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