Drug eluting stents bare metal stents or balloon only angioplasty for below the knee disease
Download
1 / 38

Drug-eluting stents, bare-metal stents, or balloon-only angioplasty for below-the-knee disease - PowerPoint PPT Presentation


  • 374 Views
  • Uploaded on

Drug-eluting stents, bare-metal stents, or balloon-only angioplasty for below-the-knee disease. Giuseppe Biondi Zoccai Division of Cardiology, University of Turin, Turin, Italy. Learning goals. Scope of the problem Systematic review Case study Take home messages. Scope of the problem.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Drug-eluting stents, bare-metal stents, or balloon-only angioplasty for below-the-knee disease' - deepak


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Drug eluting stents bare metal stents or balloon only angioplasty for below the knee disease

Drug-eluting stents, bare-metal stents, or balloon-only angioplasty for below-the-knee disease

Giuseppe Biondi Zoccai

Division of Cardiology, University of Turin, Turin, Italy


Learning goals
Learning goals angioplasty for below-the-knee disease

  • Scope of the problem

  • Systematic review

  • Case study

  • Take home messages


Scope of the problem
Scope of the problem angioplasty for below-the-knee disease

ASYMPTOMATIC ATHEROSCLEROSIS:

3-15% PREVALENCE

<2% AMPUTATION RISK AT 5 YEARS

CLAUDICATION:

1-6% PREVALENCE

<5% AMPUTATION RISK AT 5 YEARS

CHRONIC CRITICAL LIMB ISCHEMIA:

<0.5% PREVALENCE

10-20% AMPUTATION RISK AT 5 YEARS

ACUTE LIMB ISCHEMIA:

<0.1% PREVALENCE

>50% AMPUTATION RISK AT 5 YEARS

Biondi Zoccai et al, G ItalCardiol 2009


Scope of the problem ii
Scope of the problem - II angioplasty for below-the-knee disease


Scope of the problem iii
Scope of the problem - III angioplasty for below-the-knee disease


Tasc ii 2007 vs tasc 2000
TASC II 2007 vs. TASC 2000 angioplasty for below-the-knee disease


Why stents
Why stents? angioplasty for below-the-knee disease

  • Balloon-only angioplasty is fraught with:

    • Elastic recoil

    • Flow-limiting dissection

    • Constrictive remodeling

    • Neointimal hyperplasia

    • Biocompatibility

  • Stents may address these issues


Why stents1
Why stents? angioplasty for below-the-knee disease

  • Balloon-only angioplasty is fraught with:

    • Elastic recoil

    • Flow-limiting dissection

    • Constrictive remodeling

    • Neointimal hyperplasia

    • Biocompatibility

  • Stents may address these issues

BMS


Why stents2
Why stents? angioplasty for below-the-knee disease

  • Balloon-only angioplasty is fraught with:

    • Elastic recoil

    • Flow-limiting dissection

    • Constrictive remodeling

    • Neointimal hyperplasia

    • Biocompatibility

  • Stents may address these issues

DES


Why stents3
Why stents? angioplasty for below-the-knee disease

  • Balloon-only angioplasty is fraught with:

    • Elastic recoil

    • Flow-limiting dissection

    • Constrictive remodeling

    • Neointimal hyperplasia

    • Biocompatibility

  • Stents may address these issues

ABS


Explosion of data on stents for pad
Explosion of data on stents for PAD angioplasty for below-the-knee disease

PubMed queried on 16 June 2010: stent* AND (femoral OR popliteal OR femoropopliteal OR "femoro-popliteal" OR tibial OR "infra-popliteal" OR infrapopliteal OR (critical AND limb AND ischemia)) NOT (vein OR venous)


Iliac stenting just in bail out
Iliac stenting: just in bail-out? angioplasty for below-the-knee disease

DutchIliacStent Trial: randomized trial of stenting vs balloon-only PTA (withstentifcomplications or meangradient >10 mm Hg)*

*stentingfinallyperformed in 40% ofptsrandomizedto PTA

Routine stenting

PTA with

selective stenting

Klein et al, Radiology 2006


The resilient ii trial lifestent 12 month results after sfa stenting
The RESILIENT II trial: LifeStent angioplasty for below-the-knee disease12-month results after SFA stenting

Laird et al, CirculationIntevention 2010


The paradise trial
The PaRADISE trial angioplasty for below-the-knee disease

Feiring et al, J Am CollCardiol 2010


The paradise trial1
The PaRADISE trial angioplasty for below-the-knee disease

FIRST TRIAL EVER TO EMPLOY PRIMARY (I.E. DEFAULT) DRUG-ELUTING STENTING FOR BTK DISEASE

Feiring et al, J Am CollCardiol 2010


The paradise trial2
The PaRADISE trial angioplasty for below-the-knee disease

Feiring et al, J Am CollCardiol 2010


What about absorbable stents
What about absorbable stents? angioplasty for below-the-knee disease

6-month angiographic patency rate:

31.8% for AMS vs. 58.0% for PTA (p=0.013)

Bosiers et al, CardiovascInterventRadiol 2009


Learning goals1
Learning goals angioplasty for below-the-knee disease

  • Scope of the problem

  • Systematic review

  • Case study

  • Take home messages


Systematic review of btk stenting
Systematic review of BTK stenting angioplasty for below-the-knee disease

Biondi-Zoccai et al, J EndovascTher 2009


Background and methods
Background and Methods angioplasty for below-the-knee disease

  • The purpose of this work was to perform a systematic review of the literature published on the outcomes of stenting for below-the-knee (BTK) disease in patients with critical limb ischemia (CLI).

  • Potentially relevant studies of stent implantation in the infragenicular arteries in >5 patients with >1-month follow-up were systematically sought. Data were abstracted and pooled with a random-effect model to generate risk estimates with 95% confidence intervals (CI).

Biondi-Zoccai et al, J EndovascTher 2009


Included studies
Included studies angioplasty for below-the-knee disease

Biondi-Zoccai et al, J EndovascTher 2009


Results
Results angioplasty for below-the-knee disease

  • Eighteen nonrandomized studies were retrieved (640 pts).

  • After 12 months, binary restenosis occurred in 25.7% (95% CI 11.6% to 40.0%) and primary patency in 78.9% (95% CI 71.8% to 86.0%).

  • Accordingly, improvement in Rutherford class occcurred in 91.3% (95% CI 85.5% to 97.1%), with TVR in 10.1% (95% CI 6.2% to 13.9%), and limb salvage in 96.4% (95% CI 94.7% to 98.1%).

Biondi-Zoccai et al, J EndovascTher 2009


Results continued
Results (continued) angioplasty for below-the-knee disease

  • Head-to-head comparisons showed that sirolimus-eluting stents were superior to balloon-expandable bare metal stents in preventing restenosis and increasing primary patency (both p<0.001).

  • Sirolimus-eluting stents were also better than paclitaxel-eluting stents in terms of primary patency (p<0.001) and repeat revascularizations (p=0.014).

Biondi-Zoccai et al, J EndovascTher 2009


Detailed outcomes
Detailed outcomes angioplasty for below-the-knee disease

Biondi-Zoccai et al, J EndovascTher 2009


Repeat pta after btk stenting
Repeat PTA after BTK stenting angioplasty for below-the-knee disease

Biondi-Zoccai et al, J EndovascTher 2009


Learning goals2
Learning goals angioplasty for below-the-knee disease

  • Scope of the problem

  • Systematic review

  • Case study

  • Take home messages


68 year old man with left 5th toe gangrene antegrade puncture
68-YEAR-OLD MAN WITH LEFT 5TH TOE GANGRENE: ANTEGRADE PUNCTURE

COMMON FEMORAL

PROFUNDA FEMORAL

SUPERFICIAL FEMORAL


68 year old man with left 5th toe gangrene popliteal and tibial disease
68-YEAR-OLD MAN WITH LEFT 5TH TOE GANGRENE: POPLITEAL AND TIBIAL DISEASE

POPLITEAL

POSTERIOR TIBIAL?

ANTERIOR

TIBIAL?

ANTERIOR

TIBIAL

POSTERIOR TIBIAL?

PERONEAL

PERONEAL


68 year old man with left 5th toe gangrene foot disease
68-YEAR-OLD MAN WITH LEFT 5TH TOE GANGRENE: FOOT DISEASE TIBIAL DISEASE

PERONEAL

POSTERIOR TIBIAL

ANTERIOR TIBIAL


STEP 1: SUBINTIMAL ANGIOPLASTY LEADING TO EXTENSIVE DISSECTION COVERING POSTERIOR TIBIAL ARTERY OSTIUM

POPLITEAL

ANTERIOR

TIBIAL

POSTERIOR TIBIAL?

PERONEAL


STEP 2: POSTERIOR TIBIAL ARTERY ACCESS TO GAID RETROGRADE ACCESS AND INTRALUMINAL RE-ENTRY IN THE POPLITEAL

POSTERIOR TIBIAL

POSTERIOR TIBIAL

19G NEEDLE

V18 0.018” WIRE


STEP 3: RESIDUAL DISSECTIONS AFTER EXTENSIVE BALLOON-ONLY ANGIOPLASTY WITH 2.5 TO 5.0 MM BALLOONS AT 14 ATM

POPLITEAL

POSTERIOR TIBIAL

PERONEAL

POSTERIOR TIBIAL

PLANTAR


STEP 3: RESIDUAL DISSECTIONS AFTER EXTENSIVE BALLOON-ONLY ANGIOPLASTY WITH 2.5 TO 5.0 MM BALLOONS AT 14 ATM

POPLITEAL

POSTERIOR TIBIAL

WOULD YOU IMPLANT ANY STENT?

PERONEAL

POSTERIOR TIBIAL

PLANTAR


STEP 3: RESIDUAL DISSECTIONS AFTER EXTENSIVE BALLOON-ONLY ANGIOPLASTY WITH 2.5 TO 5.0 MM BALLOONS AT 14 ATM

POPLITEAL

POSTERIOR TIBIAL

WOULD YOU IMPLANT ANY STENT?

IF SO, WHICH TYPE, SIZE AND HOW MANY?

PERONEAL

POSTERIOR TIBIAL

PLANTAR


STEP 3: RESIDUAL DISSECTIONS AFTER EXTENSIVE BALLOON-ONLY ANGIOPLASTY WITH 2.5 TO 5.0 MM BALLOONS AT 14 ATM

POPLITEAL

POSTERIOR TIBIAL

NO STENT WAS ACTUALLY IMPLANTED IN THIS PATIENT, GIVEN LIMITATIONS IN DESIGN OF CURRENTLY AVAILABLE STENTS (SHORT LENGTH, LOW FLEXIBILITY, UNTAPERED DESIGN)

NONETHELESS, HE REMAINED FREE OF MAJOR AMPUTATION AND REPEAT REVASCULARIZATION UP TO 8 MONTHS AFTER PTA

PERONEAL

POSTERIOR TIBIAL

PLANTAR


Learning goals3
Learning goals ANGIOPLASTY WITH 2.5 TO 5.0 MM BALLOONS AT 14 ATM

  • Scope of the problem

  • Systematic review

  • Case study

  • Take home messages


Take home messages
Take home messages ANGIOPLASTY WITH 2.5 TO 5.0 MM BALLOONS AT 14 ATM

  • BTK implantation of bare-metal stents should be reserved to patients intolerant to clopidogrel, as restenosis rates are similar to those of balloon-only angioplasty

  • Conversely, bail-out drug-eluting stenting is beneficial for infra-popliteal lesions, but drawbacks in design of current stents limit their suitability for BTK disease

  • Primary (i.e. default) drug-eluting stent implantation in BTK lesions has been recently proposed, but further studies are needed to confirm this approach


Thank ANGIOPLASTY WITH 2.5 TO 5.0 MM BALLOONS AT 14 ATMyouforyourattentionForanycorrespondence: [email protected] and furtherslides on thesetopicsfeel free tovisit the metcardio.org website:http://www.metcardio.org/slides.html


ad