Treatment Strategies for Long Lesions of greater than 20 cm
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1 Treatment Strategies for Long Lesions of greater than 20 cm Donald L. Jacobs, MD C. Rollins Hanlon Professor and Chair Chair of the Department of Surgery Saint Louis University
2 Disclosure Speaker name: Donald Jacobs, MD... I have the following potential conflicts of interest to report: x Consulting: Abbott Employment in industry Stockholder of a healthcare company Owner of a healthcare company I do not have any potential conflict of interest
3 The challenge of long lesions Significant progress had been made in the endovascular treatment of long lesions Acute technical success Very high and fairly well defined Long term success Not as well known Multiple variables impacting on results Variable patient populations Variable anatomic location, mechanics Calcification Evolving technique/tools limited follow up
4 Durability 200 Long stent data Bare nitinol stent (protégé) 100 patients mean lesion 24.2 cm (range 16 45) 1 yr freedom from TLR 68.2% 1 yr primary patency 64.8% Viastar Viaban vs bare nitinol stent 141 patients randomized Mean lesion length 19.0 and 17.3 respectively 1 yr freedom from TLR 85% and 77% respectively 1 yr primary patency 78% and 54% respectively Bosiers M et al. J Vasc Surg. 2011;54: Lammer Jm et al, J Am Coll Cardiol. 2013;62:
5 DES in long lesions Zilver PTX single arm registry 135 patients Mean lesion length 22.6 cm 1 yr primary patency 77.6% 1 yr freedom from TLR 85.4% Bosiers, et al. J Cardiovasc Surg 54: Interwoven nitinol in long lesions Supera 500 registry 492 limbs Mean lesion length 12.6 cm 1 yr primary patency 83.3% 2 yr primary patency 72.8% SUPERB trial long lesion subset 87 pts in top tercile length Mean lesion length 12.6 cm 1 yr primary patency 88% 1 yr freedom from TLR Werner A, et al. EuroIntervention 2014:10: Rosenfield K, et al. Circ Cardiovasc Interv. 2015;8:e
6 Atherectomy for long lesions Limited data Relatively low patency Significant procedural time/radiation Significant risk of embolization Atherectomy and DCB Not yet defined but good data on mid range lesions in some reports But above risks persist with added cost concerns
7 DCB vs DES in long lesions Propensity based analysis to define similar cohorts in a real world experience Lesion length DCB N= /- 8.6 cm DES N= /- 6.5 cm Restenotic lesions 52% 44% Total occlusion 53% 63% Zeller T, et al. Journal of Endovascular Therapy. 21(3):359-68, 2014 Jun.
8 DCB and DES in long lesions 12 month follow up Restenosis PSV >2.4 DCB N=131 DES N=97 24% 30% TLR 16% 19% Zeller T, et al. Journal of Endovascular Therapy. 21(3):359-68, 2014 Jun.
9 Saint Louis University Experience with Interwoven Nitinol Stenting in Femoral-Popliteal Lesions Retrospective review April 2010 and December limbs in 48 patients Mean follow up of months Median follow up of 30 months Clinical follow up: clinical interview, ABIs, and duplex US Brescia, et al, Stenting of femoropopliteal lesions using interwoven nitinol stents Journal of Vascular Surgery Volume 61, Issue 6, Pages
10 Selected sub-set of data on lesions > 10 cm length from Brescia et al data on interwoven nitinol stents Lesion length Re-stenotic lesions Total occlusions DES N= /- 6.5 cm DCB N= /- 8.6 cm Woven nitinol N= /- 9.8 cm 44% 52% 44% 63% 53% 81% TLR 16% 19% 16% Mean FU of 27 months Brescia, et al, Journal of Vascular Surgery 61(6): , April, 2014
11 Superb Trial impact of lesion length Percent of Lesions without Restenosis by Lesion Length (12 months SUPERB IDE Trial) 100% 88% 85% 88% 50% 0% Shortest Lesions (35.4±12.3cm) Middle Lesions (73.5±10.8cm) Longest Lesions (126.1±33.4cm)
12 Saint Louis University experience with interwoven nitinol stents: Outcomes by lesion length < 15 cm (n=18) Primary patency 72.3% (13) Primary assisted patency 88.9% (16) Secondary patency 94.4% (17) cm (n=18) 83.3% (15) 88.9% (16) 88.9% (16) > 30 cm (n=18) 83.3% (15) 88.9% (16) 94.4% (17) 27 month mean and 30 month median follow up Brescia, et al, Journal of Vascular Surgery 61(6): , April, 2014
13 Summary Long lesions can be treated endovascluarly with good results using DES, DCB and interwoven nitinol showing similar 1 year results Interwoven nitinol stents show less impact of lesion length on patency With correct vessel preparation and technique, interwoven nitinol stents can provide a unique fracture free, calcium resistant, non drug dependent device for long term patency in long lesions
14 Treatment Strategies for Long Lesions of greater than 20 cm Donald L. Jacobs, MD C. Rollins Hanlon Professor and Chair Chair of the Department of Surgery Saint Louis University
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