What Stent to Use? JASVINDAR SINGH MD, FACC
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1 What Stent to Use? JASVINDAR SINGH MD, FACC ASSOCIATE PROFESSOR OF MEDICINE WASHINGTON UNIVERSITY IN ST. LOUIS DIRECTOR, CARDIAC CATHETERIZATION LAB BARNES-JEWISH HOSPITAL
2 What Stent to Use? Jasvindar Singh, MD Disclosure Research /Grant support: Volcano Corp., Abbott Vascular, Medtronic Vascular, Boston -Scientific Consulting: Volcano Corp, Trireme Medical Boston-Scientific, Abbott Vascular, Medtronic Vascular, Spectranetics
3 Outline Introduction Clinical scenarios Anatomic Subsets Future Questions and discussion
4 Current Stents
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8 Expectations of Stent Technology Efficacy Deliverable Low TLR Low Restenosis Low Late Lumen Loss Cost-Effective Safety No Device Malfunction No Early MACE Q AMI Non-Q AMI No Stent Thrombosis
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10 1 st Generation DES Cypher and Taxus Stents Both Effectively Reduce TLR
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16 2 nd Generation and beyond
17 Clinical Scenarios ACS STEMI Diabetes ESRD Patients on Chronic anticoagulation Patients Pre-op for non cardiac surgery
18 ACS-STEMI
19 ACS- STEMI
20 Diabetes
21 Diabetes
22 Other areas of concern Pts on anticoagulation
23 Left Main
24 Bifurcation Square struts Round struts
25 Bifurcation
26 Ostial Closed cell Radioopacity Structural integrity Radial strength Expansion
27 Tortuosity
28 Stent fracture
29 Stent Fracture
30 Instent Restenosis (ISR)
31 Which Design in Which Patients Superior Scaffolding, large vessel,bulky lesions, SVGs, tortuosity Uniform Side Branch expansion / less distorsion Better Side-Branch Access, smaller vessels(better M/A ratio_
32 Current DES Market Efficacy Safety Data Performance D* S* B* Xience (EES) Taxus ION (PES) Promus Premier (EES) Endeavor (ZES 1) Resolute (ZES 2) *D- deliveribility *S-structural Integrity *B- bifurcation SB access
33 Choosing DES in 2015 Lesion subsets Left Main (Body or Distal) : Promus / Xience /Resolute Ostial LM /RCA: Cypher, now Xience / Resolute Calcified : Promus Premier / Resolute/ Xience Severe Tortuosity : Promus /Resolute / Xience Bifurcation : Resolute / Xience/ Promus Diabetes: EES (Promus/Xience)/Resolute / Taxus ION STEMI: EES (Xience/Promus) / Resolute/ Taxus/Endeavor/BMS Bulky Lesion / SVGs: Resolute /Promus / Xience
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36 How do a drug + DURABLE polymer coating affect the healing cascade? Bare Metal Stents Drug minimizes restenosis Durable polymer may delay healing Increase DAPT duration Increased risk of late events DURABLE Polymer DES Minimizes Restenosis + Reduces DAPT + Reduces Late Events BIOABSORBABLE Polymer DES? Adapted from Drug-eluting stents, delayed healing, and hypersensitivity reactions, Cardiovascular News, Sept IC AB FEB2015 Page 36
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38 SYNERGY Stent Technology Design Goals Drug & Polymer Coating Abluminal (4μm) SYNERGY 74 µm PREMIER 81 µm Resolute Integrity 89 µm Everolimus Drug PLGA Polymer Platform Platinum chromium 74 μm (0.0029in) Increased Visibility Xience Xpedition 81 µm SEM of coating (x5000) Bioabsorbable Polymer Coating PLGA Abluminal 4 µm thick 85:15 ratio < 4month absorption time Luminal Drug Everolimus 100 μg/cm 2 3 month release time The SYNERGY stent is an investigational device and not for sale in the US. IC AB FEB2015 Page 38
39 Impact of Strut Thickness on Thrombogenicity Thicker Struts Associated with Increased Acute Thrombogenicity 150 µm Thick Strut DES DOWNSTREAM BVS 120 µm Biomatrix Thin Strut DES DOWNSTREAM 74 µm SYNERGY Thrombus formation assessed by immunofluorescence staining for platelet marker CD61 after 1 hour in ex-vivo pig AV shunt model Sanchez, Joner, Virmani, et al., TCT 2014; Modified from Koskinas et al. J Am Coll Cardiol 2012;59: The SYNERGY stent is an investigational device and not for sale in the US. IC AB FEB2015 Page 39
40 SYNERGY Stent Case Study Distal LAD SYNERGY Stent 2.25 mm x 38 mm Complete coverage of SYNERGY Stent at 2 months (OCT Assessment) Presented by Jose de la Torre Hernandez, MD, EuroPCR 2014 Case study not necessarily representative of all cases. Results in other cases may vary. The SYNERGY stent is an investigational device and not for sale in the US. IC AB FEB2015 Page 40
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