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HEART   INSTITUTE
Prediction of restenosis after PCI with            contemporary drug-eluting stents                       DR. ASHOK SETH  ...
Restenosis After BA and Stent   • Most significant problem for years   • DES have dramatically reduced instent     resteno...
Classification of Restenosis                      (Mehran et al. Circulation 1999;100:1872-8)HEART   INSTITUTE
Incidence of DES ISR        12%                             11-12%        10%        8%                                   ...
Delayed Restenosis        • Late ‘Catch Up’             Modest increase in NIH beyond 1-year on IVUS             study fol...
Stent Thrombosis vs Restenosis   • ISR Presents as effort angina while stent     thrombosis usually presents MI.   • TVF w...
Definitions and Classification of Restenosis and                   Stent Thrombosis          Dangas et al. J Am Coll Cardi...
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    ...
RADAR (Research on Adverse Drug Events                 & Reports)             (Nebeker JR et al. J Am Coll Cardiol 2006;47...
HEART   INSTITUTE
Mechanical Factors              (Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907)                              Sten...
Mechanical Factors                (Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907)                                ...
Technical Factors        • ‘Geographical Miss’        • Uncovered atherosclerotic plaque               • Baro trauma outsi...
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   INST...
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 ...
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. ...
Morphological Pattern of Restenosis as a Predictor of Repeat                  ISR after DES ISR Treatment           (Danga...
Treatment of DES ISR                    ‘Difficult Disease Process’        • IVUS or other imaging essential to understand...
Algorithm for the Treatment of DES Restenosis            Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART   INS...
Conclusion  • Though DES has lowered the restenosis rates of PCI, the    increased complexity of lesions being treated has...
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Prediction of Restenosis After PCI with Contemporary Drug-Eluting Stents

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Transcript of "Prediction of Restenosis After PCI with Contemporary Drug-Eluting Stents"

  1. 1. HEART INSTITUTE
  2. 2. 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
  3. 3. 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
  4. 4. Classification of Restenosis (Mehran et al. Circulation 1999;100:1872-8)HEART INSTITUTE
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. Definitions and Classification of Restenosis and Stent Thrombosis Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE
  9. 9. Possible Mechanisms of Restenosis After DES Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE
  10. 10. 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
  11. 11. 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
  12. 12. HEART INSTITUTE
  13. 13. Mechanical Factors (Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907) Stent Under expansionHEART INSTITUTE
  14. 14. Mechanical Factors (Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907) Stent Fracture • Incidence: 2-8% • Rigid closed cell stents, overlapping stents, longer stents, vessel tortuousity, angulation and torsionHEART INSTITUTE
  15. 15. Technical Factors • ‘Geographical Miss’ • Uncovered atherosclerotic plaque • Baro trauma outside stented segmentHEART INSTITUTE
  16. 16. Technical Factors • Stent Gap • Gap between two overlapping stents • Bends and CurvesHEART INSTITUTE
  17. 17. Predictors of ISR or TLR After DES Implantation Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE
  18. 18. Risk Scoring to Predict TLR in DES (Stolker et al. Circ Cardiovasc Interv. 2010;3:327-334)HEART INSTITUTE
  19. 19. 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
  20. 20. Morphologic Pattern of SES, PES, and BMS ISR Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE
  21. 21. Clinical and Angiographic Outcomes After Percutaneous Treatment of DES ISR Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE
  22. 22. 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
  23. 23. 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
  24. 24. Algorithm for the Treatment of DES Restenosis Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE
  25. 25. 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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