TLR des Stents Actifs

Transcription

1 TLR des Stents Actifs

2 No Conflict of Interest

3 Target Lesion Revascularization DES vs BMS Stettler C et al. Lancet 2007;370: N=18,023 58% 70% SES vs BMS: HR=0.30 ( ), p< PES vs BMS: HR=0.42 ( ), p< SES vs PES: HR=0.70 ( ), p<0.0021

4 BMS PES SES Target Lesion Revascularization Network Meta-Analysis: DES vs BMS Stettler C et al. Brit Med J 2008 Diabetic Patients N=3,853 BMS PES SES Non-Diabetic Patients N=10, SES vs BMS: 0.29 (0.19,0.45) PES vs BMS: 0.38 (0.26,0.56) SES vs PES: 0.78 (0.50,1.14) Years SES vs BMS: 0.29 (0.19,0.42) PES vs BMS: 0.46 (0.32,0.60) SES vs PES: 0.64 (0.49,0.84) Years BMS PES SES

5 Definitions and Classification of Restenosis

6 Ischemia Driven Repeat Revascularization Diameter stenosis 50-69% and one of the following: Recurrent angina pectoris Objective signs of ischemia at rest (ECG changes) or during exercise test (or equivalent), presumably related to target vessel Abnormal results of any invasive functional diagnostic test FFR 0.80) or IVUS minimum cross-sectional area 4 mm2 (and 6.0 mm2 for left main stem) TLR with diameter stenosis 70% even in absence of the above ischemic signs or symptoms Dangas GD et al. JACC 2010;56;

7 Mechanisms of DES Restenosis Biological Factors Drug Resistance Hypersensitivity Clinical presentation of DES ISR Usually recurrent angina Some patients present with ACS Mechanical Factors Stent Underexpansion Nonuniform Stent Strut Distribution Stent Fracture Nonuniform Drug Elution/Deposition Polymer Peeling Technical Factors Dangas GD et al. JACC 2010;56; Barotrauma Outside Stented Segment Stent Gap Residual Uncovered Atherosclerotic Plaques

8 Predictors or ISR/TLR after DES Implantatuion Dangas GD et al. JACC 2010;56;

9 Morphologic Pattern of DES-Restenosis: Sirolimus Eluting Stent (Cypher) Majority of ISR focal Dangas GD et al. JACC 2010;56;

10 Morphologic Pattern of DES-Restenosis: Paclitaxel Eluting Stent (Taxus) ISR ½ focal ½ nonfocal Dangas GD et al. JACC 2010;56;

11 ISAR-DESIRE 2: SES vs. PES for DES Restenosis 450 pts with in-ses restenosis Randomized to SES vs. PES Primary endpoint LLL at 6-8 months Mehilli J et al. JACC 2010;55:2710-6

12 Outcomes After Percutaneous Treatment of DES Restenosis Dangas GD et al. JACC 2010;56;

13 Algorithm for the Treatment of DES Restenosis Consider IVUS DEB not tested for DES-ISR! Dangas GD et al. JACC 2010;56;

14 2010 ESC EACTS Revascularization Guidelines

15 Have Newer Genera+on DES Improved Clinical Outcome? Safety Efficacy

16 Comparison of Everolimus Elu+ng and Paclitaxel Elu+ng Stents Meta Analysis of SPIRIT II, III, IV and COMPARE Clinical Outcomes Up to 3 Years TLR Cardiac Death or MI Year 1 Year 2 Year 3 Overall 0.49 ( ) 0.83 ( ) 0.44 ( ) 0.51 ( ) Year 1 Year 2 Year 3 Overall 0.65 ( ) 0.56 ( ) 0.54 ( ) 0.63 ( ) Favors EES Favors PES Favors EES Favors PES 6,789 Patients Jüni, Windecker

17 Everolimus Elu+ng vs Zotarolimus Elu+ng Endeavor Resolute Stent Serruys PW et al. N Engl J Med 2010 Target Lesion 1 Year Cardiac Death or 1 Year

18 TLR/ISR Conclusions TLR reduced by 60-70% with DES vs. BMS. DES ISR 3%-20% depending on patient/lesion characteristics and DES type. TLR with newer vs. first generation DES further reduced. Clinical presentation of DES ISR is usually recurrent angina while some patients present with ACS. Mechanisms of DES ISR can be biological, mechanical, and technical, and its pattern is predominantly focal. Best treatment option for DES-restenosis remains to be determined (newer generation DES, DEB). CABG is reserved for diffuse and repetitive ISR, especially in multivessel disease.