Stenting:επαναστένωση ISR (intra stent restenosis)

Παρουσίαση με θέμα: "Stenting:επαναστένωση ISR (intra stent restenosis)"— Μεταγράφημα παρουσίασης:

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

2 ISR can be defined clinically or angiographically.
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 %-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 (αΙΙb βIΙa, Von Villebrand, Fibronectin) ADP, thromboxane A2, Platelets recruitment (αΙΙb βΙΙIa) 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 PTA result

10 Το δίλημμα Αγγειοπλαστική με μπαλόνι Αγγειοπλαστική με ενδοπρόθεση
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 rates @ 1 year according to locations

16 Time course of ISR

17 Factors influencing ISR
Cardiovascular risk factors Endogenous risk factors Exogenous factors

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 Endogenous factors

25 Endogenous factors

26 Endogenous factors

27 Endogenous factors

28 Endogenous factors

29 Exogenous factors Stent

30 Stent Ευλυγισία Πάχος Ευκολία καθοδήγησης Ακτινική δύναμη
Exogenous factors 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

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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 ISR on coronary PTA/stent
Reo pro PDGF I antiallergic

43 Induction of vascular atrophy as a novel approach to treating restenosis. A review Seung-Kee Min MDa, Richard D. Kenagy PhDb and Alexander W. Clowes MDb, , Journal of Vascular Surgery Volume 47, Issue 3, March 2008, Pages 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.

44 But fewer reinterventions to keep the artery patent
Drug eluting stents sirolimus (rapamycin) paclitaxel inhibit smooth muscle cells and endothelial cells They inhibit ISR 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)

47

48 Drug eluting balloons plus nitinol bare stent in peripheral arteries

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

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