Mẹp nong bóng trước và sau khi đặt stent kinh nghiệm từ stent phủ thuốc đến stent tự tiêu

Absorb GT1 Only BRS currently available in the US... The Absorb scaffold needs to expand slowly to optimally realign the polymer chains.. If the “hold time” is too short the scaffold may

Tips and Tricks

From DES to BRS

Khôi Minh Lê, MD, FACC, FSCAI Co-Director Cardiac Cath Lab Eisenhower Medical Center

Rancho Mirage, CA

Absorb GT1

Only BRS currently available in the US

Absorb: What’s Different?

Absorb polymer ≠ Cobalt alloy

1 Strut size

a Thickness 157 (vs 89 μm for Xience)

b Width 190.5 – 215.9 μm (vs 90 μm for Xience)

2 Crossing profile A-BVS 1.42 mm (vs Xience 1.07 mm)

3 Does not score the vessel like a metallic stent and therefore requires more thorough lesion preparation

4 Absorb’s maximum expansion range (≤0.5 mm) is less than that

of current metallic stents

5 Radiolucent, cannot be visualized with x-ray equipment

• Avoid jailing side branches ≥2.0 mm

• Avoid heavily calcified, eccentric lesions

Recognize the Differences Between

CoCr and PLLA

• The Absorb polymer is viscoelastic which means it is

temperature and rate sensitive The Absorb scaffold needs to expand slowly to optimally realign the polymer chains

• After reaching the desired atmosphere it is important to hold for 30 seconds in order for the polymer to reset its memory

from being in the crimped state If the “hold time” is too short the scaffold may experience slight recoil

Deployment Procedure

• Deploy the scaffold slowly, in 2-atm increments, over 5 seconds, until scaffold is completely expanded

– Use a constant, slow inflation

– Count (“1, 2, 3, 4, 5” while going up 2 atm) and repeat

– [Not cutting balloon technique of quickly going up to 2 atms]

• Nominal pressures:

– 6 atm for 2.5 and 3.5 mm

– 7 atm for 3.0 mm

• Deployment pressures should range from 10 – 16 atm

• Hold maximum pressure for 30 seconds (if tolerated)

Puricel et al J Am Coll Cardiol 2016; 67(8):

921-931

Ellis et al N Engl J Med 2015; DOI:

10.1056/NEJMoa150938

*<2.4 for 2.5 and 3.0; <2.8 for 3.5

Early Experience and Absorb-Specific

Protocol

1 Oversized scaffolds*

2 Incomplete deployment

“Absorb-Specific Protocol”

Improved 1 year Scaffold Thrombosis

3.0%

Pre-dilatation Using the device only in vessels where it could be fully deployed Implanting the device only in reference vessels of the same size Post dilatation

1.0%

“Absorb-Specific Protocol”

Improved 1 year Scaffold Thrombosis

3.0%

Pre-dilatation Using the device only in vessels where it could be fully deployed Implanting the device only in reference vessels of the same size Post dilatation

Prepare the Lesion

Fail to prepare, prepare to fail

• Full expansion of pre-dilatation balloon

(noncompliant balloon sized 1:1)

• [Consider contrast injection with balloon

expanded to confirm proper sizing]

• Maximum 20-40% residual stenosis after dilatation

pre-Resistant Fibrocalcific Lesions

• High pressure NC balloon

• “Cutting wire” angioplasty

• Cutting/scoring balloon

• Rotational/orbital atherectomy

Delivering the Scaffold

• Guide catheter selection

Size Appropriately

• IC Nitroglycerin

• Compare to expanded pre-dilatation balloon

• Use alternative sizing/imaging tools

– QCA

– IVUS

– OCT

Sizing Guidelines

• Scaffolds used in tapered vessels should be sized

to the larger/proximal vessel

• When in doubt, size up because the stent cannot

be further expanded more than 0.5 mm

Post Dilate

Goals

1 Embed scaffold struts into the vessel wall

2 Achieve <10% final residual stenosis

3 Ensure full strut apposition

Non-Compliant Post-Dilatation Balloon

Size Recommendations

• Post dilate with noncompliant balloon sized ≤ 0.5

mm over scaffold diameter

• Recommended pressure >16 atm

SPECIAL SITUATIONS

Overlapping Stents

Farooq et al JACC Intv 2013;6:523-32

Overlapping Absorb Struts

Overlapping Scaffolds

• Minimize amount of

overlap (single marker)

• Consider end-to-end with

Overlapping Scaffolds

SPECIAL SITUATIONS

Side Branches/Bifurcations

Suggested Algorithm for Side

• DES preferred for SB

• Always finish with

Bifurcation BVS Stenting

Seth et al Catheter Cardiovasc Interv

2014;84:55-61

BVS Bifurcation OCT

Seth et al Catheter Cardiovasc Interv

2014;84:55-61