Αγγειοπλαστική σε Eπαναστενωτικές Bλάβες
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1 Αγγειοπλαστική σε Eπαναστενωτικές Bλάβες Βάιος Π. Τζίφος Δ/ντής Γ Καρδιολογικής Κλινικής - Επεμβατικής Καρδιολογίας. Ερρίκος Ντυνάν HC
2 The Mehran s Classification for BMS-ISR Prognostic Value Pattern (1) Need for Repeat Revascularization (2) I (Focal) 19 % II (Diffuse) 35 % III (Proliferative) 50% IV (Occlusive) 98% 1. Mehran R et al. Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome. Circulation Nov 2; 100(18): Solinas E et al Angiographic patterns of drug-eluting stent restenosis and one-year outcomes after treatment with repeated percutaneous coronary intervention. Am J Cardiol Aug 1; 102(3):311-5.
3 Optimize the Treatment of ISR 1: Operator or Technique Dependent Stent undersizing, Incomplete lesion coverage, Stent under expansion, Stent malposition 2: Stent mechanical properties Recoil because of loss of radial force, Stent fractures, and altering increase in shear stress 3: Patient- and biological conditions 4: BMS or DES Metal allergy, Local inflammatory response to the drug or the polymer, rigid scar tissue within the stent or neoatherosclerosis, which can occur years after stent placement.
4
5 BMS - ISR vs DES - ISR Diffuse 6m DM is Independent Predictor of ISR Easier to Treat Better FU Focal 2-5 y (Early & Late) DM is Independent Predictor of ISR More Challenging to Treat Unsatisfactory FU
6 Neoatheromatosis: Presentation & Predictors Acute clinical presentation secondary to neoatherosclerotic plaque rupture and thrombus formation. Late stent thrombosis is related to neoatheromatosis? Younger age Longer stent age ( 48 months) Sirolimus-eluting stent or Paclitaxel-eluting stent Active smoking Chronic kidney disease Angiotensin-converting enzyme LDL-cholesterol levels above 70 mg/dl The pathology of neoatherosclerosis in human coronary implants bare-metal and drug-eluting stents. J Am Coll Cardiol Mar 15; 57(11): Therapeutic Options for In-Stent Restenosis.Nicolais C, Lakhter V, Virk HUH, Sardar P, Bavishi C, O'Murchu B, Chatterjee S Curr Cardiol Rep Feb 12; 20(2):7..
7 Optimize the Treatment of ISR Attempts Over the Years: High-pressure balloons, Scoring and cutting balloons, Ablative therapy with laser directional, and rotational atherectomy, etc Local drug-delivery strategies Brachytherapy, restenting with same or different DES, and drug-coated balloons (DCB)
8 Balloon Angioplasty Versus Elective Sirolimus- Eluting Stenting (RIBS II) TAXUS V ISR Intracoronary Stenting or Angioplasty for Restenosis Reduction-Drug-Eluting Stents for In-Stent Restenosis (ISAR-DESIRE) Rotational Atherectomy Versus Balloon Angioplasty for Diffuse In-Stent Restenosis (ROSTER)
9 A Meta-analysis on different strategies for the treatment of ISR 5,923 patients from 27 trials with a follow-up ranging from 6 to 60 months. Primary endpoint: The most effective treatment for % diameter stenosis angio FU. Everolimus-eluting stents difference = 9.0% (95% CI to -2 2) diameter stenosis vs. DCB, 9.4% (-17 4 to -1 4) vs. Sirolimus-eluting stents, 10.2% (-18 4 to -2 0) vs. Paclitaxel-eluting stents, 19.2% (-28 2 to -10 4) vs. Brachytherapy, 23.4% (-36 2 to -10 8) vs. BMSs, 24.2% (-32 2 to -16 4) vs. Balloon Angioplasty 31.8% (-44 8 to -18 6) vs. Rotablation. - BVS? Siontis GC et al. Percutaneous coronary interventional strategies for treatment of in-stent restenosis: a network meta-analysis Lancet Aug 15; 386(9994):
10 ESC Myocardial Revascularization 2018
11 Optimize the Treatment of ISR Rather than focusing on how to improve the treatment of DES- ISR, our efforts should be directed to prevention of DES-ISR. Optimal stent deployment, including imaging-guided implantation by intravascular ultrasound or optical coherence tomography and Vessel preparation Adequate coverage of the lesion Verifying stent expansion and apposition to the vessel wall. Reducing the strut thickness and eliminating the polymer could further reduce the restenosis rates of DES.
12 #1: Neoatheromatosis or Late ISR Treated with DES-> CB-DCB + DES Dec. 2015, W, 45 yo, DM, Previous PCI ( RCA), ACS
13 #1: Neoatheromatosis or Late ISR Treated with DES-> CB-DCB + DES DES (BP) 3.0/ /24mm
14 #1: Neoatheromatosis or Late ISR Treated with DES-> CB-DCB + DES Final Result
15 #1: Neoatheromatosis or Late ISR Treated with DES-> CB-DCB + DES Oct.2018, UA minimal effort
16 #1: Neoatheromatosis or Late ISR Treated with DES-> CB-DCB + DES Pantera DCB 3.0/25, 2.5/30mm + DES (BP) 3.0/22mm
17 #1: Neoatheromatosis or Late ISR Treated with DES-> CB-DCB + DES Final Result
18 #2: Neoatheromatosis Treated with CB + BVS May 2005, M, 43 (actual age 55) yo, Smoker, Dyslipidemic, ACS
19 #2: Neoatheromatosis Treated with CB + BVS 2 Cypher Stents 3.5/33mm + 3.0/13mm (Crush Technique)
20 #2: Neoatheromatosis Treated with CB + BVS 2 Cypher Stents 3.5/33mm + 3.0/13mm (Crush Technique)
21 #2: Neoatheromatosis Treated with BVS Final Result (2005)
22 #2: Neoatheromatosis Treated with CB + BVS Sept. 2017, UA.
23 #2: Neoatheromatosis Treated with CB + BVS 3.5/10MM CB PCI
24 #2: Neoatheromatosis Treated with CB + BVS Post CB Result
25 #2: Neoatheromatosis Treated with CB + BVS MAGMARIS BVS 3.5/20mm
26 #2: Neoatheromatosis Treated with CB + BVS Final Result
27 #2: Neoatheromatosis Treated with CB + BVS Sept. 2018: Angio FU
28 # 3: Late ISR Treated with CB + DES M, 68 yo, DM (oral), stable angina, 2VD, previous (2017) PCI (LAD, RCA crux)
29 # 3: Late ISR Treated with CB + DES
30 # 3: Late ISR Treated with CB + DES 3.5/10mm CB,
31 # 3: Late ISR Treated with CB + DES 3.5/10mm CB, 3.0/24mm (BP) DES
32 # 3: Late ISR Treated with CB + DES 3.5/10mm CB, 3.0/24mm (BP) DES, Final Kiss
33 # 3: Late ISR Treated with CB + DES Final Result
34 Conclusion Treatment of DES in-stent restenosis remains challenging and associated with poorer clinical and angiographic results than treatment of bare-metal stent in-stent restenosis, further studies including more patients and longer follow-up are still warranted in this adverse setting. + In our days personalized treatment modalities can improve acute and hopefully long term results in patients with ISR. Alfonso F,et al. A Prospective Randomized Trial of Drug-Eluting Balloons Versus Everolimus-Eluting Stents in Patients With In-Stent Restenosis of Drug-Eluting Stents: The RIBS IV Randomized Clinical Trial. J Am Coll Cardiol Jul 7; 66(1):23-33.
35 Ευχαριστώ πολύ για την προσοχή σας.
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