Dace Sondore, Aigars Lismanis,Dace Sondore, Aigars Lismanis,

Ieva Briede, Andrejs Ērglis

Latvian Centre of CardiologyLatvian Centre of Cardiology

Pauls Stradins Clinical University Hospital, Riga,LATVIA

Disclosures

S peaker’snam e:DaceS ondore

Ihavethefollow ingpotential conflicts of interest to report: Ihavethefollow ingpotential conflicts of interest to report: Research contracts Consulting

Employment in industry Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company Owner of a healthcare company

Other(s)

Idonothaveany potentialconflictofinterest

EvolutionofP CIEvolutionofP CI

•• 1977: Balloon Angioplasty (POBA)1977: Balloon Angioplasty (POBA)•• 1977: Balloon Angioplasty (POBA)1977: Balloon Angioplasty (POBA)

•• 1986: Bare Metal Stent (BMS)1986: Bare Metal Stent (BMS)

•• 2001: Drug Eluting Stent (DES)2001: Drug Eluting Stent (DES)•• 2001: Drug Eluting Stent (DES)2001: Drug Eluting Stent (DES)

•• 2006: Drug Eluting Balloon (DEB)2006: Drug Eluting Balloon (DEB)

•• 2009: DES with b/a Polymer2009: DES with b/a Polymer•• 2009: DES with b/a Polymer2009: DES with b/a Polymer

•• 2011:2011: BioresorbableBioresorbable SScaffoldcaffold

O urP .S tradinsHospitalDataO urP .S tradinsHospitalData

2016 - total number of PCI- 39822016 - total number of PCI- 3982

PCI of CTO- 394PCI of CTO- 394

••BioresorbableBioresorbable sscaffoldscaffolds usage since 2013 Janv

CT O ’sCharacteristics

•Long lesions

•Fibrocalcified lesions with high plaque burden1

•Proximal and distal fibrous cap containing densely packed collagen2

•Usually requires longer segment stenting

(all dissection/re-entry techniques)

1.- Rubartelli A , et al. Eur Heart J 2010

2.- Srivatsa SS et al. J Am Coll Cardiol 1997;29:955-63

R eocclusionafterP CIofCT O ’s

Associated with:

•Stented segment length1•Stented segment length

•MLD after stent implantation2

•Residual diameter stenosis3

•Stent Type 4

- More often after STAR technique4- More often after STAR technique4

- More often in retrograde approach3

1.- Sallam M,et al. J Invasive Cardiol 2001;13:511-5

2.- Choi SW,et al. Clin Cardiol 2003;26:265-8

3.- Isaaz K. J Inv Card 2013 Jul;25(7):323-9

4.- Valenti R et al. JACC 2013 Feb;60(5)

Alster-O CT -CT O S tudy

Heeger Christian-Hendrik. EuroIntervention 2014;10

W hyW hy BioresorbableBioresorbableS caffold?S caffold?

••Decrease late adverse eventsDecrease late adverse events•• Late thrombosisLate thrombosis•• Late thrombosisLate thrombosis

•• Hypersensitivity reactionsHypersensitivity reactions (chronic inflammation)(chronic inflammation)

•• Stent fracturesStent fractures

••Restoration ofRestoration of vasomotionvasomotion

••Does not restrict positive arterial remodelingDoes not restrict positive arterial remodeling••Does not restrict positive arterial remodelingDoes not restrict positive arterial remodeling

••Permits nonPermits non--invasive imaging of arteryinvasive imaging of artery

••Permits bypass surgery in futurePermits bypass surgery in future••Permits bypass surgery in futurePermits bypass surgery in future

Eur Heart J. 2012 Jun;33(11):1325-33

BioresorbableBioresorbableS caffoldsS caffolds

IgakiIgaki--T am aiT am ai P LP L LL AA

BVSBVS ::

IgakiIgaki--T am aiT am ai P LP L LL AA

P LP L LL AABVSBVS ::BioresorbableBioresorbableVascularS caffoldVascularS caffold

R EVAR EVAT yrosineT yrosine--

P olicarbonateP olicarbonate

P LP L LL AA

R EVAR EVA

BITBIT

P olicarbonateP olicarbonate

P A EP A E--S alicylateS alicylate

BiotronikBiotronik

BITBIT P A EP A E--S alicylateS alicylate

M agnesiumM agnesiumBiotronikBiotronik M agnesiumM agnesium

BVS VascularR esponseto3 Years:S M C R ichN eointim aIncorporatingAllS trutsN eointim aIncorporatingAllS truts

Porcine Coronary Artery Model

BVS inCT O ’s

• Is one of the most challenging scenarios to test, due tolong fibrocalcified lesions with high plaque burden 1, 2long fibrocalcified lesions with high plaque burden 1, 2

• In this setting vessel pretreatment is most needed• In this setting vessel pretreatment is most needed

• Adequate BVS optimisation with NC is necessary• Adequate BVS optimisation with NC is necessary

1.- Rubartelli A , et al. Eur Heart J 20102.- Galassi AR, et al. EuroIntervention 2011

P .S tradinsHospitalApproach:

•Aim- avoid ’’full metal jacket’’ by covering total CTO segmentwith DESwith DES

•Method- after CTO crossing with guidewire, predilatation with•Method- after CTO crossing with guidewire, predilatation withSC balloon, then pretreatment with cutting balloon

- DES implantation in ostial/proximal segment

- BVS implantation in CTO body- BVS implantation in CTO body

- postdilatation with NC balloon

•Follow-up- at 12 month angio and OCT control

CaseExam pleCaseExam ple

Male 73 y.o.

Clinical presentation:Clinical presentation:

Stable angina III.

Previous PCI with DES LAD 2 month ago.Previous PCI with DES LAD 2 month ago.

Hypertension I.

Dyslipidemia.Dyslipidemia.

Syntax score -35Syntax score -35

IntendedEquipm ent(retrogradeapproach)

B othfe m ora l a pproa ch –7F JR 4SH ,6F EB U 3,75 B othfe m ora l a pproa ch –7F JR 4SH ,6F EB U 3,75

M icroca the te rFine C ross 150cm ,C hoice floppy a nd SionB la ck ,G a ia 2 M icroca the te rFine C ross 150cm ,C hoice floppy a nd SionB la ck ,G a ia 2

Pre dila ta tion- withR e gula rba lloon2,0-20m m ,3,0-30m m ,

C utting ba lloon3,25-10m mC utting ba lloon3,25-10m m

Ste nts:D ES 3.5-24m m (R C A ostia l) Ste nts:D ES 3.5-24m m (R C A ostia l)

B iore sorba ble sca ffold(A bsorb)3.5-23m m (R C A m id)

Postdila ta tion- N C ba lloon3.75- 15m m Postdila ta tion- N C ba lloon3.75- 15m m

Fe m ora l closure :A ngioSe a l

P redilatationw ith3,0-30 m m S C balloon

P retreatm entw ith3,25-10 m m Cuttingballoon

AbsorbIm plantation DES Im plantation

P ostdilatationw ithN C 3,75-15 m m

9 M onthFollow -upO CT9 M onthFollow -upO CT

M agnesium Alloy BiodegradableS tentM agnesium Alloy BiodegradableS tent(AM S ,(AM S ,BiotronikBiotronik,Inc.),Inc.)

Magnesium and the Human Body

• Essential element for human bodyinvolved in the synthesis of more than

(AM S ,(AM S ,BiotronikBiotronik,Inc.),Inc.)

involved in the synthesis of more than300 enzymes (4th most commonmineral)

• Quantity in human body: ~ 20 g

• Daily need (adult) : ~ 350 mg

• Quantity in the intracellular space: >40%

3.0 x 10 mm stent: ~ 3 mg3.0 x 10 mm stent: ~ 3 mg

••Degradation by replacement with Calcium and PhosphorousDegradation by replacement with Calcium and Phosphorous••Degradation by replacement with Calcium and PhosphorousDegradation by replacement with Calcium and Phosphorous

(2 months)(2 months)

Erbel et al., Lancet 2007;369(9576):1869-75

Is’’FullM etalJacket’’ aP ast?T hankyou!T hankyou!

S um m aryS um m ary