Transcript of "Prediction of Restenosis After PCI with Contemporary Drug-Eluting Stents"
Prediction of restenosis after PCI with contemporary drug-eluting stents DR. ASHOK SETH FRCP (LOND), FRCP (EDIN), FRCP (IREL), FACC, FSCAI, FCSI, DSc. CHAIRMAN CHIEF OF CARDIOLOGYCHAIRMAN – CARDIOLOGY COUNCIL, FORTIS GROUP OF HOSPITALS FORTIS ESCORTS HEART INSTITUTE PRESIDENT – CARDIOLOGICAL SOCIETY OF INDIAHEART INSTITUTE
Restenosis After BA and Stent • Most significant problem for years • DES have dramatically reduced instent restenosis. • Low rates of ISR in DES still a problem.HEART INSTITUTE
Classification of Restenosis (Mehran et al. Circulation 1999;100:1872-8)HEART INSTITUTE
Incidence of DES ISR 12% 11-12% 10% 8% 6-7% 6% 5-6% 4% 2% 0% Native Denovo Real Life Patients Real Life Patients Lesion 1st Gen DES 1st Gen DES 2nd Gen DESHEART INSTITUTE
Delayed Restenosis • Late ‘Catch Up’ Modest increase in NIH beyond 1-year on IVUS study follow up. – Delayed healing response – Persistent biological reaction – Hypersensitivity reaction to durable polymer ‘Therefore longer term follow up’HEART INSTITUTE
Stent Thrombosis vs Restenosis • ISR Presents as effort angina while stent thrombosis usually presents MI. • TVF within 30-days is usually stent thrombosis while ISR is usually later. • DES has delayed the time frame of ISR • Both ISR and Stent thrombosis may co-exist.HEART INSTITUTE
Definitions and Classification of Restenosis and Stent Thrombosis Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE
Possible Mechanisms of Restenosis After DES Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE
Biologic Factors • Drug Resistance • Hyper sensitivity – Allergy to Nickel / Molybdenum of 316 to stenosis steel. – RADAR STUDY (Research on Adverse Drug / Device Adverse Reports) - Drug Hypersensitivity for DES.HEART INSTITUTE
RADAR (Research on Adverse Drug Events & Reports) (Nebeker JR et al. J Am Coll Cardiol 2006;47:175-181) • 5783 AE after DES • 261 Hypersensitivity Reaction • 17 DES cause of HS • 4 Died of stent thrombosis between 4-18 monthsHEART INSTITUTE
Technical Factors • Stent Gap • Gap between two overlapping stents • Bends and CurvesHEART INSTITUTE
Predictors of ISR or TLR After DES Implantation Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE
Risk Scoring to Predict TLR in DES (Stolker et al. Circ Cardiovasc Interv. 2010;3:327-334)HEART INSTITUTE
Predictors of DES Restenosis (Corbett et al. Circulation. 2006;114:II_688) • 2269 lesions 1283 patients (2003-2005) • Angio FU 70% DES ISR : SES 16.9% : PES 16.8%HEART INSTITUTE
Morphologic Pattern of SES, PES, and BMS ISR Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE
Clinical and Angiographic Outcomes After Percutaneous Treatment of DES ISR Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE
Morphological Pattern of Restenosis as a Predictor of Repeat ISR after DES ISR Treatment (Dangas et al. JACC 2010; 56: 1897-907) Repeat ISR TLR 60% 57% 50% 40% 30% 23% 20% 18% 10% 10% 0% Focal ISR Non Focal ISR DES ISRHEART INSTITUTE
Treatment of DES ISR ‘Difficult Disease Process’ • IVUS or other imaging essential to understand the underlying mechanism. • OPTIONS – Balloon angioplasty – DEB – DES : Same DES : Different DES – VBT – CABGHEART INSTITUTE
Algorithm for the Treatment of DES Restenosis Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE
Conclusion • Though DES has lowered the restenosis rates of PCI, the increased complexity of lesions being treated has resulted in DES ISR being an important problem. • The predictors of restenosis in DES era are similar to the BMS era, but DES ISR can occur later and tends to be more focal and this has a better prognosis than BMS ISR. • Diffuse DES ISR is a very ‘difficult animal’ as the pathophysiology and causative mechanism of DES ISR are in many cases unclear and hence treatment options are ‘hit and trial’. • Further studies new DES and Bioresorbable stents are on the way to overcome this important problem.HEART INSTITUTE
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