Drug Eluting Stents:Pre & Post DES Vessel Treatment
Ted Feldman, MD, FACC, FSCAI
Drug Eluting Stents:Pre & Post DES Vessel Treatment
Ted Feldman, MD, FACC, FSCAI
April 28-30th 2005Angioplasty Summit
Seoul, Korea
Malappostion vs residual stenosis• SAT vs restenosisPre-treatmentStent deploymentPost-dilatationIVUS
Malappostion vs residual stenosis• SAT vs restenosisPre-treatmentStent deploymentPost-dilatationIVUS
Drug-eluting stent thrombosis
JACC 45: 954-959, 2005
REALITY
REALITY
T-SEARCH
RESEARCH
SIRIUS – IVUS Analysis
No associated clinical events in any patient with incomplete apposition at baseline or follow-up
Incomplete Stent Apposition
Stent underexpansion & residual stenosis vs stentthrombosis after sirolimus-eluting stent implantation
Kenichi Fujii JACC 45: 995-998, 2005
n= 15 SAT after successful SES implantation vs 45 matched controls
<.00146%62%Plaque burden.816%13%Malapposition
<.0019%67%Residual stenosis
<.001.85.65Stent expansion
<.0016.2mm24.3mm2MSA
pNo SATSAT
Independent predictors: underexpansion (p = 0.03) and residual stenosis (p = 0.02).
11.614.2
17.4
10.2
6.85.4
0
5
10
15
20
<14 14-16 >16
DEPLOYMENT PRESSURE (atm)
PressureTVR
Deployment Pressure vs TVRTAXUS IV
Kutcher et al AJC 94(6A) 2004
In-Stent RestenosisInadequate Initial Stent Expansion
PRE Post RA 1.75/2.15mm
prior 3mm Stent
Post 3.75mm PTCA
Malappostion vs residual stenosis• SAT vs restenosisPre-treatmentStent deploymentPost-dilatationIVUS
Vessel vs Device Considerations
As you go through lifeWhatever be your goalKeep your eye upon the donutAnd not upon the hole
33
27
0
5
10
15
20
25
30
35
PTCA Rota
% F
inal
Ste
noFacilitated Angioplasty
Vessel vs Balloon Compliance
JACC 27:552,1996
*1.05
0.98
0.94
0.96
0.98
1
1.02
1.04
1.06
PTCA Rota
Bal
loon
/Arte
ry R
*
0.69
0.78
0.64
0.66
0.68
0.7
0.72
0.74
0.76
0.78
0.8
PTCA Rota
PTC
A
*
Efficiency = Final Lumen/Balloon Diameter
Low Pressure Balloon InflationPTCA 3.2mm Vessel 2.5mm Burr
90% Stenosis
Pressure x Diameter2 x Wall ThicknessF=
6 atm x 0.32mm =F= 6 atm x 2.5mm2 x 1.44mm 2 x 0.35mm
0.67 atm =F= 21.43 atm
Cutting Balloon Ultra2
Device Atherotome100X Magnification
0.014” Wire 100X Magnification
Cutting BalloonAtherotome
.005”
CoronaryStentStrut
HumanHair
.003”
Atherotome Surgical Scalpel
100 A 300 A
Cutting Balloon
Ostial RCAPRE
3x10mm Cutting Balloon12atm
Post Cutting Balloon
Post Rota
2mm Rota
Post 4mm stent
Effects of focused force angioplasty: pre-clinical experience
Meerkin DS, Lee SH, Tio FO, Grube E, Wong SC, Hong MK
J Invas Cardiol 2005;17:203-206
Malappostion vs residual stenosis• SAT vs restenosisPre-treatmentStent deploymentPost-dilatationIVUS
Under Expansion Routinely Occurs (POSTIT)
Optimal stent deployment is only achieved in 29% of patients with current stent delivery systems
With post dilatation, the frequency of achieving optimum stent deployment doubled from 21% to 42%
Minimal stent area increased from 6.6+/- 2.2 to 7.8+/-2.3mm2 with post dilatationBrodie et al, Cathetrization and Cardiovasc Int 2003. 59:184-192
Cypher
Malappostion vs residual stenosis• SAT vs restenosisPre-treatmentStent deploymentPost-dilatationIVUS
Prior S
tents
Additional Stent
Calcified Vessel
PTCA4.0x9mm
24 atm
PRE POST high pressure PTCA
Pressure = Dilatation Force
Pressure vs Dilatation ForceDilatation Force
Straw Test
0.0
5.0
10.0
15.0
20.0
25.0
30.0
0 2 4 6 8 10 12 14 16 18 20 22 24
Pressure (ATM)
Dila
tati
on F
orc
Stent Delivery Balloon NC Ranger
Malappostion vs residual stenosis• SAT vs restenosisPre-treatmentStent deploymentPost-dilatationIVUS
CircLAD
LAD
Diag
Diag