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  • cardiovascular diseases cause more than 15 million deaths in the world each year, according to the World Health Organization (WHO; Geneva). They account for 50% of all deaths in several developed countries, and more than 50% in Africa and Western and Southeast Asia. They are also the major cause of death in adults. In addition, many cardiovascular incidents are not necessarily fatal, but may impair the ability to lead a normal daily life, resulting in enormous healthcare costs (estimated at $50–150 billion per year) to society. 17.3 % million died in 200880% of CVD deaths takes place in low and middle-income countries23.6 million people will die from CVDsBecause PCI is performed under local anesthesia and requires only a short (1-day) hospitalization, its use in suitable patients can greatly decrease recovery time and expense compared to coronary bypass surgery.lower elective mortality rate than bypass surgery (0.4–1.0%, compared to a rate of 1–3%)
  • 3000 B.C. — Egyptians perform bladder catheterizations using metal pipes.400 B.C. — Catheters prepared from hollow reeds and pipes are used in cadavers to study the function of cardiac valves. 1711 — Hales conducts the first cardiac catheterization of a horse using brass pipes, a glass tube and the trachea of a goose. 1844 — French physiologist Bernard coins the term "cardiac catheterization" and uses catheters to record intracardiac pressures in animals. 2004 — Boston Scientific gets its Taxus drug-eluting stent approved; many studies are published demonstrating the vastly improved outcomes from drug-eluting stents
  • The quality of bare-metal stents has consistently improved since they were first introduced in the U.S. in 1994. Bare-metal stents provide structural support to help keep the cleared artery open after angioplasty. Bare-metal stents help to prevent the artery from re-narrowing and the need for a repeat procedure. The medical name for this narrowing is stenosis, so when it occurs again, it is called "re-stenosis" or simply, restenosis. However, about 25% of the time, the arteries may become blocked up again after placement of a bare-metal stentA drug-coated stent is a bare-metal stent with a special drug coating. It has the same support benefits as a bare-metal stent for keeping the artery open after angioplasty. In addition, the stent releases a drug over time to further reduce the chance of re-blockage. Arteries commonly become blocked up again about 7% of the time with drug-coated stents compared to about 25% for bare-metal stents.
  • The stent itself is an expandable metal alloy framework. Many DES are based on a bare-metal stent (BMS). The stents have elaborate mesh-like designs to allow expansion, flexibility and in some cases the ability to make/enlarge side openings for side vessels. Cobalt chrome alloy is stronger (and more radio-opaque) than the usual 316L stainless steel so the struts can be thinner which seems to reduce the degree of restenosis. (The L605 CoCr alloy has less nickel than 316L stainless steel and so may cause less allergy.)A coating, typically of a polymer, holds and elutes (releases) the drug into the arterial wall by contact transfer. The first few DES licenced used durable coatings, but some newer coating are designed to biodegrade after or as the drug is eluted. Coatings are typically spray coated or dip coated. There can be one to three or more layers in the coating e.g. a base layer for adhesion, a main layer for holding the drug, and sometimes a top coat to slow down the release of the drug and extend its effect.The drug is mainly to inhibit neointimal growth (due to proliferation of smooth muscle cells) which would cause restenosis. Much of the neointimal hyperplasia seems to be caused by inflammation. Hence immunosuppressive and antiproliferative drugs are used. Both sirolimus and paclitaxel were previously used for other medical applications; new drugs are being evaluated for coronary stents. [7][31]
  • Why Clinical trials have shown the benefits of coronary stenting with BMS over other methods of angioplasty, including balloon angioplasty and atherectomy. Drug-eluting stents (DES) have also been extensively studied, and are generally superior to bare-metal stents as regards Major Adverse Cardiac Events (MACE, generally defined as death, myocardial infarction, or the need for a repeat revascularization procedure.) Stents are indicated to improve the diameter of the coronary artery lumen, when narrowing (generally because of atherosclerosis) causes ischemia (reduced oxygen delivery to the muscle supplied by that artery
  • Coronary angioplasty is a common medical procedure. Although angioplasty is normally safe, there is a small risk of serious complications, such as:
  • The illustration shows the restenosis of a stent-widened coronary artery. In figure A, the expanded stent compresses plaque, allowing normal blood flow. The inset image on figure A shows a cross-section of the compressed plaque and stent-widened artery. In figure B, over time, tissue grows through and around the stent, causing a partial blockage and abnormal blood flow. The inset image on figure B shows a cross-section of the growth of the tissue around the stent.
  • Recent studies suggest that there is a higher risk of blood clots forming in medicine-coated stents compared to bare metal stents (nonmedicine-coated). The Food and Drug Administration (FDA) reports that medicine-coated stents usually don't cause complications due to blood clots when used as recommended.When medicine-coated stents are used in people with advanced CAD, there is a higher risk of blood clots, heart attack, and death. The FDA is working with researchers to study medicine-coated stents, including their use in people with advanced CAD.Taking medicine as prescribed by your doctor can lower the risk of blood clots. People with medicine-coated stents are usually advised to take an anticlotting drug, such as clopidogrel and aspirin, for months to years to lower the risk of blood clots.As with all procedures, it's important to talk to your doctor about your treatment options, including the risks and benefits to you.
  • The drugs that may be useful in preventing in-stent restenosis (ISR) fall into four major categories; anti-neoplastics, immunosupressives, migration inhibitors, and enhanced healing factors. ISR is primarily due to natural healing mechanisms including endothelial cell migration and extracellular matrix formation, collectively know as intimal hyperplasia. Platelets are attracted by the damaged tissue and they further the endothelial cell response as well as form thrombosis in the area around the stent [1]. Compounds that can inhibit ISR and intimal hyperplasia are excellent candidates for drug eluting stentsAnti-neoplastics: Anti-proliferative compounds include paclitaxel, QP-2, actinomycin, statins and many others. Paclitaxel was originally used to inhibit tumor growth by assembling microtubules that prevent cells from dividing. It has also recently been observed to attenuate neointimal growth [2].Immunosupressives: Immunosupressives are generally used to prevent the immune rejection of allogenic organ transplants. The general mechanism of action of most of these drugs is to stop cell cycle progression by inhibiting DNA synthesis. Everolimus, sirolimus, tacrolimus (FK-506), ABT-578, interferon, dexamethasone, and cyclosporine all fall into this category. The sirolimus derived compounds appear especially promising in their ability to reduce intimal thickening [2].Migration Inhibitors : These compounds are aimed at preventing endothelial cell migration to the inside of the stent. Once smooth muscle cells migrate to the luminal side of the stent, they can produce extracellular matrix and begin to occlude blood flow. Therefore, inhibiting their migration can have great therapeutic applications for preventing in stent restenosis. Examples of these compounds are batimastat and halofuginone. Batimastat, for example, is a potent inhibitor of matrix metalloproteinase enzymes. It can prevent the matrix degradation that is necessary for cells to free themselves to move. If the cells cannot move, they can not invade the stent area. Enhanced Healing Factors : Vascular endothelial growth factor (VEGF) promotes healing of the vasculature. In the context of stents, this would heal the implantation site and reduce platelet sequestration due to injury related chemotaxis. Nitrous oxide donor compounds may also replicate this effect. Healing of the vessel wall seems to be the gentlest approach to preventing ISR, but
  • Cells DNA replication occurs during this phase.increase in size in Gap 1. The G1 checkpoint control mechanism ensures that everything is ready for DNAsynthesis,During the gap between DNA synthesis and mitosis, the cell will continue to grow. The G2 checkpoint control mechanism ensures that everything is ready to enter the M (mitosis) phase and divide. Cell growth stops at this stage and cellular energy is focused on the orderly division into two daughter cells. A checkpoint in the middle of mitosis (Metaphase Checkpoint) ensures that the cell is ready to complete cell division
  • Sirolimus eluting stent (cypher)Paclitaxel eluting stent (taxus)
  • The first successful trials were of sirolimus-eluting stents. A clinical trial in 2002 led to approval of the sirolimus-eluting Cypher stent in Europe in 2002. After a larger pivotal trial (one designed for the purpose of achieving FDA approval), published in 2003, the device received FDA approval and was released in the U.S. in 2003. Sirolimus is a macro cyclic lactone immunosuppressive agent that inhibits the cell division cycle and cellular proliferation by promoting kinase activation and halting the cellular growth phase
  • Sirolimus is released from the CYPHER stent from the PEVA/PBMA polymer into the surrounding area by diffusion. [3] This mechanism can be described by Fick's law of diffusion, and is dependent upon concentration of drug both inside and outside the polymer matrix. The greater the difference between drug concentration inside and outside the polymer matrix, the faster the release of drug will occur. As mentioned previously, the outer layer of PEVA/PBMA minimizes the burst effect following stent implantation. The outer PEVA/PBMA layer also slows the rate of sirolimus diffusion allowing the drug to be released gradually over a longer period. [4] The concentration of drug decreases with first order elimination kinetics. Approximately 50 percent of the total drug is eliminated within the first 10 days of implantation. The drug is 90 percent removed from the stent by about 60 days, and is completely removed by about 90 days following implantation. [5] The peak drug concentration occurs about 4 hours after implantation. [6] This release profile provides just enough drug release immediately after stent implantation to prevent neointimal hyperplasia, without any of the side effects of systemic administration.
  • Soon thereafter, a series of trials of paclitaxel-eluting stents led to FDA approval of the Taxus stent in 2004Paclitaxel is a mitotic inhibitor used in cancerchemotherapy. Paclitaxel stabilizes microtubules and as a result, interferes with the normal breakdown of microtubules during cell divisionTogether Paclitaxel and Sirolimus are two of the most promising drugs for use in stents, as several others have run into problems with lumen loss ,late thrombosis, delayed restenosis, and aneurysm formation
  • Allergy Not on antiplatelets & anticoagulantsInfection at the site of accessIrregular heart beatTotal occlusion of vesselsWorsening of heart & lung function
  • zotarolimus eluting stent (endeavour)Everolimus eluting stent (xience-v)
  • MOA :It is a semi-synthetic derivative of rapamycin. It was designed for use in stents with phosphorylcholine as a carrier The mechanism (or mechanisms) by which the Endeavor Zotarolimus-Eluting Coronary Stent System affects neointimal production as seen in clinical studies has not been established conclusively. In vitro, zotarolimus inhibited growth factor-induced proliferation of human coronary artery smooth muscle cells and also demonstrated binding affinity with FKBP 12 (binding protein). The suggested mechanism of action of zotarolimus is to bind to FKBP 12, leading to the formation of a trimetric complex with the protein kinase mTOR (mammalian target of rapamycin), inhibiting its activity. Inhibition of mTOR activity leads to inhibition of cell cycle progression from the GI to the S Zotarolimus is an immunosuppressant medication that was designed to be used in coronary stents. Stents help to reduce complications in patients with cardiac disorders. They also improve the patient’s chances for recovery when coronary intervention is needed. Because stents do carry risks such as hemorrhages and thrombosis, drug-eluting stents were developed. These stents have a polymer membrane, which theZotarolimus is placed into so it can be released slowly into tissues and will prevent the body to negatively respond to the stent with an inflammatory reaction.Indications for UseThe Zotarolimus-eluding stent is indicated for use in patients who have atherosclerosis to the degree that it has caused their coronary arteries to narrow. This occurs due to fatty plaque build-up along the lining of the artery best online pharmacy no prescription.How Zotarolimus-Stents WorkPlacing the Zotarolimus-stent into the narrowed artery requires a catheter to be inserted through a blood vessel of the groin or arm. The catheter is pushed through the blood vessel until it reaches the plaque-buildup area. A balloon on the end of the catheter is then inflated to open the narrowed artery as it pushes the fatty deposits against the arterial wall. The catheter is then removed and the Zotarolimus-stent is delivered through the same blood vessel opening until it is positioned in the area of the artery that was previously expanded. With the Zotarolimus-stent also having a balloon tip, it is expanded to fit the artery wall. This procedure allows the narrowed artery to regain its width so normal blood flow to the heart can be restored. The catheter is then removed leaving the stent in place where it remains. Zotarolimus is then slowly released into the tissue of the artery wall to prevent re-narrowing of the artery. Without treating the narrowed artery, a heart attack can occur. The use of Zotarolimus-stents also prevents the complication of normal tissue overgrowth while the artery is healing kamagra online.ContraindicationsThe Zotarolimus-Eluting Stent should not be used in patients who are allergic to Zotarolimus or the metal or polymer coating that is in the stent. It is also contraindicated in patients who cannot take blood thinners or aspirin and those who have an arterial blockage that is so severe that the catheter balloon cannot be inflated for placing the stent.Looking for cheap generic medication? Visit online pharmacy no prescription to get high quality medical service.Zotarolimus Side EffectsAlthough actual side effects are not completely known about Zotarolimus , side effects that have occurred when Zotarolimus was administered through intravenous injection include rash, abdominal pain, infection, headache, dry skin, hematuria, diarrhea, anemia and application site reaction.
  • BRAND NAME : XIENCE VEverolimus when adverse effects such as very late stent thrombosis with is a sirolimus derivative in which the hydroxyl at position first-generation DES may become apparent. The investigators C40 of sirolimus has been alkylated with a 2-hydroxyethyl report a significant 32% reduction in target-vessel failure group, resulting in increased solubility in several organic (10.7% versus 15.4%, hazard ratio0.68, 95% CI 0.48 to solvents and galenic excipients. Although binding of everolimus- 0.98, P 0.04) and a 45%reduction in major adverse cardiac mus to the FKBP 12 domain is 3-fold and immunosuppressive- events (7.3% versus 12.8%, hazard ratio 0.55, 95% CI 0.36 sive activity in vitro is 2- to 5-fold lower than with sirolimus,
  • Having said all that about the possible complications, the final word is that when done in the right circumstances, in the right patient using the right techniques… it can be a very rewarding procedure…
  • The drug specifically and irreversibly inhibits the P2Y12 subtype of ADP receptor, which is important in activation of platelets and eventual cross-linking by the protein fibrin.Instructions from your doctor:How much activity or exercise you can do.When you should follow up with your doctor.What medicines you should take.What you should look for daily when checking for signs of infection around the area where the tube was inserted. Signs of infection may include redness, swelling, or drainage.When you should call your doctor.
  • Aspirin isGlycoproteinIIb/IIIa inhibitors are frequently used during percutaneous coronary intervention (angioplasty with or without intracoronary stent placement).They work by preventing platelet aggregation and thrombus formation. They do so by inhibition of the GpIIb/IIIa receptor on the surface of the platelets.They may also be used to treat acute coronary syndromes, without percutaneous coronary intervention, depending on TIMI risk.They should be given intravenously. The oral form is associated with increased mortality and hence should not be given.In integrin nomenclature glycoprotein IIb/IIIa is called αIIbβ3. given for 1-6 months after stenting and 1yr after ACBG.
  • many research and development activities are under way. In an attempt to offer differentiated products, researchers are exploring the possibility of incorporating drugs such as estradiol, dexamethasone, and pimecrolimus into future DES systems. Each compound has different mechanisms of action that are being studied in clinical trials to determine whether advantages exist over commercially available productsOther agents used in drug-eluting stents include angiopeptin, corticosteroids, and prohealing agents.[52] Clinical data confirming the pharmacologic effects of these agents on smooth muscle cells and neointimal growth are relatively weak or lacking. Animal studies have indicated that a drug-eluting stent loaded with angiopeptin reduces neointimal growth when compared with bare metal stents.[73] The role of antiinflammatory agents in a drug-eluting stent is unclear, based on experience with methylprednisolone- and dexamethasone-coated stents.[74] Corticosteroids most likely have no effect on the cell cycle, but they may be useful against restenosis due to their antiinflammatory activity. By decreasing inflammation that results from arterial injury, corticosteroids may reduce smooth muscle cell proliferation.[75] Some researchers have suggested that agents with a prohealing effect may provide a safer and more natural approach to restenosis prevention than other types of agents.[52]Estrogens have been tested as a component of the drug-eluting stent. A drug-eluting stent loaded with estradiol reduced neointimal growth compared with a control stent.[76] This reduction in neointimal growth is not attributed to alteration in the cell cycle but to estradiol's potential to reduce smooth muscle cell migration and proliferation, promote vascular healing, and stimulate angiogenesis[77]
  • IGAKI-TAMAI® STENT” Bioabsorbable stent is formed of biodegradable polymer PLLA (poly-L-lactic acid). The stent has the characteristics of being dissolved into water and carbon dioxide and absorbed into vessel tissue within a few years after implantation. It is possible to use also for patients who could not receive a stent due to with metal allergies or being still growing. Even though a stented segment becomes narrow again, the implanted PLLA stent which does not remain in the body permanently will not interfere with other procedures such as restenting, Furthermore, PLLA stent is more useful for containing drugs compared to metal stents, and thus, it has been intended as a platform for drug eluting stents.
  • DAPT drug associated prothrombotic events
  • Health beat

    1. 1. Drug Eluting Stents (Des) Presenter : Dr. Shantibhushan K Kamble, PG Guide: Dr. S. B. Patel
    2. 2. Introduction• Cardiovascular diseases cause more than 15 million deaths in the world each year. (WHO; Geneva).• They account for 50% of all deaths in several developed countries.• Healthcare costs (estimated at $50–150 billion per year)• Newer techniques like per cutaneous interventions(PCI) by using stent increases survival rate and decreases morbidity.• Advantage: Requires only a short (1-day) hospitalization, greatly decrease recovery time and expense compared to coronary bypass surgery.• lower elective mortality rate than bypass surgery (0.4–1.0%, compared to a rate of 1–3
    3. 3. Historical account ….• 3000 B.C. — Egyptians perform bladder catheterizations using metal pipes.• 400 B.C. — Catheters prepared from hollow reeds and pipes are used in cadavers.• 1711 — Hales conducts the first cardiac catheterization of a horse using brass pipes, a glass tube and the trachea of a goose.• 1844 — French physiologist Bernard coins the term "cardiac catheterization" .• 2004 — Boston Scientific gets its Taxus drug- eluting stent approved.
    4. 4. Metallic stents• First introduced in the U.S. in 1994• These devices differ from each other with respect to : i) Composition (e.g., stainless steel, cobalt chromium alloy, or nickel chromium alloy), ii) Architectural design, and iii) Delivery system (i.e, the balloon catheter that delivers the stent).
    5. 5. Metallic stents Bare-metal stents provide structural support the artery after angioplasty. Bare-metal stents help to prevent the artery from re-narrowing. However, about 25% of the time, the arteries may become blocked up again after placement of a bare-metal stent
    6. 6. Drug releasing stents Drug releasing stents are coated with an anti-proliferative drug, which allows drug elution into the coronary wall for weeks after stent implantation. Studies have shown that they are better than bare metal stents as they reduce the incidence of re-stenosis and overall cardiac adverse events.
    7. 7. Drug releasing stents A drug-coated stent is a bare-metal stent with a special drug coating. It also support the artery to kept open after angioplasty. In addition, the stent releases a drug over time to further reduce the chance of re-blockage. Arteries commonly become blocked up again about 7% of the time with drug-coated stents compared to about 25% for bare-metal stents
    8. 8. Types of Stent
    9. 9. Parts of DES• Parts of DES – Stent Platform – Coating – Drug
    10. 10. Indications of using Stents Drug-eluting stents (DES) are generally superior to bare-metal stents as regards Major Adverse Cardiac Events  (MACE, generally defined as death, myocardial infarction, or the need for a repeat revascularization procedure.)  Stents are indicated to improve the diameter of the coronary artery lumen, when narrowing causes ischemia (to the muscle supplied by that artery)
    11. 11. What Are the Risks of Coronary Stenting• The risk of complications is higher in:  People aged 75 and older  People who have kidney disease or diabetes  Women  People who have poor pumping function in their hearts  People who have extensive heart disease and blockages
    12. 12. Risks Bleeding from the blood vessel where the catheter was placed. Damage to blood vessels from the catheter. An allergic reaction to the dye given during the angioplasty. An arrhythmia (irregular heartbeat). Damage to the kidneys caused by the dye used. Heart attack (3–5 percent of people). Stroke (less than 1 percent of people).
    13. 13. Complications From Stents• Restenosis – There is a chance that the artery will become narrowed or blocked again in time, often within 6 months of angioplasty
    14. 14. Complications From Stents• Blood Clots  Taking medicine as prescribed by your doctor can lower the risk of blood clots.  People with medicine Coated stents are usually advised to take an anti clotting drug, such as clopidogrel and aspirin, for months to years to lower the risk of blood clots.
    15. 15. Complication from stent Pathopysiology of stent thrombosis
    16. 16. Types Of DrugAnti-Neoplastics Anti-Proliferative Migration Enhanced Healing Inhibitors FactorsSirolimus Taxol (paclitaxel) Batimistat BCP671Tacrolimus Actinomycin Prolyl Hydrosylase VEGF InhibitorsEverolimus Methotraxate Halofunginone EstradiolsLeflunomide Angiopeptin C-preteinase NO Donor Inhibitors CompoundsM-Prednisolone Vincristine Probucol EPC antibodiesDexamethasone MitomycineCyclosporine StatinsMycophenolic Acid C MYC antisenseMizoribine Abbott ABT-578
    17. 17. Cell Cycle Inhibition Sirolimus S Everolimus ABT-578 X G0 G1 G2 CellResting cycle Cell division X M Paclitaxel
    18. 18. First Generation Stent• Sirolimus eluting stent• Paclitaxel eluting stent
    19. 19. Sirolimus The first Approved DES in Europe (2002). After a larger pivotal trial, the device received FDA approval and was released in the U.S. in 2003. It is an immunosuppresant drug , that inhibits the cytokine stimulated proliferation of T cells. MOA: Binds to FK-binding protein-12(FKBP-12) FKBP-12 binds to specific cell cycle regulatory protein , the mammalian target of rapamycin (mTOR) kinase mTOR inhibition prevents cell cycle progression from G1 to S.
    20. 20. sirolimus• Sirolimus is released from the CYPHER stent• It is dependent upon concentration of drug both inside and outside the polymer matrix.• Approximately 50 percent of the total drug is eliminated within the first 10 days of implantation.• The drug is 90 percent removed from the stent by about 60 days• Completely removed by about 90 days• Peak drug concentration occurs about 4 hours
    21. 21. sirolimus• Indications : In pt with symptomatic ischemic disease due lesion of length < 30 mm in native coronary arteries with reference diameter of >2.5 to < 3.5 mm• Contraindications: Hypersensitivity to sirolimus Hypersensitivity to polymer• ADRs’: Arrhythmias Myocardial infarction Pesudoanuerysm Vessel spasm
    22. 22. Paclitaxel• Paclitaxel-eluting stents led to FDA approval of the Taxus stent in 2004.• Paciltaxel is in the antineoplastic family of compounds• Mechanism of Action: Paciltaxel binds to microtubules in dividing cells and causes them to assemble, thereby preventing mitosis.• Indications: For improving luminar diameter for the treatment of de novo lesion in native coronary arteries > 2.5 to < 4mm in diameter in lesion < 28 mm in length.
    23. 23. Paclitaxel• Contraindications: Allergy Not on antiplatelets & anticoagulants Infection at the site of access Irregular heart beat Total occlusion of vessels• ADR’s: Abnormal liver values Anemia GI disturbances Loss of hair Muscle pain
    24. 24. Why need 2nd generation DES• Further reduce in restenosis.• To prevent inhibition of endothelial cells.• Reduction of risk of stent thrombosis.• Second generation stent Zotarolimus eluting stent Everolimus eluting stent
    25. 25. Zotarolimus Zotarolimus is an immunosuppressant MOA : • Binds to FKBP 12,leading to the formation of a trimetric complex with the protein kinase mTOR• Inhibition of mTOR activity• Inhibition of cell cycle progression from the GI to the S phase. Indications: In atherosclerosis to the degree that it has caused their coronary arteries to narrow.
    26. 26. Zotarolimus Contraindications:• Allergic to Zotarolimus or the metal or polymer coating that is in the stent.• Cannot take blood thinners or aspirin• Those who have an arterial blockage that is so severe that the catheter balloon cannot be inflated for placing the stent. ADRs’• Although actual side effects are not completely known• S/E on IV rash, abdominal pain, infection, headache, dry skin, hematuria, diarrhea, anemia and application site reaction
    27. 27. EverolimusIt is a novel semisynthetic Macrolide immunosuppresant Synthesized by chemical modification of rapamycin (sirolimus )MOA: Inhibition of mTOR appears to be the mechanism by which everolimus inhibits cell proliferation.Indications: Pt with symptomatic heart disease due to denovo coronary artery lesions ( length ≤ 28mm) with reference vessel diameter of 2.25 mm to 4.25mm.
    28. 28. Everolimus• Contraindications : Pt who can not receive antiplatelates Pt with lesion that prevent complete angioplasty balloon inflation or proper placement of stent. With hypersensitivity to everolimus related compounds• ADR’s: Abrupt closure Allergy & Hypersensitivity to contrast agent or cobalt. Bleeding complications MI
    29. 29. How successful isAngioplasty and stenting?• Angioplasty/ stenting is successful in treating the narrowing/blockage of the artery in the vast majority of patients (over 70%).• In the small number of patients in whom the procedure is unsuccessful, a surgical bypass operation may be offered as an alternative.
    30. 30. Comparative Studies SES PES P valueMajor adverse cardiac 6.2 percent 10.8percent 0.009eventsMI 2.8percent 3.5 percent 0.49Angiographic restenosis 6.6 percent 11.7 percent 0.02Target-lesion 4.8percent 8.3percent 0.03revascularization
    31. 31. Endeavor III Study• At 9 months follow up target rate revascularization rate was 9.8 % in zotarolimus eluting stent compared to 3.5% (p-0.04) in sirolimus eluting stent .• However at 24 months both showed same results.
    32. 32. Spirit III TrialAt 12 mths Everolimus- paclitaxel eluting P value eluting stent stent (taxus)Major adverse 5.8% 9.9% <0.01cardiac eventTarget vessel 3.3% 5.6% <0.05revascularization
    33. 33. Life after stenting• Going Home Most people go home 1 to 2 days after the procedure. Instructions from your doctor• Medications Medicine to prevent blood clots from forming. e.g..Aspirin and Clopidogrel Taking medicine as directed is very important. If a stent was inserted, the medicine reduces the risk that blood clots will form in the stent. Blood clots in the stent can block blood flow and cause a heart attack.
    34. 34. Life after stenting• Recovery & Recuperation Most people recover from angioplasty and return to work about one week after being sent home• Lifestyle Changes Making healthy lifestyle changes can help treat CAD and maintain the good results from angioplasty  Quit smoking if you smoke.  Be physically active.  Lose weight if youre overweight or obese.  Reduce stress.  Take medicines as your doctor directs to lower high blood pressure or high blood cholesterol.
    35. 35. Future prospective• Possible upcoming drug in future – Many research and development activities are under way. Dexamethasone Estradiol Pimecrolimus
    36. 36. Cobalt chrome alloy VS stainless steel• More Strong.• More radio-opaque• Struts can be thinner which seems to reduce the degree of restenosis.• less nickel than 316L stainless steel and so may cause less allergy.
    37. 37. Bioabsorbable stents• Since stent itself is foreign body, so prothrombogenic.• Igaki-Tamai stent- from poly L lactic polymer• 25 pts have implanted it , with target lesion revascularization rate of 6.7% at 6 moths.• BVS STENT - Release everolimus from poly L lactic polymer .
    38. 38. DES Producing CompaniesJohnson & Johnson / sirolimus (CYPHER)Medtronic / zotarolimus (ENDEAVOR)Abbot / Everolimus ( XIENCE )Boston Scientific ( TAXUS)Biosensors Int. (BIOMATRIX)
    39. 39. Cost of stent• Sirolimus Stent approximately 80,000- 100,000.• Supralimus Stent approximately 60,000.• Bare metal Stent- 20,000 - 40,000.
    40. 40. In Our Hospital• In our hospital and in most of the hospitals we use only drug eluting stents• Sirolimus is used always• Occasionally Supralimus• Rarely Bare metal stents are used
    41. 41. summ• Cardiovascular diseases are main cause of premature mortality and morbidity in the world• Many treatments are available for T/t of cardiac disease like medications , PCI, change in the dietary habits• The drug eluting stents are promising one ,which prevents or decrease this mortality and morbidity due CVDs.• Many trial shows that Sirolimus eluting stents are best and commonly used world wide.• In case of Failure of DES alternatives are available in forms of coronary artery bypass grafting.
    42. 42. Thank you !

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