Drug eluting stents will solve the problem! Against JUNE...Commeau Cardiovasc Interv Radiol 2006 29...
Transcript of Drug eluting stents will solve the problem! Against JUNE...Commeau Cardiovasc Interv Radiol 2006 29...
1MEET 2008 –
Drug eluting Drug eluting stents will solve stents will solve
the problem! the problem! AgainstAgainst
MEET 2008 – Session 5Below the knee arteries & limb salvage
M. BosiersK. Deloose P. Peeters
2MEET 2008 –
CLI with BTK-pathology
Focal lesion15%
Diffuse lesions85%
3MEET 2008 –
1/ Focal lesion
• Minority of cases
LL<20mm
DES effect ontotal treated area
PTA + DES
4MEET 2008 –
1/ Focal lesion
• QVA shows good patency with low late lumen loss
pre post 6M LLS = 0.4mm
Evolution of MLDas measured by QVA
Bosiers et al. J Cardiovasc Surg (Torino). 2006 Apr;47(2):171-6.
5MEET 2008 –
1/ Focal lesion
100 @ 7.7M97 @ 7.7M
Sirolimus DES6230
CommeauCardiovasc Interv Radiol 2006
96.0 @ 12M86.4 @ 12M6629SiablisJ Endovasc Ther 2007
-100 @ 6M3030ScheinertEuroIntervention 2006
88.5 @ 12M30.0 @ 12MPaclitaxel DES 5029SiablisJ Vasc Intervent Radiol 2007
95.0 @ 6M83.7 @ 6M
Non-elutingstents
4224RandCardiovasc Interv Radiol 2006
29
50
N
100 @12M40.5 @12M65SiablisJ Endovasc Ther 2007
89.3 @12M62.8 @12M62BosiersEuroIntervention 2007
LS % PP %Stent typen
N=patients, n=lesions
Sirolimus Sirolimus elutingeluting stents stents mightmight bebe beneficialbeneficial
Paclitaxel Paclitaxel elutingeluting stents stents mightmight bebe hazardoushazardous
• Stenting results : single center
6MEET 2008 –
1/ Focal lesion
ONGOING RANDOMIZED CONTROLLED TRIAL• BMS (Vision) vs DES (XIENCE V) – DESTINY
– 140 patients (70 Vision – 70 Xience V) – 5 European sites (Bosiers, Peeters, Scheinert, Zeller, Commeau)– 1° Endpoint = Angiographic patency (In-stent binary restenosis >50%) – First inclusion March ’07
ClinicalTrials.gov Identifier: NCT00510393
DESTINYDESTINY--trial can confirm trial can confirm whether DES for whether DES for focalfocal infrapopliteal lesionsinfrapopliteal lesions
really improves patency!!!really improves patency!!!
7MEET 2008 –
2/ Long diffuse lesions
• Majority of cases = daily practice
LL~200mm
Residual stenosis
PTA with long low-pressure balloon
Focal stenting with DES
8MEET 2008 –
2/ Long diffuse lesions
PrePre--opop PostPost--opop
PTA with long low-pressure balloons followed by focal stenting
9MEET 2008 –
• The problem of DES in long diffused lesions
• Long term vessel patency is limited bypatency rate of segment treated with PTA only
2/ Long diffuse lesions
PTA PTA onlyonlyDESDESPTA PTA onlyonly
Follow-up
Procedure
10MEET 2008 –
2/ Long diffuse lesions
• Coronary DES trials showed– Inadequate lesion coverage
may contribute to edge stenosisIncreased risk for restenosis if full index lesion is not completely covered by DES
Sakurai et al. Am J Cardiol 2005;96:1251–1253.
11MEET 2008 –
• DES only effective if full lesion coverage
PRICE ISSUE = does this excellent patency justifythe increased treatment cost???
2/ Long diffuse lesions
fullfull DES effectDES effect
Follow-up
Procedure
12MEET 2008 –
Is DES cost-beneficial?
NO!!!
2/ Long diffuse lesions
CLI treatment is all about
saving the limb
Limbsalvage
Primarypatency
30%
Romiti et al. J Vasc Surg 2008;47:975-81.
13MEET 2008 –
Conclusion
In the majority of cases, Drug eluting stents willNOT solve the problem
In long diffuse lesions, PTA + non-DES bail-out stenting
gives good limb salvageNO ECONOMICAL BENEFIT TO USE DES