl ecting our aggressive interventional approach. While our surgeons are not involved in the decision-making process, we typically present patients with left main disease to them.

Popma: Deciding whether a patient receives CABG or multivessel PCI is a multidisciplinary approach at Beth Israel. We work with our surgeons and ask their opinion on patients who have complex CAD, particularly with respect to comorbidities, such as prior stroke and reduced left ventricular ejection fraction, or the elderly. While we are not routinely using the SYNTAX Score, we apply the concepts of the score, in such cases as complicated left main bifurcation disease or diffuse disease in diabetic patients. If there are no surgical contraindications, those patients are moved to CABG. With respect to the specific subset of left main disease, we also have been using surgery as the default therapy.

Stone: We have a collaborative relationship with our surgeons, but don’t regularly consult them. Surgery could be recommended for left main disease, complex triple-vessel disease or a nonrecanalized CTO. However, it’s only about 10 to 20 percent of the cases that could go either way. In that small population, we stop the procedure, take the patient off the table and call for a formal surgical consult. This is most important in patients with complex triple-vessel or left main disease. All left main cases if they are unprotected would be good surgical candidates, although we continue to perform PCI on unprotected left mains in the post-SYNTAX era. Yet, the patient has to be informed because it hasn’t yet made the guidelines or received widespread acceptance. We do not use the SYNTAX Score because it was only tested in a cohort of patients with triple-vessel or left main disease, and hasn’t been tested against other predictive instruments.

Yeung: We have a long-standing conference on Saturday mornings, which is attended by most of the cardiac surgeons and cardiologists both from the university and community. Generally, we use that forum to discuss patients who could receive either treatment. The discussion is very helpful because it establishes a seamless method to approach diffi cult cases. Instead of the SYNTAX Score, we mainly employ qualitative eyeballing, assessing how many bifurcations, how