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Article in EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology · August 2005
Source: PubMed
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Georgios Sianos1, MD, PhD; Marie-Angèle Morel2, BSc; Arie Pieter Kappetein3, MD, PhD;
Marie-Claude Morice4, MD; Antonio Colombo5, MD; Keith Dawkins6, MD; Marcel van den Brand7, MD, PhD;
Nic Van Dyck8, RN; Mary E Russell9, MD; Friedrich W. Mohr10, MD; Patrick W Serruys1* MD, PhD
1. Department of Interventional Cardiology, Erasmus Medical Center, Thoraxcenter Rotterdam, The Netherlands
2. Cardialysis BV, Rotterdam, The Netherlands
3. Department of Cardiothoracic Surgery, Erasmus Medical Center, Thoraxcenter, Rotterdam, The Netherlands
4. Institut Cardiovasculaire Paris Sud, Massy, France
5. San Raffaele Hospital, Milano, Italy
6. Southampton General Hospital, Southampton, UK
7. Ouderkerk aan den ijssel, The Netherlands
8. Boston Scientific Corporation, Maastricht, The Netherlands
9. Boston Scientific Corporation, Natick Massachusetts, USA
10. Herzzentrum, Leipzig, Germany
Introduction adverse cardiac events was comparable in both approaches, even
Optimal revascularization strategy in patients with coronary artery though the number of vessels and lesions treated were higher than
disease remains a subject of debate between interventional cardiol- in the previous trials19. However, it has been argued that despite the
ogists and surgeons. Numerous large scale randomized trials fact that patients with two or three vessel disease have been includ-
addressed this issue comparing coronary artery bypass grafting ed in the aforementioned trials, in the "real world" both intervention-
(CABG) with percutaneous coronary intervention (PCI) in patients al cardiologists and surgeons are often confronted with more com-
with multivessel disease (MVD). Initially these trials compared mul- plex anatomy. Numerous exclusion criteria and disagreement
tivessel balloon angioplasty with CABG1-6 and in a later period mul- between the surgeons and the interventional cardiologists allowed
tivessel stenting with CABG7-11. These studies clearly demonstrated only 2%-12% of the patients screened to be randomized13.
that there was no difference between the two therapeutic modalities Another characteristic of these trials was the heterogeneity in the
regarding mortality and non fatal myocardial infarction but patients complexity of coronary artery disease of the patients enrolled13. For
treated with balloon angioplasty or stenting required more often example, a patient with distal a left-main stem trifurcation lesion in
repeat revascularization procedures related to restenosis12,13. combination with an occluded right coronary artery is pooled
Clearly stenting reduced the gap in the event free survival rate together with a patient with three focal lesions in the mid portions of
between the two revascularization strategies from 32% in CABRI the three coronary arteries. Both are characterised as routinely
trial (91% versus 59% in favour of CABG) to 14% in ARTS I trial named “3-vessel disease”, despite the fact that the first patient rep-
(89% versus 75%) but still surgery remained the gold standard for resents a greater therapeutic challenge for the interventional cardi-
patients with MVD with an event free survival rate around 90%14. ologist and has completely different prognosis compared to the sec-
Recently the drug eluting stents were introduced and proven to be ond patient regardless of the revascularization strategy; percuta-
very effective in reducing restenosis and the incidence of repeat neous or surgical. The absence of grading of the severity of coro-
revascularisation15-18. In the recently conducted ARTS II trial the nary artery disease and the lack of comparison of lesion complexity
sirolimus eluting stents were compared with historical CABG data based on pre-treatment angiographic criteria between various
from the ARTS I trial in patients with MVD. The incidence of major groups severely limits the interpretation of the results of these trials.
* Corresponding author: Head of Interventional Cardiology, Ba 583, Thoraxcenter, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD,
Rotterdam, The Netherlands
E-mail : [email protected]
© Europa Edition 2005. All rights reserved.
EuroInterv.2005;1:219-227 - 219 -
The SYNTAX Score: an angiographic tool grading the complexity of coronary artery disease
Thus, for the selection of the optimal revascularization strategy for 5 times, the LAD approximately 3,5 times (84/16 x 0.66) and the
patients with three vessel and/or left main stem disease there are circumflex 1,5 times as much blood as the RCA to the left ventricle.
three major requirements: In a left dominant system the RCA does not contribute to the blood
1. The conductance of an “all comer” (no exclusion criteria) study supply of the ventricle. Thus the LM supplies 100% of the flow to
in such patients. the LV. The RCA contribution of blood flow to the LV is now supplied
2. Consensus between the interventional cardiologist and the car- by the LCX. Hence the LAD provides 58% (weighing factor 3.5) and
diothoracic surgeon for the treatment plan. the LCX 42% (weighing factor 2.5) of the total flow to the LV. Using
3. The quantification of the complexity of coronary artery disease, the same principle of relative blood supply to the LV all coronary
taking into account not only the number of significant lesions and segments has been given a weighing factor factor, Table 1.
their location, but also the complexity of each lesion independently. The contribution of each coronary segment to the blood flow to the
The SYNTAX (SYNergy between PCI with TAXUS™ and Cardiac LV is used as a multiplication factor for the calculation of the
Surgery) study was organized as an all comer study for patients with Leaman score and as such has been transferred to the SYNTAX
significant lesions in the left main stem and/or the three epicardial score.
coronary arteries. It will be comprised of a randomized arm and two A lesion is defined as significant when it causes (50% reduction in
registries for patients that are not suitable for one of the two revas- luminal diameter by visual assessment in vessels (1.5mm. Less
cularization strategies. Patients who have a preference for one of severe lesions should not be included in the SYNTAX score. The per-
the treatment strategies or patients in whom medical treatment is cent diameter stenosis is not considered in the algorithm. Distinction
suggested they will be included in the screening log. has been made only between occlusive (100% diameter stenosis)
The SYNTAX score has been developed for this study to prospec- and non occlusive (50-99% diameter stenosis) disease.
tively characterise the coronary vasculature with respect to the A multiplication factor of 2 is used for non-occlusive lesions and 5 for
number of lesions and their functional impact, location, and com- occlusive lesions reflecting the difficulty of the percutaneous treat-
plexity. Higher SYNTAX scores, indicative of more complex disease ment, Table 1. Importantly, all other adverse lesion characteristics
are hypothesized to represent a bigger therapeutic challenge and to considered in the SYNTAX score have an additive value, Table 2.
have potentially worse prognosis.
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The SYNTAX Score: an angiographic tool grading the complexity of coronary artery disease
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Clinical research
Aorto-ostial lesions lesions and the vessel segments involved per lesion and they
appear once. The maximum number of lesions allowed is twelve
A lesion is classified as aorto-ostial when it is located immediately at
and each lesion is characterized by a number, 1 to 12. The lesions
the origin of the coronary arteries from the aorta. It applies only to
will be scored in the numerical order inserted in question 3. Each
segments 1 and 5. In case of absence of a LM (double ostium of
lesion can involve one or more segments. In this case each vessel
the Left Coronary Artery), the segments 6 of the LAD and 11 of the
segment involved contributes to the lesion scoring. There is no limit
LCX originate directly from the aorta and consequently may also
in the number of segments involved per lesion.
involve aorto-ostial lesions. Aorto-ostial location is regarded as an
The last nine questions refer to adverse lesion characteristics and
adverse characteristic since the treatment of such lesions is techni-
are repeated for each lesion.
cally more challenging.
The question referring to a total occlusion is the first one. If a total
occlusion is scored, answers must be given to detailed sub-ques-
Diffuse disease/Small vessels
tions. The last of these sub-questions refers to the presence or
Present when at least 75% of the length of the segment distal to the absence of side branches and their size. If there are no side branch-
lesion has a vessel diameter of <2mm, irrespective of the presence es or if their diameter is <1.5 mm then the questions related to the
or absence of disease at that distal segment. It is a parameter intro- trifurcation and bifurcation lesions will be automatically skipped
duced to reflect the more challenging creation of a surgical anasto- since vessels <1.5 mm are not considered large enough for treat-
mosis in small or diseased vessels. ment either with PCI or CABG. If side branches with diameter
1.5 mm are involved then the lesion is considered as both total
The SYNTAX score algorithm (Table 3) occlusion and bifurcation lesion and the algorithm will continue with
The SYNTAX score is calculated by a computer program consisting of all the questions. The same is the case for non-occlusive lesions.
sequential and interactive self-guided questions. The algorithm con- With the exception of the selection of the type in case of a bifurca-
sists of twelve main questions. They can be divided in two groups: tion or a trifurcation lesion all the other questions of the algorithm
The first three determine the dominance, the total number of can be answered by selecting “yes” or “no”.
1 1 1
2 2 2
16 16 16
Patent segment
Occluded segment
Segment distal from the occlusion filled with collateral flow (visualised by contrast)
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The SYNTAX Score: an angiographic tool grading the complexity of coronary artery disease
A B C
Prebranch Parent
Vessel
Only
Postbranch
D E F Prebranch
Bifurcation Ostial &
Ostial
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Bridging collaterals: Small channels running in parallel to the vessel and con-
necting proximal vessel to distal and being responsible for the ipsilateral collat-
eralization
Trifurcation: A junction of three branches, one main vessel and two side-
branches. Trifurcations are only scored for the following segment junctions: Lesion 2
3/4/16/16a, 5/6/11/12, 11/12a/12b/13, 6/7/9/9a and 7/8/10/10a Segment 11: 1,5x2 3
+ Tortuosity 2
Bifurcation: A junction of a main vessel and a side branch of at least 1.5mm in Lesion 2 score: 3
diameter. Bifurcations are only scored for the following segment junctions:
5/6/11, 6/7/9, 7/8/10, 11/13/12a, 13/14/14a, 3/4/16 and 13/14/15.
Bifurcation lesions may involve one segment (types A, B and E), two segments
(types C, F and G) or three segments (type D).
Aorto ostial: A lesion is classified as aorto-ostial when it is located immediate- Lesion 3
ly at the origin of the coronary vessels from the aorta (applies only to segments Segment 1 : 1x2 2
1 and 5, or to 6 and 11 in case of double ostium of the LCA). Lesion 3 score: 2
Severe tortuosity: One or more bends of 90° or more, or three or more bends
of 45° to 90° proximal of the diseased segment.
Length >20mm: Estimation of the length of that portion of the stenosis that
has ≥ 50% reduction in luminal diameter in the projection where the lesion
appears to be the longest. (In case of a bifurcation lesion at least one of the Lesion 4
branches has a lesion length of >20mm). Segment 1: 1x2 2
+ tortuosity 2
Heavy calcification: Multiple persisting opacifications of the coronary wall vis- + Lenght 1
ible in more than one projection surrounding the complete lumen of the coro- lesion 4 score: 5
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The SYNTAX Score: an angiographic tool grading the complexity of coronary artery disease
coronary arteries with four lesions each but the calculated SYN- 7. Hueb W, Soares PR, Gersh BJ, Cesar LA, Luz PL, Puig LB, Martinez EM,
TAX score differs greatly (54.5 versus 17) reflecting the more Oliveira SA, Ramires JA. The medicine, angioplasty, or surgery study
complex pattern of coronary artery disease in the patient with the (MASS-II): a randomized, controlled clinical trial of three therapeutic
strategies for multivessel coronary artery disease: one-year results. J Am
higher score.
Coll Cardiol. 2004;43:1743-51.
1. Hamm CW, Reimers J, Ischinger T, Rupprecht HJ, Berger J, 13. Hoffman SN, TenBrook JA, Wolf MP, Pauker SG, Salem DN, Wong JB.
Bleifeld W. A randomized study of coronary angioplasty compared with A meta-analysis of randomized controlled trials comparing coronary artery
bypass surgery in patients with symptomatic multivessel coronary disease. bypass graft with percutaneous transluminal coronary angioplasty: one- to
German Angioplasty Bypass Surgery Investigation (GABI). N Engl J Med. eight-year outcomes. J Am Coll Cardiol. 2003;41:1293-304.
1994;331:1037-43. 14. Serruys PW. ARTS I - the rapamycin eluting stent; ARTS II - the rosy
2. King SB 3rd, Lembo NJ, Weintraub WS, Kosinski AS, Barnhart HX, prophecy. Eur Heart J. 2002;23:757-9.
Kutner MH, Alazraki NP, Guyton RA, Zhao XQ. A randomized trial compar-
15. Colombo A, Drzewiecki J, Banning A, Grube E, Hauptmann K,
ing coronary angioplasty with coronary bypass surgery. Emory Angioplasty
Silber S, Dudek D, Fort F, Schiele F, Zmudka K, Guagliumi G, Russell ME;
versus Surgery Trial (EAST). N Engl J Med. 1994;331:1044-50.
TAXUS-II Study Group. Randomized study to assess the effectiveness of
3. Coronary angioplasty versus coronary artery bypass surgery: the slow- and moderate- release polymer-based paclitaxel-eluting stents for
Randomized Intervention Treatment of Angina (RITA) trial. Lancet. coronary artery lesions. Circulation 2003;108(7):788-794.
1993;341:573-80.
16. Stone GW, Ellis SG, Cox DA, Hermiller J, O'Shaughnessy C,
4. Rodriguez A, Boullon F, Perez-Balino N, Paviotti C, Liprandi MI, Mann JT, Turco M, Caputo R, Bergin P, Greenberg J, Popma JJ,
Palacios IF. Argentine randomized trial of percutaneous transluminal coro- Russell ME; TAXUS-IV Investigators. A polymer-based, paclitaxel-
nary angioplasty versus coronary artery bypass surgery in multivessel dis- eluting stent in patients with coronary artery disease. N Engl J Med.
ease (ERACI): in-hospital results and 1-year follow-up. ERACI Group. 2004;350:221-31.
J Am Coll Cardiol. 1993;22:1060-67.
17. Morice MC, Serruys PW, Sousa JE, Fajadet J, Ban Hayashi E, Perin M,
5. First-year results of CABRI (Coronary Angioplasty versus Bypass
Colombo A, Schuler G, Barragan P, Guagliumi G, Molnar F, Falotico R;
Revascularisation Investigation). CABRI Trial Participants. Lancet.
RAVEL Study Group. Randomized Study with the Sirolimus-Coated Bx
1995;346:1179-84.
Velocity Balloon-Expandable Stent in the Treatment of Patients with de
6. Comparison of coronary bypass surgery with angioplasty in patients novo Native Coronary Artery Lesions. A randomized comparison of a
with multivessel disease. The Bypass Angioplasty Revascularization sirolimus-eluting stent with a standard stent for coronary revascularization.
Investigation (BARI) Investigators. N Engl J Med. 1996;335:217-25. N Engl J Med. 2002;346:1773-80.
- 226 -
Clinical research
18. Moses JW, Leon MB, Popma JJ, Fitzgerald PJ, Holmes DR, 23. Ryan TJ, Faxon DP, Gunnar RM, Kennedy JW, King SB, Loop FD,
O'Shaughnessy C, Caputo RP, Kereiakes DJ, Williams DO, Teirstein PS, Peterson KL, Reeves TJ, Williams DO, Winters WLJ. Guidelines for percu-
Jaeger JL, Kuntz RE; SIRIUS Investigators. Sirolimus-eluting stents versus taneous transluminal coronary angioplasty. A report of the American
standard stents in patients with stenosis in a native coronary artery. N Engl College of Cardiology/American Heart Association Task Force on assess-
J Med. 2003;349:1315-23. ment of diagnostic and therapeutic cardiovascular procedures (subcom-
mittee on percutaneous transluminal coronary angioplasty). Circulation
19. Serruys PW, Ong AT, Colombo A, Dawkins K, de Bruyne B, Fajadet J,
1988;78:486-502.
et al. Arterial Revascularization Therapies Study Part II: Sirolimus-Eluting
Stents for the Treatment of Patients With Multivessel de novo Coronary 24. Hamburger JN, Serruys PW, Scabra-Gomes R, Simon R, Koolen JJ,
Artery Lesions. 54 th ACC Annual Scientific Session, Orlando, USA Fleck E, Mathey D, Sievert H, Rutsch W, Buchwald A, Marco J, Al-Kasab SM,
2005;Sunday, Mar 06, 2005. Pizulli L, Hamm C, Corcos T, Reifart N, Hanrath P, Taeymans Y.
Recanalization of total coronary occlusions using a laser guidewire (the
20. American Heart Association Grading Committee. Coronary Artery
European TOTAL Surveillance Study). Am J Cardiol. 1997;80:1419-23.
Disease Reporting System. Circulation 1975;51:31-3.
25. Topol EJ. Textbook of interventional cardiology, 3rd ed.
21. Serruys PW, Unger F, van Hout BA, van den Brand MJ, van
Philadelphia: WB Saunders Co.;1998. p 728.
Herwerden LA, van Es GA, Bonnier JJ, Simon R, Cremer J, Colombo A,
Santoli C, Vandormael M, Marshall PR, Madonna O, Firth BG, Breeman A, 26. Lefevre T, Louvard Y, Morice MC, Dumas P, Loubeyre C,
Morel MA, Hugenholtz PG. The ARTS study (Arterial Revascularization Benslimane A, Premchand RK, Guillard N, Piechaud JF. Stenting of bifur-
Therapies Study). Semin Interv Cardiol. 1999;4(4):209-19. cation lesions: classification, treatments, and results. Catheter Cardiovasc
Interv. 2000;49:274-83.
22. Leaman DM, Brower RW, Meester GT, Serruys P, van den Brand M.
Coronary artery atherosclerosis: severity of the disease, severity of angina
pectoris and compromised left ventricular function. Circulation.
1981;63(2):285-99.
- 227 -