Repairing Coronary Arteries Neal Kleiman Director Cardiac Catheterization Laboratory Methodist DeBakey Heart Center Profes...
Courtesy of Dr. Paul Tierstein
Courtesy of Dr. Paul Tierstein
Angioplasty:  The Thirtieth Anniversary Gruntzig Patient
 
Balloon Angioplasty:  The Initial Concept “ Footprints in the snow”
Mechanism of Angioplasty Landau C et al. N Engl J Med 1994;330:981-993
Angioplasty:  Issues Seeking Solutions <ul><li>The atheromatous plaque is part of the arterial wall, not simply a harmful ...
How are these problems manifest following angioplasty? <ul><li>Failed procedure: 5% (vessel just can’t be dilated)  </li><...
Angioplasty – The major issue for the last thirty years <ul><li>How to modulate the vascular and blood reactivity to the b...
Chung, I.-M. o et al. J Am Coll Cardiol 2002;40:2072-2081 Restenosis Or “Scar Formation” After Angioplasty – The Role Of T...
Why not Scoop out the plaque? DCA picture
Why not grind it up?
Why not vaporize it?
316 L Stainless Steel 130-140    strut) or Co-Cr Alloy (80-90   strut)
 
Stents vs POBA <ul><li>Improved arterial lumen </li></ul><ul><ul><li>Reduces recoil </li></ul></ul><ul><ul><li>Scaffolds t...
Drug Eluting Stents <ul><li>Stent + Drug + Polymer </li></ul><ul><li>The drug prevents cell replication by interfering wit...
Drug Eluting Stents <ul><li>Polymer controls the release of drug at the appropriate rate (currently 2-4 weeks) </li></ul><...
Paclitaxel Drug Eluting Stent System (Taxus) Elastomeric, Polyolefin Derivate
Sirolimus Drug Eluting Stent System (Cypher) PBMA / EVA
Heterogeneity of Re-Endothelializaiton in a Drug-Eluting Stent Finn, Circulation: 2007
Cumulative Incidence of DES Thrombosis in the Rotterdam-Bern Registry Daemen: Lancet: 2007:369: 667 <ul><li>Accumulated ea...
<ul><li>16 RCTs; 8,695 Patients </li></ul><ul><li>Follow-up to 4 Years </li></ul><ul><li>Reduced Risks of Re-intervention:...
New Approaches to Stenting Coronary Arteries <ul><li>Thinner stent struts </li></ul><ul><li>New polymers </li></ul><ul><ul...
Evolution of PCI:  The Dominant Coronary Revascularization Therapy  Dr. Don Baim, FDA Panel Meeting December 2006 Progress...
 
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Repairing Coronary Arteries, pumpsandpipesmdhc

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Repairing Coronary Arteries, pumpsandpipesmdhc

  1. 1. Repairing Coronary Arteries Neal Kleiman Director Cardiac Catheterization Laboratory Methodist DeBakey Heart Center Professor of Medicine Weill Medical College of Cornell University
  2. 2. Courtesy of Dr. Paul Tierstein
  3. 3. Courtesy of Dr. Paul Tierstein
  4. 4. Angioplasty: The Thirtieth Anniversary Gruntzig Patient
  5. 6. Balloon Angioplasty: The Initial Concept “ Footprints in the snow”
  6. 7. Mechanism of Angioplasty Landau C et al. N Engl J Med 1994;330:981-993
  7. 8. Angioplasty: Issues Seeking Solutions <ul><li>The atheromatous plaque is part of the arterial wall, not simply a harmful deposit on a normal structure </li></ul><ul><li>Blood vessels rarely follow linear courses </li></ul><ul><li>The artery is reactive and blood is reactive ! </li></ul><ul><ul><li>All intra-arterial procedures injure the wall and provoke scar formation (“restenosis”) </li></ul></ul><ul><ul><li>Blood is a substance that when provoked , turns from a viscous fluid into a solid (clot) </li></ul></ul>
  8. 9. How are these problems manifest following angioplasty? <ul><li>Failed procedure: 5% (vessel just can’t be dilated) </li></ul><ul><li>Abrupt closure: 5% </li></ul><ul><li>Periprocedural heart attack: 10% (3/4 of these are very small) </li></ul><ul><li>Renarrowing or restenosis: 30% - 40%, particularly in long areas of blockage, and patients with diabetes. </li></ul>
  9. 10. Angioplasty – The major issue for the last thirty years <ul><li>How to modulate the vascular and blood reactivity to the barotrauma caused by balloon injury. </li></ul><ul><ul><li>Preventing vascular smooth muscle cells from forming “scars” inside blood vessels </li></ul></ul><ul><ul><li>Preventing platelets from forming clots on the injured areas </li></ul></ul>
  10. 11. Chung, I.-M. o et al. J Am Coll Cardiol 2002;40:2072-2081 Restenosis Or “Scar Formation” After Angioplasty – The Role Of Tissue Ingrowth
  11. 12. Why not Scoop out the plaque? DCA picture
  12. 13. Why not grind it up?
  13. 14. Why not vaporize it?
  14. 15. 316 L Stainless Steel 130-140  strut) or Co-Cr Alloy (80-90  strut)
  15. 17. Stents vs POBA <ul><li>Improved arterial lumen </li></ul><ul><ul><li>Reduces recoil </li></ul></ul><ul><ul><li>Scaffolds tears and dissections </li></ul></ul><ul><li>Reduces abrupt vessel closure </li></ul><ul><li>Restenosis reduced from 40%  20% </li></ul><ul><li>No documented reduction the rates of death or heart attack </li></ul>
  16. 18. Drug Eluting Stents <ul><li>Stent + Drug + Polymer </li></ul><ul><li>The drug prevents cell replication by interfering with cellular reproduction. </li></ul><ul><li>Reduces in-stent renarrowing 20%  <5% and the need for repeat procedures </li></ul><ul><li>In 2006, accounted for 90% of stent use in the US and 30%-50% in Europe </li></ul><ul><li>In 2007, use is approx 70% in US and 20% in Europe </li></ul>
  17. 19. Drug Eluting Stents <ul><li>Polymer controls the release of drug at the appropriate rate (currently 2-4 weeks) </li></ul><ul><li>Strut separation and contact with the arterial wall influence the rate of drug delivery and possibly the clinical outcome. </li></ul><ul><li>The stent thus becomes both a scaffold and a platform </li></ul>
  18. 20. Paclitaxel Drug Eluting Stent System (Taxus) Elastomeric, Polyolefin Derivate
  19. 21. Sirolimus Drug Eluting Stent System (Cypher) PBMA / EVA
  20. 22. Heterogeneity of Re-Endothelializaiton in a Drug-Eluting Stent Finn, Circulation: 2007
  21. 23. Cumulative Incidence of DES Thrombosis in the Rotterdam-Bern Registry Daemen: Lancet: 2007:369: 667 <ul><li>Accumulated early and midterm implantation experience </li></ul><ul><li>8,146 Patients initially  981 at f/u </li></ul><ul><li>24% of patients with thrombosis were on clopidogrel and aspirin </li></ul>0.6%/year late thrombosis
  22. 24. <ul><li>16 RCTs; 8,695 Patients </li></ul><ul><li>Follow-up to 4 Years </li></ul><ul><li>Reduced Risks of Re-intervention: HR = 0.74 (0.63-0.87) and </li></ul><ul><li>Stent Thrombosis: HR = 0.66 (.46-.94) </li></ul><ul><li>No  in Risk of MI: HR = 0.84 (0.69-1.03) </li></ul>
  23. 25. New Approaches to Stenting Coronary Arteries <ul><li>Thinner stent struts </li></ul><ul><li>New polymers </li></ul><ul><ul><li>Phosphorylcholine (PC) – mimics the outer layer of a normal cell membrane </li></ul></ul><ul><ul><li>Bioabsorbable polymers – elute the appropriate medication and then disappear </li></ul></ul><ul><li>Bioabsorbable stents </li></ul><ul><ul><li>Entire stent itself is reabsorbed over a period of six months </li></ul></ul><ul><li>Endothlial Precursor Cell (EPC) Capture </li></ul>
  24. 26. Evolution of PCI: The Dominant Coronary Revascularization Therapy Dr. Don Baim, FDA Panel Meeting December 2006 Progressive improvements in success, safety, and durability, as serial new technologies have been launched. Innovations over time 0 10 20 30 40 POBA early POBA late Stent early Stent late DES Event Rate % 1977 1985 1997 1994 2003-present Failure Em CABG Restenosis Stent thrombosis VLST

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