Advances in Stent Technology

Transcription

1 Nurse/Technologist Symposium Advances in Stent Technology Antonietta Tolentino, CCRN, MSN, ANP-C Adult Nurse Practitioner, Cardiac Catheterization Laboratory The Zena and Michael A. Weiner Cardiovascular Institute The Mount Sinai Medical Center, New York Send the Speaker Questions at;

2 No Disclosures

3 Outline Metallic DES with Durable Polymers DES with Biodegradable Polymers Nonpolymeric DES Stents with Novel Coatings Biodegradable Stents Self Expanding Stents Bifurcation Stents Drug eluting balloons (DEB) Coronary Stents Looking Forward Garg, S. & Serruys, P. JACC Vol.56. No. 10 Supp S. 2010

4 30 Years in the Evolution of PCI Sigwart et al., Eur. Interven. 2011;7:K8-10

5 Stent Thrombosis

6 Stent Thrombosis: A Multifactorial Process Patient & Lesion Factors l l l l l ACS, unstable angina Underlying coagulopathy, malignancy Diabetes, low EF or chronic renal failure Vessel size, lesion length, arterial structure Vulnerable plaque regions Procedural Complexity l Morphometric (under-expansion, malapposition) l Morphologic (dissection, thrombus, protrusion) l Mechanical vessel injury l Anti-thrombotic therapy Stent Thrombogenicity l Material l Design l Surface coating l Adjunctive therapeutic agents Honda et al, Circulation 2003;108:2

7 Drug Eluting Stents Next Generation

8 Thin Stent Strut Profiles on New Stent Platforms

9 New Durable Polymer Metallic Stents (A, B) The cobalt chromium Elixir DESyne novolimus-eluting stent crimped (A) and expanded (B). A is reproduced with permission from Costa et al. (14). (C, D) The platinum chromium everolimus-eluting Element stent crimped (C) and expanded (D). Images C and D are courtesy of Boston Scientific.

10 DES with Biodegradable Polymers NEVO Stent Design (A) The NEVO cobalt chromium stent, which has an open-cell design and unique reservoirs that contain a biodegradable polymer and sirolimus mix that (B) completely biodegrades within 90 days.

11 Nonpolymeric DES BioFreedom & VESTAsync Stent

12 Nonpolymeric DES Perceived Advantages Avoidance of adverse effects of a polymer s presence long term Improved healing Improvement to the integrity of stent s surface Shorter duration DAPT

13 Stents with Novel Coatings The Genous Stent (A) Schematic representation of the endothelial progenitor cell (EPC) capture technology. The CD-34 antigens on the surface of the EPCs attach to the anti-cd-34 antibodies on the stent s surface, promoting endothelialization. (B) The stainless steel Genous stent. B courtesy of Orbus Neich.

14 Overview of Biodegradable Stents Company Picture Polymer/Drug Features Igaki-Tamai (2000) PLLA PLLA plus Tranilast Zig-zag design deployed with a heated balloon Biotronik (2006) Magnesium alloy Balloon expandable design Abbott (BVS) (2006) PLLA with everolimus Balloon expandable Reva Medical (2008) BTI (2008) Tyrosine poly carbonate with iodine radio-opacity Salicylic acid blended into polymer Design has ratchet links for deployment Balloon expandable

15 Bioresorbable Vascular Scaffold Potential Advantages Restore the vessel to a more natural state, capable of natural vascular function Eliminate chronic sources of vessel irritation and inflammation Vessels remain free for future treatment options Reduce the need for prolonged DAPT Allows for use of non-invasive imaging techniques (CCTA)

16 Bioabsorption & Drug Release Pattern of the BVS Device The early loss of radial strength has been addressed with the new Revision 1.1 BVS stent (data on file at ABBOTT Vascular).

17 BVS Device (A) The first-generation BVS device, Revision 1.0. (B) The second-generation device, Revision 1.1. There is a clear change in the device design with the out-of-phase zigzag pattern connected directly or by straight bridges (A, Revision 1.0) being replaced by the in-phase hoops linked by straight bridges (B, Revision 1.1).

18 Bioabsorbable Stent Technology Abbott Bioabsorbable Stent (BVS) ABSORB Trial Serruys et al. Lancet 2009

19 Self-Expanding (SE)Stents (A) The vprotect Luminal Shield stent. (B, C) The CardioMind Sparrow stent. (B) Illustrates the flexibility of the Sparrow stent delivery system, whereas (C) demonstrates the smaller profile of the Sparrow stent compared with a conventional balloon-expandable stent, and a 6-F guiding catheter. (B, C) Reprinted with permission from Chamie et al. (168).

20 Self-Expanding Dedicated Bifurcation Stents Conical stents for the geometry of the ostium Stents that facilitate provisional SB stenting and maintain direct access to the SB after MB stenting (A) Axxess, (B) Sideguard, and (C) Stentys.

21 Balloon-Expandable Dedicated Bifurcation Stents Stents designed to treat the SB first. Designed for those bifurcation lesions with significant SB disease; a 2 nd stent is required for the MB (A) Antares, (B) Invatec Twin-Rail, (C) Multi-Link Frontier, (D) Nile Croco/Pax, (E) Petal, (F) Tryton.

22 Drug-Eluting Balloons (DEBs) Anti-proliferative effect (Paclitaxel) Absence of polymer & stent struts Coronary (ISR) and Peripheral applications

23 Summary No single stent design and polymer type will be suitable for all patients and lesion types. Stent selection should take into account patient characteristics, such as the ability to take long-term DAPT, and lesion characteristics such as the presence of bifurcation lesion. New stent technology appears to allow interventional cardiologists to make these choices, with anticipation that this will result in improved long-term clinical efficacy & safety.