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The evolution of stent design for chronic iliac vein obstruction
Stephen BlackConsultant Vascular Surgeon
Clinical Lead for Venous and Lymphoedema SurgeryGuys and St Thomas Hospital London
They
Not ‘Strong’ Enough
Arterial stent Expanded with Venous Stent
Design Process
5
Designing is Cyclic and Iterative
• Design inputs, i.e. Clinical requirements drive the design and development process
• Feedback repeats the design process
• We as users need to provide feedback
6
Design Inputs
• Inputs and Requirements (Design Criteria)
• Ideally, requirements lead to a design centered in a Venn diagram
• An optimized design is achievable
7
IDEAL
OPTIMIZED DESIGN
DESIGN REQUIREMENT #1
DESIGN#1 & #3
DESIGN#1 & #2
DESIGN#2 & #3
Design Constraints
• Design inputs have real world constraints
• Requirements and constraints often compete
• The ideal design is unachievable
8
Types of Requirements and Criteria
• Clinical Requirements (i.e. Safety, Patency)
• Engineering Requirements (Functionality, Specifications)
• Regulatory requirements
• Intellectual Property
• Manufacturability
• Development Cost
• Time to market
9
Intellectual Property Requirements
• Intellectual Property (IP) has become a requirement for medical devices to protect the product and company, especially in the United States
• According to US Patent & Trademark Office, the total number of medical device patents granted has increased by approx. 169% from 7,443 in 2009 to 19,992 in 2014
Regulatory Requirements
• MDD 93-42-EEC: Council Directive concerning medical devices
• ISO 13485: Medical devices – Quality management systems – Requirements for regulatory purposes
• ISO 14971: Medical devices – Application of risk management to medical devices
• 21 CFR 820: FDA Quality System Regulation
• ISO 25539-2: Cardiovascular implants Part 2: Vascular stents
• ISO 10993: Biological evaluation of medical devices
• ISO 11135: Sterilization of heath care products
• FDA Guidance: Non-clinical engineering tests and recommended labeling for intravascular stents and associated delivery system
11
Clinical Requirements
• The purpose of the venous stent is to maintain an open lumen to allow flow, and reduce congestion and hypertension
• Effectiveness determined through patency rates
• Safety through low adverse events rates
• Improvement of venous symptomatic scores, i.e. CEAP and VCSS, can also be requirements
12
Engineering Requirements
– Crush Resistance
– Flexibility
– Radial Strength
– Deployment
– Scaffolding (Coverage)
– Diameters & Lengths
13
“The ideal stent would be flexible with moderate radial force, no foreshortening, and allow for very precise and
accurate placement.” - Brooke Spencer, MD, FSIR
“The ideal stent has to be reasonably long and flexible, yet
provide adequate radial strength to withstand opposing
forces at the choke points.” - Seshadri Raju, MD, FACS
“Some desirable features are common to all stents, not just venous devices, and include
precise deployment, good visibility,
and flexibility of both a low profile
delivery catheter and the deployed stent. However, certain attributes are more suited
for venous applications, such as larger diameters (≥14 mm) and appropriate
levels of radial force and crush resistance.” - Mahmood K. Razavi, MD, FSIR
Venous Stenting: Expectations and Reservations; Raju S, Razavi MK, Spencer B, Williams DM, Endovascular Today, July 2013
Engineering Conflicts and Optimization
• Design Conflicts– Strength vs Flexibility vs Foreshortening
– Scaffolding/Coverage vs Flexibility
– Crush Resistance and Radial Strength vs Deployment
• Each requirement is a “lever” that can be moved, however, it may affect and move other levers
• Optimization of a design is based on how all the levers are prioritized
14
Other Requirements/Constraints
• Manufacturability– Without efficient manufacturing process, product cost
can be high– Without robust manufacturing process, defects and
yields may jeopardize product quality
• Development Cost– Increases with more design features and optimization– Increases with design complexity
• Time to market– Multi-year long process from concept to product release– First-to-market typically establishes leadership and
market share
15
It is principally about Radius
Radial Resistive Force: How much circumferential
load a stent can resist
Chronic Outward Force:How much the stent pushes outward. Changes w diameter expansion. Often called Radial Force.
Stent Strength
Crush Resistance: How much the stent can
resist a single load
Radial Resistive Force
-5
0
5
10
15
20
0 5 10 15 20
Ho
op
Str
en
gth
(N
)
Diameter (mm)
16mm Stent Radial Strength
Hybrid
Open Cell
Closed Cell
Braided
Radial Resistive Force: How much circumferential
load the stent can take
Crush Resistance
0
0,2
0,4
0,6
0,8
1
1,2
1,4
0 1 2 3 4 5 6 7 8
Sten
t Fo
rce
(N)
Extension (mm)
Closed Cell
Closed Cell -midpoint
Closed Cell -endpoint
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0 1 2 3 4 5 6 7 8
Sten
t Fo
rce
(N)
Extension (mm)
Open Cell
Open Cell -midpoint
Open Cell -endpoint
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
0 1 2 3 4 5 6 7 8
Sten
t Fo
rce
(N)
Extension (mm)
Hybrid
Hybrid - midpoint
Hybrid - endpoint
0
0,5
1
1,5
2
2,5
3
0 1 2 3 4 5 6 7 8
Sten
t Fo
rce
(N)
Extension (mm)
Braided
Braided -midpoint
Braided -endpoint
Flexibility
Competitive Designs
Closed Cell Open Cell Hybrid Braided
Crush Resistance + - - ++
Flexibility + ++ ++ -
Radial Strength + - ++ --
Deployment + + -- -
Scaffolding ++ - -- +
Diameters & Lengths + - + +
Cook Zilva Vena
Bard Venovo
Sinous-Venous
Veniti Vici
25
Peak/Valley
Bridge
Cell
Strut RingStrut
Strut Ring
Bridge
Sinus Obliquus
Others
• Medtronic – Abre
• Gore - ? (good platform with Tigris)
• Abbott - ?
• Small start up companies
Patency
Technical Flow
Clotting
Stent Choice
Placement
Errors
Mistakes
Inflow!!!
CFV
APLS
Behcet’s
Anti-coagulation
Deep venous reconstruction programme
2006 2007 2008 2009 2010 2011 2012 2013 2014 20150
20
40
60
80
Acute DVT
Chronic PTS
Nu
mb
er o
f P
atie
nts
Total patients seen 444
Total patients having intervention 220
TABLE 1
April 2012 and November 2015
ACUTE PATEINTS
88% of CDT
patients had a
venous stent
CHRONIC
PATEINTS
Ulcer healed in 6/14
patients (43%)
Venous Stenting is Not New…
• Significant body of clinical work
– Existing stents (off label)…Wallstent
– Good success treating venous outflow obstruction (peer review publications)
• Current generation of stents in USA IDE trials IDE and available OUS
– VIVO Trial – Zilver Vena (Cook Medical)- completed
– VIRTUS Trial – VICI VENOUS STENT (VENITI, Inc.) - completed
– Venovo (Bard) - Startedrecruitment
– Abre (Medtronic) – Next year April
– Sinus Venous/Obliquus (Optimed) – No trial as yet
– Wallstent (BSCI) – No trial
Safety and efficacy of current designs
Conclusions
• The stent alone is not the panacea
• Know each device and technical issues
• Be honest in feedback and know this is just the beginning
• We need long term patient outcome data to support use
• We do not have data yet to know if this is durable