Coronary Stents: Past, Present and Future

Transcription

1 Kardiologie Kardio Lunch Coronary Stents: Past, Present and Future Christoph Kaiser Universitätsspital Basel

2 Rubin GS, The first balloon-expandable coronary stent, University of Queensland Press 2014 Modified from Nabel and Braunwald s A Tale of Coronary Artery disease and Myocardial Infarction

3 The Stent: a Metal Prosthesis Roguin A, Circ Cardiovasc Interv 2011;4:206-9

4 The Stent: a Metal Prosthesis Roguin A, Circ Cardiovasc Interv 2011;4:206-9

5 The Stent: a Metal Prosthesis Johannes Fredericus Esser Stenting of facial wounds

6 Rubin GS, The first balloon-expandable coronary stent, University of Queensland Press 2014

7 The Stent: a Metal Prosthesis Word stent was used the first time March 28 th, 1986 first coronary stent implanted Roguin A, Circ Cardiovasc Interv 2011;4:206-9

8 Interventional cardiology in Switzerland

9 Interventional cardiology in Switzerland n= 34.

10 The Achilles Heel of Coronary stenting: In-Stent- Restenosis 20-30%

11 In-Stent- Restenosis: Therapeutic Approaches Kryotherapy Thermotherapy Light Therapy Sonotherapy Brachytherapy

12 In-Stent- Restenosis: 2002: Drug-eluting Stent SIRIUS Moses J et al. N Engl J Med 2003;349:

13 In-Stent- Restenosis: 2002: Drug-eluting Stent

14 2006: ESC Firestorm BASKET-LATE Pfisterer et al, J Am Coll Cardiol 2006;48:

15 2006: ESC Firestorm Sonntagszeitung, September 10th, 2006

16 What s different in 2nd generation DES? New platforms and alloys (Cobalt-chromium, thinner struts) New drugs (Everolimus, Biolimus, Zotarolimus, no Paclitaxel) Less drugs, different release-kinetics New polymers, biodegradable polymers Progress in implantation techniques

17 Progress with 2nd generation DES BASKET-PROVE II Kaiser C. et al. Circulation 2015;131:74-81

18 Progress with 2nd generation DES BASKET-PROVE II Kaiser C. et al. Circulation 2015;131:74-81

19 Progress with 2nd generation DES BASKET-PROVE II Kaiser C. et al. Circulation 2015;131:74-81

20 Results with contemparary DES EES: TVR non-mi-related: 3,1 % ST: 0.7% Stone G, N Engl J Med 2007; Kaiser C et al, Circulation 2015;131:74-81

21 DES Today Today

22 What about good old BMS? 2006

23 6-9 month TVR (%) What about good old BMS? 25 BMS Trials DES Trials RAVEL (Bs Velocity) 20 TAXUS V (EXPRESS II) BASKET (MLVISION) DELIVER (ML Penta) TAXUS VI (EXPRESS) SIRIUS (Bx Velocity) 5 0 Stent- PAMI (PS) EPISTENT (PS) Stent strut thickness (μm) Tung R, et al. Ann Int Med, 2006;44:913-19; interpreted by C. Lotan, TCT 2007.

24 DES: unmet needs I Ectatic vessels, bypass grafts, high thrombus burden..

25 Bifurcations. DES: unmet needs II

26 Drawbacks of DES (Late) Stent thrombosis Metal Jacket Stiffness Loss of Vasomotion Psychology (foreign body) CT-Visibility Khouzam RN et al. J Am Coll Cardiol 2010;56:1605

27 The Future: Biodegradable Stents?? Poly Lactic Acid Sacaffolds (ABSORB: Abbot-Vascular)

28 Baseline 6 Months 2 Years 5 Years De Bruyne, B. TCT 2014 Cohort B OCT images - courtesy of RJ van Geuns, Erasmus Medical Center, Netherlands

29 ABSORB: How solid are the data? Observational Randomized Registry De Bruyne, B. TCT 2014 Cohort B OCT images - courtesy of RJ van Geuns, Erasmus Medical Center, Netherlands

30 ABSORB III Ellis SG,et al, N Engl J Med 2015;

31 GHOST Registry (n=1 189) BASKET-PROVE-II (12 Months) EES: 3,1 % 0.7% Capodanno D. et al. Eurointervention 2015; 10: Kaiser C, et al. Circulation 2015;131:74-81

32 The Future: Biodegradable Stents?? Windecker S et al, J Am. Coll Cardiol 2015

33 The Future: Biodegradable Stents??

34 Today ABSORB Stents Today

35 The Future: Biodegradable Stents?? J Int. Cardiol 2004

36 The Future: Biodegradable Stents?? n=123 Primary EP: 6 months Haude M, et al. Lancet 2016;387:31-29

37 Today Magnesium bioabsobable scaffolds today

38 Conclusions As long as we implant stents in coronary arteries, we will face restenosis and stent thrombosis in rare cases. Due to impressive improvements in stent design, polymers, drugs and implantation techniques during the last years, new generation DES have nearly reached a highest possible level of effectiveness and safety. Differences in effectivenes and safety between the currently available DES are small and not clinically relevant for the individual patient. Therefore, industry and investigators should stop to spend enormous resources in trials comparing these devices. Compared to the early DES-trials, current BMS achieve much better results and may still be used - however, with a higher TVRrate.

39 Conclusions Biabasorbable scaffolfds are a new promising technology with satisfactory acute results. Safety, however, is still of concern and randomized data are poor. DES BMS Mg-Scaffolds ABSORB

40 Thank You For Your Attention!