Vai trò của stent tự tiêu trong điều trị bệnh lý nhiều thân mạch vành

BRS in Multivessel CAD Faisal Latif, MD FACC FSCAI, Ramesh Daggubati, MD FACC FSCAI Associate Chief of Cardiology Director of Interventional Cardiology Winthrop University Hospital Mineola, NY USA BVS ready for clinical use? 60 months Symptom Severity Yes ! Absorb A Absorb B Courage Trial Absorb Extend Absorb II Stents Vs Meds Absorb III/IV Disease Severity ?? Syntax Trial BVS Expand DES Vs Surgery #Fact Despite a larger profile (ABSORB: 1.4mm, vs Xience 1.1mm), device success was 99.2% in B1/B2 lesions (98.3%) In registries (e.g ABSORB Expand), the device success was 98.2% in complex lesions Procedural characteristics Absorb Metallic DES (n=187) (n=365) p-value 40.9% 35.6% 0.19 59.1% 64.4% 0.19 0.0% 0.0% - 38.0% 48.2% 0.04 LMS 0.6% 2.2% 0.28 LAD 48.6% 53.3% 0.32 SVG 0.0% 0.0% - Clinical Presentation Stable angina Unstable angina/ NSTEMI STEMI Multi-vessel disease Treated Vessels† Procedural characteristics Procedural variables Number of stents Average Stent diameter, mm Total stent length, mm Type of scaffold/ stent Absorb Everolimus-eluting stent Bare-metal stent Sirolimus-eluting stent Others Absorb Metallic DES (n=187) (n=365) p-value 2.16±1.32 1.51±0.83 2xULN >3xULN >5xULN 13.3% 9.8% 7.1%6.1% 4.9% 2.5% 0.6% 0.6% #Fact Cardiac biomarker rise < 48 hours after the index procedure and per-protocol peri-procedural MI did not differ between the two arms Incidence of anatomic complications assessed by angiography in patients with periprocedural MI Absorb BVS (N=335 pts) 3.9% 2.7% 0% EES (N=166 pts) 1.2% 0.6% 0% Side branch occlusion after device implantation 2.7% 0.6% 0.18 Side branch occlusion improvement after NTG 0% 0% 2.7% 0.6% 0.18 0.6% 0.6% Abrupt closure Distal embolization coronary perforation Flow limiting dissection (NHLBI type F) 0% 0.3% 0% 0% 0.6% 0% 0% 0% 0.33 1 coronary dissection after pre dilatation (NHLBI D or E) 0.3% 0% coronary dissection after device implantation 0% 0% Thrombus during procedure Disruption of collateral flow 0% 0% 0% 0% 1 0.6% 0% Per protocol peri-procedural MI Type 1: Side Branch Occlusion, % (N) Side branch occlusion after pre dilatation Side branch occlusion after procedure Type 2: Angiographic Other Complication, % (N) Non-indentifiable mechanism causes, % (N) p value 0.16 0.18 #Fact Cardiac biomarker rise < 48 hours after the index procedure and per-protocol peri-procedural MI did not differ between the two arms When the cardiac biomarker rise was subcategorized according to contemporary PMI criteria such as the 3rd universal definition and the SCAI definition, PMI rates were: • • • • 5·2% vs 2·5% (CKMB >5x ULN) 32·0% vs 26·9% (troponin >5x ULN, 3rd Universal) 0·6% vs 0·6% (CKMB >10x ULN, SCAI) 4·6 % vs 1·9 % (troponin >70x ULN, SCAI) These results strongly emphasize the arbitrary character of any definition of PMI ABSORB 1-Year Meta-analysis ABSORB II, ABSORB III, ABSORB Japan, ABSORB China Meta-analysis summary BVS (N=2164) CoCr-EES (N=1225) RR [95% CI] Fixed effect P Value I2 P het 0.8% 0.7% 1.12 [0.47, 2.69] 0.80 NA NA - Cardiac 0.4% 0.3% 1.26 [0.33, 4.82] 0.74 NA NA - Non-cardiac 0.4% 0.4% 1.02 [0.32, 3.25] 0.97 NA NA 5.7% 4.0% 1.34 [0.97, 1.85] 0.08 0% 0.71 2.9% 2.2% 1.29 [0.82, 2.03] 0.27 0% 0.75 - Peri-procedural (SCAI def) 0.8% 0.8% 0.97 [0.44, 2.14] 0.94 0% 0.63 - Non-peri-procedural (AIII def) 2.8% 1.8% 1.48 [0.91, 2.40] 0.11 0% 0.93 - TV-MI 5.1% 3.3% 1.45 [1.02, 2.07] 0.04 0% 0.80 - Non-TV-MI 0.7% 0.9% 0.75 [0.34, 1.66] 0.48 0% 0.94 All-cause mortality All MI - Peri-procedural (AIII def) NA = not applicable - cannot test for heterogeneity because no events were present in one cell in of the trials; het = heterogeneity Baseline Angio 68 mm BVS: 28/3.0, 28/3.5, 12/3.5 Index Procedure 1y FU Individualize the therapy • BRS in multivessel disease is possible • No RCT of BRS in MVD • Registries show that there is small periprocedural MI in MVD stenting with BRS We need data !!! ... Procedural variables Number of stents Average Stent diameter, mm Total stent length, mm Type of scaffold/ stent Absorb Everolimus-eluting stent Bare-metal stent Sirolimus-eluting stent Others Absorb Metallic... revascularization Composite of death, MI and TLR Definite stent/ scaffold thrombosis Acute/subacute Late Absorb Drug-eluting metallic stents (n=187) 2.2% 1.7% (n=365) 1.9% 0.0% p-value 0.76 0.04... clinical use? 60 months Symptom Severity Yes ! Absorb A Absorb B Courage Trial Absorb Extend Absorb II Stents Vs Meds Absorb III/IV Disease Severity ?? Syntax Trial BVS Expand DES Vs Surgery #Fact Despite