A simplified Coronary Lesion Classification system, predicting success and complications of PCI
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A simplified Coronary Lesion Classification system, predicting success and complications of PCI Ronald Krone MD Professor of Medicine Washington University School of Medicine
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A little history In 1988 the American College of Cardiology and American Heart Association task force published a classification of coronary lesions designed to establish the risk of PTCA, now known as balloon angioplasty. This was based on the experience of the preceding 10 years, a period when the balloon crossing the intended lesion was said to occur only 75% of the time.
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Ryan TJ, et al. Guidelines for PTCA. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty). Circulation 1988;78:486-502
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Ellis Modification of the ACC/AHA lesion classification system 1990 Ellis type A = ACC/AHA type A Ellis type B1 = 1 type B characteristic Ellis Type B2 = >1 type B characteristic Ellis Type C1 = 1 Type C characteristic Ellis Type C2 = >1 Type C characteristic Ellis SG, Vandormael MG, Cowley MJ, and the POSCH Group.: Coronary morphologic and clinical determinates of procedural outcome with angioplasty for multivessel coronary disease: implications for patient selection. Circulation 1990;82:1193-1202 In an attempt to refine the classification, Ellis et al devided the B and C classes into B1 and B2 and C1 and C2.
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Tan et al evaluated the Ellis et al Modifications and found: 729 Patients 1990-1993 91% success 3.3% complications No differences found between type A and B1 Significant differences between B1 and B2 No difference between C 1 and C 2. Tan K, Sulke N, Taub N, Sowton E: Clinical and lesion morphological determinants of coronary angioplasty success and complications: Current experience. J.Am.Coll.Cardiol. 1995;25:855-865
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The BARI Angiographic core lab evaluated various lesion characteristics for reproducibility: Rosen AD, et al. and the BARI Study Group.: How reliable is the assessment of coronary angiography? Circulation 1993;88 (Suppl I):I 653(Abstract) Botas J,et al, and the BARI Investigators.: Angiographic correlates of lesion relevance and suitability for PTCA and CAB in the BARI study Am J Cardiol 1996;77:805-814 C lesions could be reproducibly distinguished from A or B lesions A B or C lesions could not be reproducibly distinguished
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Introduction of the SCAI Lesion Classification system Because of the lack of differences between the B2 and C lesions as well as the lack of reproducibility in the classification as it stood, we introduced a simplified classification system, combining the ACC/AHA class C or not C (ie “high risk” or not) with whether the vessel was patent or not patient, both highly reproducible lesion characteristics. Krone RJ, Laskey WK, Johnson C, Kimmel SE, Klein LW, Weiner BH, Cosentino JJA, Johnson SA, Babb JD, for the Registry Committee of the Society for Cardiac Angiography and Interventions.: A simplified lesion classification for predicting success and complications of coronary angioplasty. Am J Cardiol 2000;85:1179-84
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METHODS The Data were collected from 139 hospitals from 1/98 to 9/00. Data were entered locally using ACC Certified data entry software into version 1.1 of the database. Data was transmitted by floppy disc to the ACC National Cardiovascular Data Registry and checked for consistency and completeness. Only the 65,974 single vessel procedures were analyzed to focus results on the lesion classification, especially complications. 337 lesions were classified as both A and occluded (.5%) which is erroneous since the definition of a Type A excludes occlusion. These were not analyzed, as were the 3711 lesions that were not classified. Data were analyzed using SPSS 10.1 statistical software
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100,292 Total PCI admissions 65,974 Single vessel PCIs 337 Occluded Type As 3711 Missing lesion data 61,926 Single vessel PCIs
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Percent of Lesions in each SCAI lesion class
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M.A.C.E. MACE = In hospital death, acute myocardial infarction, emergent PCI or emergent CABG
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MACE = In hospital death, acute myocardial infarction, emergent PCI or emergent CABG M.A.C.E.
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Conclusion: The simpler SCAI Lesion Classification System emphasizing Patency and based on 7 lesion criteria (AHA/ACC Class C) provided greater discrimination for both success and complications between the lowest and highest risk groups than the AHA/ACC criteria utilizing 28 criteria.
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Stent Usage by ACC/AHA lesion classification for All patients and Patients with and without Acute MI 67%
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Stent Usage by SCAI lesion classification for All patients and Patients with and without Acute MI 54%
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ALL Patients--Stented vs Non Stented ACC/AHA and SCAI lesion classification systems Success rates with stents all > 95%, without stents-varies by LCS
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M.A.C.E. No Acute MI
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M.A.C.E. Acute MI
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Conclusion The Likelihood of Stenting a lesion is related to the lesion classification system If a stent can be used, success is greater than 95% If a stent cannot be used, success varies according to lesion complexity Lesion Complexity and stent use predict complications The SCAI lesion system which combined ACC/AHA Class C with vessel patency permits a steeper gradient of results, predicting both stent usage and results if stents cannot be used.
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References Krone, RJ. Classification of Coronary Lesions. 2nd Virtual Congress in Cardiology. Argentine Federation of Cardiology 2002. http://www.fac.org.ar/scvc/llave/interven/krone/kronei.htm Krone RJ, Shaw RE, Klein LW, Block PC, Anderson HV, Weintraub WS, Brindis RG, McKay CR ACC-National Cardiovascular Data Registry. Evaluation of the ACC/AHA (American College of Cardiology / American Heart Association) and the SCAI (Society for Coronary Angiography and Interventions) lesion classification system in the current “stent era” of coronary interventions: A report from the ACC National Cardiovascular Data Registry. Am J Cardiol. 2003 Aug 15;92(4):389-94 Krone RJ, Laskey WK, Johnson C, Kimmel SE, Klein LW, Weiner BH, Cosentino JJA, Johnson SA. A simplified lesion classification for predicting success and complications of coronary angioplasty. Am J Cardiol 2000; 85:1179-1184 Krone RJ, Kimmel SE, Laskey WK, Klein LW, Schechtman, KB, , Cosentino JJA, Babb, JD, Weiner BH. Evaluation of the Society for Coronary Angiography and Interventions’ lesion classification system in 14,133 patients with percutaneous coronary interventions in the current stent era. Cathet Cardiovasc Intervent 2002;55:1-7 Shaw RE, Anderson HV, Brindis RG, Krone RJ, Klein LW, McKay CR, Block PC, Shaw LJ, Hewitt K, Weintraub WS, and the ACC-NCDR. Development of a risk adjustment mortality model using the American College of Cardiology¯National Cardiovascular Data Registry (ACC¯NCDR) experience: 1998¯2000 J Am Coll Cardiol 2002; 39:1104-1112
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