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DÉCLARATION DE LIENS D'INTÉRÊT AVEC LA PRÉSENTATION
Speaker's name : Stéphane CARLIER, Mons ☑ Consultant, Boston Scientific
Facteurs favorisants de restnose et de rocclusion dans la CTO - - PowerPoint PPT Presentation
Facteurs favorisants de restnose et de rocclusion dans la CTO - - PowerPoint PPT Presentation
Facteurs favorisants de restnose et de rocclusion dans la CTO Stphane CARLIER Chadi Ghafari UMONS & CHU Ambroise Par, Mons, B DCLARATION DE LIENS D'INTRT AVEC LA PRSENTATION Speaker's name : Stphane CARLIER, Mons
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Resténose post recanalisation CTO
- C’est regarder à une partie du problème de la RESTENOSE
- La RESTENOSE est un phénomène complexe
– touche 5-10% DES – se présente en SCA: 30-60 %
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Histopathology
- Inflammatory reaction post arterial injury persisting >90 d
Risk Factors
- Patient characteristics
- Lesion types
- Procedural factors
- DM
Mercado N et al Clinical and QCA predictors of coronary restenosis: J Am Coll Cardiol 2001; 38: 645–652
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Histopathology
- Inflammatory reaction post arterial injury persisting >90 d
Risk Factors
- Patient characteristics
- Lesion types
- Procedural factors
- DM
Mechanisms
- Biological
- Arterial
- Stent factors
- Implantation factors
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Biological mechanisms
- Resistance to antiproliferative drugs
– Genetically or acquired
- Hypersensitivity reactions
– To the polymer – To the metallic stent platform
- Inflammatory biomarkers and genetics
– Role of MMP, PAI-1, C3a and C5a
- Wall shear stress
- Vessel remodeling / Glagov effect
- Late restenosis: chronic inflammation, neoatherosclerosis…
Arterial Mechanisms
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Stent Factor
- From BMS stent era…
- Network meta-nalysis BMS vs DES
De Feyter PJ et al IVUS predictors for 6-mo QCA restenosis. Circulation 1999; 100:1777–1783 Raffaele Piccolo et al DES or BMS for PCI: systematic review and individual patient data meta-analysis. Lancet 2019; 393:2503–10
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Classification des resténoses
- R Mehran et al 1999
Focal
- DES
Diffuse
- BMS
The patterns of restenosis in SES and PES The predominant pattern of restenosis is a focal pattern of restenosis, although diffuse and proliferative restenosis are still seen with DES. *P- value calculated for the overall observed difference in the pattern of restenosis in PES and SES groups. SES indicates sirolimus- eluting stent; PES: paclitaxel- eluting stent; DES: drug-eluting stent. Reproduced with permission from Corbett et al
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Minimal Stent Lumen Area
1 2 3 4 5 6 7 8 9 10
Minimum stent CSA
0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8 0,9 1
Stent expansion
(mm2)
p<0.001 p<0.001
Stent thrombosis (n=15) Matched controls (n=45)
J Am Coll Cardiol 2005;45 995-8
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J Am Coll Cardiol 2005;45 995-8
Significant residual stenosis in reference segments
67 9 20 40 60 80 100
Stent thrombosis (n=15) Matched controls (n=45)
(%)
p<0.001
A significant residual reference segment stenosis was defined as a reference minimum lumen CSA <4mm2 and a plaque burden >70%
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Histopathology
- Inflammatory reaction post arterial injury persisting >90 d
Risk Factors
- Patient characteristics
- Lesion types
- Procedural factors
- DM
Mechanisms
- Biological
- Arterial
- Stent factors
- Implantation factors
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nonSTEMI → 1 DES in RCA…
dans un autre hôpital
Procedure Factor
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LL 18/12/1934 – F 84 y
- Planned recath on 17/10/2019 for lesions Cx and LAD
Early restenosis RCA, + FFR LAD → CABG
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- PCI 20/10/2019: The RCA…
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Megatron 3.5x16 16 atm OPN 3.5x15 30 atm
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25
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DA 18/09/1952 67 y preDM Male
4 Jun 2019 Unstable angina Tropo I: 1 (N<15) Stent LAD 2009 13 Jun
Chest pain in rest and exercise since 2-3 weeks, ~2009
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Sapph 2.75x18 14 atm Magmaris 3.5x25 16 atm NC 3.75x15 20 atm
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13/6/2019 8/8/2019
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8/8/2019
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Resténose en fonction technique CTO
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IVUS Guidance for CTO: evidence from RCT
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Clinical Impact of IVUS–Guided CTO Intervention with Zotarolimus- vs Biolimus-Eluting Stent (CTO-IVUS)
Circ Cardiovasc Interv. 2015;8. DOI:10.1161/CIRCINTERVENTIONS.115.002592
Angiographic and clinical comparisons of IVUS-- versus angiography-guided DES implantation for CTO: two-year results from the randomised AIR-CTO study
EuroIntervention 2015;10:1409-1417
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Clinical evidence from RCT
- Prospective RCT involving 8 experienced IVUS sites in China
- Randomized 1448 all comers, 2nd gen DES
Zhang J. et al. TCT 2018 Late Breaking Clinical Trial J Am Coll Cardiol. 2018 Dec 18;72(24):3126-3137. doi: 10.1016/j.jacc.2018.09.013
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Clinical evidence from Registries
DI MARIO
Ki Hong et al. J Am Coll Cardiol. Volume 12, Issue 7, 8 April 2019, Pages 607-620
From 03/2003 through 12/2015, 6,005 patients undergoing PCI for complex lesions with drug-eluting stents were enrolled from a prospective institutional registry. All enrolled subjects had at least1 complex lesion (defined as bifurcation, chronic total occlusion, left main disease, long lesion, multivessel PCI, multiple stent implantation, in- stent restenosis, or heavily calcified lesion). 1,674 IVUS guided procedure vs 4,331 with only angiography
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EuroIntervention 2018;14-online publish-ahead-of-print June 2018 Clinical use of intracoronary imaging. Part 1: guidance and optimization of coronary interventions. An expert consensus document of the European Association of Percutaneous Cardiovascular Interventions
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A-t-on besoin d’IVUS pour les procédures de CTO?
EuroIntervention 2018;14- An expert consensus