in stent restenosis in the des era - greek cardiology · 2015-10-07 · in stent restenosis in the...
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IN STENT RESTENOSIS IN THE DES ERA
EFTIHIA SBAROUNI, FESC, FACC
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DES ISR
• 5-10% overall, 10-20%recurrent ISR
• Low rate but not benign
• Outcomes worse with DES ISR vs
BMS ISR
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Differences BMS and DES restenosis
• Diffuse pattern more
common
• LL max by 6-8 months
• Endothelialization 3-6
months
• Neoatheroscalerosis
infrequent, late
• Focal pattern more
common
• LL up to 5 yrs
• Endothelialization up to 48
months
• Neoatheroscalerosis
frequent, early
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Rittger H et al. JACC 2012;59:1377-82
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DEB for ISR (1)
• 436 DES and 114 BMS
• Early angio (6-12 months, 89% lesions)
• Late angio (12-24 months, 88% lesions)
• Early:21.1% vs 13%, TLR:13.9% vs 7%
• Late:16.8% vs 2.5%, TLR 24.2% vs 8.7%
• No difference between 1st and 2nd
generation
Habara et al. JACC 2015;66:14-22.
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DEB for ISR (2)
Early
<2.5mm
% diameter stenosis post-PCI
In-stent occlusion
Late
DES-ISR
Hemodialysis
% diameter stenosis at early angio
Habara et al. JACC 2015;66:14-22.
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DEB
• Predilation
• Balloon length to cover 2mm at both
proximal and distal margins
• Inflation time for 60 seconds
• No post-dilation
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Unanswered qs for DEB
• ? Better lesion preparation with
cutting balloon
• ? Limus more effective
– Superior antiproliferative with metal
stents
• Duration of DAPT
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Cutting and scoring balloon
• Cutting
– Simple
– Avoids balloon slippage outside stent
– Deep incision
• Scoring
– More flexible and deliverable
• RESCUT: BMS ISR cutting vs BA similar results
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Song H-J et al JACC 2012;59:1093-100
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ISAR-DESIRE-2
JACC 2010;55:2710-6
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ISAR-DESIRE-2
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Torguson r et al AJC 2006;98:1340-4
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Brachytherapy
• Brachyterapy superior to BA and ablation
• Issues – geographic miss,
– Edge restenosis
– delayed healing
• SISR,TAXUS V ISR: BMS ISR DES vs radiation. DES better
• Meta-analysis DES vs BT ISR: no difference in AMI, death, TLR
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Rotablation
• Only BMS diffuse ISR
– ROSTER (small single center) BA vs
rota positive
– ARTIST (large multi-center) BA vs rota
negative
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11 RCT’s for ISR
• BMS and DES
• Superiority DEB and DES vs POBA
• DEB vs DES
– Comparable efficacy (TLR)
– Trend for lower risk of AMI and all cause
mortality for DEB
Lee et al JACC cardiovasc interv 2015;8:382-94.
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Network meta-analysis
• 27 trials, 5932 pts, 6-60 months f/up
• 17 BMS, 10 DES
• 2001-2014
• EES, PCB, SES, PES, VBT, BMS, BA, ROTA
• EES: restenosis, TLR
• PCB:2nd best (similar to SES, PES but without new layer)
Siontis et al; Lancet 2015:386:655-64
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Kawamoto et al. JACC interv 2015
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Kawamoto et al. JACC interv 2015
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Kawamoto et al. JACC interv 2015
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Kawamoto et al. JACC interv 2015
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Conclusions
• DES ISR rare but more complex
• DES ISR DES or DEB
– Better than POBA
– Always IVUS
– DEB: less metal layers, less DAT, large side branch,
multiple times
– DES: better acute gain (large volume of hyperplastic
tissue), stent fracture, edge restenosis, suboptimal
result post DEB
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Recurrent ISR DES
• 2008-2013
• 171 lesions
• 82 → 2nd gen DES, 68 → DCB
• Acute gain 2.09±0.53 mm vs 1.60±0.62 mm, p<0.001
• MACE 14% vs12.3% at 1 yr, ns
• MACE 28.8%43.5% at 2 yrs, ns
• Mostly TLR (ns)
• Lesion length, early recurrence (within 1 year) independent predictors
Kawamoto et al; JACC card interv 2015:
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BMS ISR
• RIBS I
– BA VS BMS: no difference
• ISAR DESIRE
– SES VS PES VS BA : BA worse
• RIBS II
– SES VS BA :BA worse
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BMS vs DES
Reduction of TLR but prolonged DAT
One month for BMS
Twelve months for DES
Useful for subsets with high risk of
restenosis
LMS, SVG, DM, ISR, bifurcation lesions,
small vessels, long lesions, multiple
lesions
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DES STENTS
• 1ST generation
– SES not manufactured
– PES inferior (thrombosis, TLR)
• 2nd generation
– Everolimus
– Zotarolimus
- Better than 1st generation (safer, more
effective)
- Comparable efficacy and safety
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ISR-general
• incidence
– BMS era ISR:20-40% of all PCI’s
– DES era ISR:3-20%
• Clinical presentation
– BMSUA 26-53%, AMI 5-20%
– DESUA 16-66%, AMI 1-20%
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Cosgrave J et al JACC 2006;47:2399-404
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Kandzari et al JACC interv 2011
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Byrne et al JACC 2011
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DES ISR
• Low rate but not benign
• Outcomes worse with DES ISR vs
BMS ISR
• Multiple mechanisms
– Stent underexpansion, stent fracture
– Residual uncovered atheroma
– Tissue hyperplasia (resistance to drug,
nonuniform drug deposition, or
hypersensitivity to stent)
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ISAR DESIRE-2
• PES vs SES for SES ISR
– Similar results
– JACC 2010;55:2710-6.
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Habara S JACC interv 2011;4:149-54
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PEPCAD-DES
• PCB vs POBA for DES ISR
– PCB better
– JACC 2012 ; 59: 1377-82
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ISAR-DESIRE 3
• PCB vs POBA vs PES for SES ISR
– DEB better than POBA
– DEB similar to PES
– LANCET 2013; 381:461-7.
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Unanswered qs for DES
• Bioresorbable scaffolds
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Cosgrave J et al Am H J 2007;153:354-9
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Carg S et al CCI 2007;70:9-14
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RIBS IV
• DEB vs EES for DES ISR
– EES better
– JACC 2015;66:23-33.
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PCI
• POBA vs BMS
• Treatment of
abrupt closure
• Reduction of
restenosis
• BMS vs DES
• Reduction of
restenosis but
prolonged DAPT
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BMS
• High bleeding risk
• Pending surgery
• Non-compliance
• Low restenosis risk in large vessels
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Restenosis definition
• >50% diameter stenosis at the stent
or its edges (5mm adjacent to the
stent)
• 12% for DES if routine angiography
• Severity and pattern
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Mehran et al Circulation 1999;100:1872-78
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Cosgrave J et al 2006;47:2399-404
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Costa et al AHJ 2007;153:447-9