prediction of restenosis after pci with contemporary drug-eluting stents
Post on 16-Apr-2015
7 Views
Preview:
DESCRIPTION
TRANSCRIPT
H E A R T I N S T I T U T E
H E A R T I N S T I T U T E
Prediction of restenosis after PCI with contemporary drug-eluting stents
DR. ASHOK SETH
FRCP (LOND), FRCP (EDIN), FRCP (IREL), FACC, FSCAI, FCSI, DSc.
CHAIRMAN CHIEF OF CARDIOLOGY
CHAIRMAN – CARDIOLOGY COUNCIL, FORTIS GROUP OF HOSPITALS
FORTIS ESCORTS HEART INSTITUTE
PRESIDENT – CARDIOLOGICAL SOCIETY OF INDIA
H E A R T I N S T I T U T E
Restenosis After BA and Stent
• Most significant problem for years • DES have dramatically reduced instent
restenosis. • Low rates of ISR in DES still a problem.
H E A R T I N S T I T U T E
Classification of Restenosis (Mehran et al. Circulation 1999;100:1872-8)
H E A R T I N S T I T U T E
Incidence of DES ISR
5-6%
11-12%
6-7%
0%
2%
4%
6%
8%
10%
12%
Native Denovo Lesion 1st Gen DES
Real Life Patients 1st Gen DES
Real Life Patients 2nd Gen DES
H E A R T I N S T I T U T E
Delayed Restenosis • Late ‘Catch Up’
Modest increase in NIH beyond 1-year on IVUS study follow up.
– Delayed healing response – Persistent biological reaction – Hypersensitivity reaction to durable polymer
‘Therefore longer term follow up’
H E A R T I N S T I T U T E
Stent Thrombosis vs Restenosis
• ISR Presents as effort angina while stent thrombosis usually presents MI.
• TVF within 30-days is usually stent thrombosis while ISR is usually later.
• DES has delayed the time frame of ISR • Both ISR and Stent thrombosis may co-exist.
H E A R T I N S T I T U T E
Definitions and Classification of Restenosis and Stent Thrombosis
Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907
H E A R T I N S T I T U T E
Possible Mechanisms of Restenosis After DES Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907
H E A R T I N S T I T U T E
Biologic Factors
• Drug Resistance • Hyper sensitivity
– Allergy to Nickel / Molybdenum of 316 to stenosis steel.
– RADAR STUDY (Research on Adverse Drug / Device Adverse Reports) - Drug Hypersensitivity for DES.
H E A R T I N S T I T U T E
RADAR (Research on Adverse Drug Events & Reports)
(Nebeker JR et al. J Am Coll Cardiol 2006;47:175-181)
• 5783 AE after DES • 261 Hypersensitivity Reaction • 17 DES cause of HS • 4 Died of stent thrombosis between
4-18 months
H E A R T I N S T I T U T E
H E A R T I N S T I T U T E
Mechanical Factors (Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907)
Stent Under expansion
H E A R T I N S T I T U T E
Mechanical Factors (Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907)
Stent Fracture • Incidence: 2-8%
• Rigid closed cell stents, overlapping stents, longer stents, vessel tortuousity, angulation and torsion
H E A R T I N S T I T U T E
Technical Factors • ‘Geographical Miss’ • Uncovered atherosclerotic plaque
• Baro trauma outside stented segment
H E A R T I N S T I T U T E
Technical Factors • Stent Gap
• Gap between two overlapping stents
• Bends and Curves
H E A R T I N S T I T U T E
Predictors of ISR or TLR After DES Implantation Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907
H E A R T I N S T I T U T E
Risk Scoring to Predict TLR in DES (Stolker et al. Circ Cardiovasc Interv. 2010;3:327-334)
H E A R T I N S T I T U T E
Predictors of DES Restenosis (Corbett et al. Circulation. 2006;114:II_688)
• 2269 lesions 1283 patients (2003-2005) • Angio FU 70% DES ISR : SES 16.9% : PES 16.8%
H E A R T I N S T I T U T E
Morphologic Pattern of SES, PES, and BMS ISR Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907
H E A R T I N S T I T U T E
Clinical and Angiographic Outcomes After Percutaneous Treatment of DES ISR
Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907
H E A R T I N S T I T U T E
Morphological Pattern of Restenosis as a Predictor of Repeat ISR after DES ISR Treatment
(Dangas et al. JACC 2010; 56: 1897-907)
18%
57%
10%
23%
0%
10%
20%
30%
40%
50%
60%
Focal ISR Non Focal ISR
Repeat ISR TLR
DES ISR
H E A R T I N S T I T U T E
Treatment of DES ISR ‘Difficult Disease Process’
• IVUS or other imaging essential to understand the underlying mechanism.
• OPTIONS – Balloon angioplasty – DEB – DES : Same DES : Different DES – VBT – CABG
H E A R T I N S T I T U T E
Algorithm for the Treatment of DES Restenosis Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907
H E A R T I N S T I T U T E
Conclusion • Though DES has lowered the restenosis rates of PCI, the
increased complexity of lesions being treated has resulted in DES ISR being an important problem.
• The predictors of restenosis in DES era are similar to the BMS era, but DES ISR can occur later and tends to be more focal and this has a better prognosis than BMS ISR.
• Diffuse DES ISR is a very ‘difficult animal’ as the pathophysiology and causative mechanism of DES ISR are in many cases unclear and hence treatment options are ‘hit and trial’.
• Further studies new DES and Bioresorbable stents are on the way to overcome this important problem.
top related