Drug Eluting Stents for in stent restenosis Powerpoint Presentation

Drug Eluting Stents for in stent restenosis

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Slide 1 :

Dr Adrian Banning, The John Radcliffe, Oxford Drug eluting stents for in-stent restenosis

Slide 2 :

Case Presentation (1) 44-year old man August 2001 presents with Unstable Angina, severe LAD stenosis. Direct stent - 3.5x15 NIR Elite October 2001: recurrent angina, severe stenosis just proximal to the stent. 3.5x8 Express, partially overlapping the first April 2002: recurrent angina - diffuse in-stent restenosis. CABG with LIMA->LAD

Slide 3 :

Case Presentation August 2001 stent October 2001: stent April 2002: CABG with LIMA->LAD, June 2002 Recurrent angina Management? Exercise test on treadmill?

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Case Presentation (2) August 2002: cath - failed LIMA graft- enrolled in a multicenter registry (non-polymeric paclitaxel DES at concentration of 3.0 µg/mm2 DELIVER II ) 2 “Achieve” stents 3.5x18 and 3.5x23 mm in the mid LAD Entire previously stented segment was covered Optimized with high-pressure 3.5 mm NC balloon, no IVUS

Slide 6 :

Case Presentation (2) August 2002: cath - failed LIMA graft- enrolled in a multicenter registry (non-polymeric paclitaxel DES at concentration of 3.0 µg/mm2 DELIVER II ) 2 “Achieve” stents 3.5x18 and 3.5x23 mm in the mid LAD Entire previously stented segment was covered September 2003 (13 months) recurrent angina Further angiogram 5th in 22 months

Slide 7 :

September 2003 PRE-INTERVENTION

Slide 8 :

September 2003 Intervention number 4 IVUS guidance Cypher 3.0x23 and 3.0x23 covering all the previously stented segment with overlap. 3.5 NC balloon multiple inflations (up to 24 atm) IVUS used to check MLA>5 mm2

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September 2003 POST-INTERVENTION

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April 2004 (8 months post) FOLLOW UP

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April 2004 (8 months post) FOLLOW UP

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What is “in stent restenosis” Densely packed neointima mainly VSMC and matrix Like a keloid scar Not atheroma

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The pre-DES era

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Treatment modality does not matter

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Vascular brachytherapy good short term results

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DES era: a bad start

Slide 20 :

Data from registries

Slide 21 :

Cypher stent: Brazilian and Dutch experience

Slide 22 :

Long term follow-up

Slide 23 :

QCA data: late catch up?

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IVUS data: reassuring

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SECURE registry

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Stent underexpansion is still important !!!

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Sequential IVUS analysis of lumen and stent dimensions

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Practical tips for treating ISR Prevent ISR using DES or properly expanded BMS! much less diffuse ISR When treating ISR Use preinflation/cutting balloon Cover the whole stented segment with generous margins IVUS guidance (mandatory for DES failure) Optimally expand both stents with NC balloons

Slide 36 :

Conclusions DES can treat ISR as well (and probably better than) any other modality including brachy and surgery!! Definitive trials will be published shortly Radiotherapy has a limited role in the future

Slide 37 :

TOO much radiation is bad for you

Slide 38 :

Even a little radiation can be bad for you! And who is that young man?

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Don’t know but……

Slide 40 :

More pictures on SexyDrRobCrook.com.uk

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Thank you The end

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Ongoing studies

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Final result does

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	flintoff 5 Years ago. Category: Cardiology

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