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

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

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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

  • Scope of the problem

  • Systematic review

  • Case study

  • Take home messages


Scope of the problem

Scope of the problem

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


Scope of the problem iii

Scope of the problem - III


Tasc ii 2007 vs tasc 2000

TASC II 2007 vs. TASC 2000


Why stents

Why stents?

  • 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?

  • 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?

  • 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?

  • 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

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?

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: LifeStent12-month results after SFA stenting

Laird et al, CirculationIntevention 2010


The paradise trial

The PaRADISE trial

Feiring et al, J Am CollCardiol 2010


The paradise trial1

The PaRADISE trial

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

Feiring et al, J Am CollCardiol 2010


What about absorbable stents

What about absorbable stents?

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

  • Scope of the problem

  • Systematic review

  • Case study

  • Take home messages


Systematic review of btk stenting

Systematic review of BTK stenting

Biondi-Zoccai et al, J EndovascTher 2009


Background and methods

Background and Methods

  • 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

Biondi-Zoccai et al, J EndovascTher 2009


Results

Results

  • 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)

  • 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

Biondi-Zoccai et al, J EndovascTher 2009


Repeat pta after btk stenting

Repeat PTA after BTK stenting

Biondi-Zoccai et al, J EndovascTher 2009


Learning goals2

Learning goals

  • 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

PERONEAL

POSTERIOR TIBIAL

ANTERIOR TIBIAL


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

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

POPLITEAL

ANTERIOR

TIBIAL

POSTERIOR TIBIAL?

PERONEAL


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

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

POSTERIOR TIBIAL

POSTERIOR TIBIAL

19G NEEDLE

V18 0.018ā€¯ WIRE


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

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


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

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


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

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


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

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

  • Scope of the problem

  • Systematic review

  • Case study

  • Take home messages


Take home messages

Take home messages

  • 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


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

ThankyouforyourattentionForanycorrespondence: [email protected] and furtherslides on thesetopicsfeel free tovisit the metcardio.org website:http://www.metcardio.org/slides.html


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