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Stenting:επαναστένωση ISR (intra stent restenosis) Μετεκπαιδευτικό Πρόγραμμα στην Αγγειοχειρουργική - Ενδαγγειακή Χειρουργική Κ. Α. Φίλης Αν. Καθηγητής.

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Παρουσίαση με θέμα: "Stenting:επαναστένωση ISR (intra stent restenosis) Μετεκπαιδευτικό Πρόγραμμα στην Αγγειοχειρουργική - Ενδαγγειακή Χειρουργική Κ. Α. Φίλης Αν. Καθηγητής."— Μεταγράφημα παρουσίασης:

1 Stenting:επαναστένωση ISR (intra stent restenosis) Μετεκπαιδευτικό Πρόγραμμα στην Αγγειοχειρουργική - Ενδαγγειακή Χειρουργική Κ. Α. Φίλης Αν. Καθηγητής ΕΚΠΑ

2 Definitions ISR can be defined clinically or angiographically. Clinically, it is defined as the presentation of recurrent ischaemia Angiographically, ISR is the presence of >50% diameter stenosis in the stented segment. 50%-70% : moderate 70%-99% : severe Teirstein PS, N Engl J Med, 1997

3 Cellular response to injury Platelet adherence and degranulation (10-30min) –Subenthothelial collagen exposure –Platelets adherence (α ΙΙb β IΙa, Von Villebrand, Fibronectin) –ADP, thromboxane A 2, –Platelets recruitment (α ΙΙb β ΙΙIa) –Platelets degranulation (PDGF) Leukocyte, monocytes, macrophages SMC proliferation and migration (1day – 3months) Endothelial cell regrowth

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6 Diffuse in stent restenosis

7 Initial role of stents : optional to support the dissected ballooned plaque from further dissection-rupture to prevent arterial recoil by their radial force

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9 PTA result

10 Το δίλημμα Αγγειοπλαστική με μπαλόνι – Constrictive remodeling (αναδιαμόρφωση σύσπασης) – Elastic recoil (ελαστική επαναφορά) Αγγειοπλαστική με ενδοπρόθεση – Αυξημένη μυο-ενδοθηλιακή υπερπλασία

11 Intimal hyperplasia

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15 Various ISR 1 year according to locations

16 Time course of ISR

17 Factors influencing ISR

18 Cardiovascular factors Smoking Diabetes Hyperlipidemia

19 Effect of smoking in ISR Cardiovascular factors

20 Effect of diabetes in ISR Cardiovascular factors P=0.89 (NIDM) P=0.04 (IDM)

21 Genomic Blood flow Plaque

22 Genomic Endogenous factors

23 Blood flow Endogenous factors

24 Plaque

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26

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29 Exogenous factors Stent

30 Exogenous factors Stent Ευλυγισία Πάχος Ευκολία καθοδήγησης Ακτινική δύναμη Ικρίωμα/Σκαλωσιά Βιοσυμβατότητα Μηχανική αντοχή Αντίσταση στη ρήξη

31 Stent asymetry Exogenous factors

32 Self expanding V balloon expanded Exogenous factors

33 Cell design Exogenous factors

34 Strut Thickness Exogenous factors

35 Stent fracture Exogenous factors

36 Restenosis-Thrombosis Pharmacologic prevention ASA & Heparin ASA & Ticlopidin

37 Restenosis-Thrombosis Pharmacologic prevention

38

39 Gold standard : Clopidogrel + aspirin

40 Σημασία των αντιαιμοπεταλιακών Αναστολή αιμοπεταλιακής δραστικότητας με σκοπό την πρόληψη της οξείας θρόμβωσης της αγγειοπλαστικής Ανεπαρκή για την επαναστένωση

41 Prevention of ISR Medicines Drug eluting stents Brachytherapy, Cryoplasty Genes

42 Medicines Medicines ISR on coronary PTA/stent PDGF I antiallergic Reo pro

43 Induction of vascular atrophy as a novel approach to treating restenosis. A review Seung-Kee Min MD a, Richard D. Kenagy PhD b and Alexander W. Clowes MD b,, a b intimal thickeningendothelial injury and inflammationsmooth muscle cell hyperplasia, extracellular matrix accumulation After vascular reconstruction, luminal narrowing is in part caused by intimal thickening, the consequence of endothelial injury and inflammation, smooth muscle cell hyperplasia, and extracellular matrix accumulation. It may be possible to induce these lesions to shrink. This novel approach to the treatment of restenosis is supported by animal experiments and a few clinical observations demonstrating vascular atrophy in response to drugs such as Gleevec (EDGF I). A potential limitation to this approach might be the formation of aneurysms. Journal of Vascular Surgery Volume 47, Issue 3Journal of Vascular Surgery Volume 47, Issue 3, March 2008, Pages

44 Drug eluting stents sirolimus (rapamycin) paclitaxel inhibit smooth muscle cells and endothelial cells 1.They inhibit ISR 2.They are more thrombogenic Clinical practice : no benefit in survival, no benefit in MACE, But fewer reinterventions to keep the artery patent

45 Drug eluting stents in peripheral arteries SMART (SIROLIMUS) CORDIS ENDOVASCULAR ZILVER (PACLITAXEL) COOK

46 Drug eluting balloons in peripheral arteries  THUNDER trial (Local Taxane with Short Exposure for Reduction of Restenosis in Distal Arteries), 2008  Femoral Paclitaxel (FemPac) trial, 2008  ILLUMENATE trial, 2013, euroPCR  DANCE trial, 2013, MEET (subenthothelial dexamethazone injections)

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48 Drug eluting balloons plus nitinol bare stent in peripheral arteries

49 VIASTAR study, 2013 – Heparin-bonded stent-graft V metal stent – For type D lesions Stent-grafts in peripheral arteries

50 Biodegradable Stents

51 Brachytherapy

52 Gene therapy Genetically engineered cells secreting a thrombolytic enzyme (tPA) which are topically applied (on the stent). Major problem : cells are moving away by the blood flow.

53 Conclusions ISR is a stable endothelial reaction to injury STRATEGIES TO INHIBIT ISR systematic topical systematic topical edicines DES, Drug eluting balloons Medicines DES, Drug eluting balloons Brachytherapy, Brachytherapy, Cryoplasty Cryoplasty Photodynamic therapy Photodynamic therapy Genes Genes


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