1. HEART INSTITUTE

2. Prediction of restenosis after PCI withcontemporary drug-eluting stents DR. ASHOK SETHFRCP (LOND), FRCP (EDIN), FRCP (IREL), FACC, FSCAI, FCSI, DSc.CHAIRMAN CHIEF OF CARDIOLOGYCHAIRMAN CARDIOLOGY COUNCIL, FORTIS GROUP OF HOSPITALSFORTIS ESCORTS HEART INSTITUTE PRESIDENT CARDIOLOGICAL SOCIETY OF INDIAHEART INSTITUTE 3. Restenosis After BA and Stent Most significant problem for years DES have dramatically reduced instent restenosis. Low rates of ISR in DES still a problem.HEART INSTITUTE 4. Classification of Restenosis(Mehran et al. Circulation 1999;100:1872-8)HEART INSTITUTE 5. Incidence of DES ISR12% 11-12%10%8%6-7%6%5-6%4%2%0%Native DenovoReal Life Patients Real Life PatientsLesion 1st Gen DES 1st Gen DES2nd Gen DESHEART INSTITUTE 6. Delayed Restenosis Late Catch Up Modest increase in NIH beyond 1-year on IVUS study follow up. Delayed healing response Persistent biological reaction Hypersensitivity reaction to durable polymer Therefore longer term follow upHEART INSTITUTE 7. Stent Thrombosis vs Restenosis ISR Presents as effort angina while stent thrombosis usually presents MI. TVF within 30-days is usually stent thrombosis while ISR is usually later. DES has delayed the time frame of ISR Both ISR and Stent thrombosis may co-exist.HEART INSTITUTE 8. Definitions and Classification of Restenosis and Stent ThrombosisDangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE 9. Possible Mechanisms of Restenosis After DESDangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE 10. Biologic Factors Drug Resistance Hyper sensitivity Allergy to Nickel / Molybdenum of 316 to stenosis steel. RADAR STUDY (Research on Adverse Drug / Device Adverse Reports) - Drug Hypersensitivity for DES.HEART INSTITUTE 11. RADAR (Research on Adverse Drug Events & Reports) (Nebeker JR et al. J Am Coll Cardiol 2006;47:175-181) 5783AE after DES 261 Hypersensitivity Reaction 17DES cause of HS 4 Died of stent thrombosis between4-18 monthsHEART INSTITUTE 12. HEART INSTITUTE 13. Mechanical Factors(Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907)Stent Under expansionHEART INSTITUTE 14. Mechanical Factors(Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907) Stent Fracture Incidence: 2-8% Rigid closed cell stents,overlapping stents, longerstents, vessel tortuousity,angulation and torsionHEART INSTITUTE 15. Technical Factors Geographical Miss Uncovered atherosclerotic plaque Baro trauma outside stented segmentHEART INSTITUTE 16. Technical Factors Stent Gap Gap between two overlapping stents Bends and CurvesHEART INSTITUTE 17. Predictors of ISR or TLR After DES Implantation Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE 18. Risk Scoring to Predict TLR in DES (Stolker et al. Circ Cardiovasc Interv. 2010;3:327-334)HEART INSTITUTE 19. Predictors of DES Restenosis(Corbett et al. Circulation. 2006;114:II_688) 2269 lesions1283 patients (2003-2005) Angio FU 70% DES ISR: SES 16.9%: PES 16.8%HEART INSTITUTE 20. Morphologic Pattern of SES, PES, and BMS ISR Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE 21. Clinical and Angiographic Outcomes After PercutaneousTreatment of DES ISR Dangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE 22. Morphological Pattern of Restenosis as a Predictor of RepeatISR after DES ISR Treatment (Dangas et al. JACC 2010; 56: 1897-907)Repeat ISR TLR60%57%50%40%30%23%20% 18% 10%10%0%Focal ISR Non Focal ISR DES ISRHEART INSTITUTE 23. Treatment of DES ISRDifficult Disease Process IVUS or other imaging essential to understandthe underlying mechanism. OPTIONS Balloon angioplasty DEB DES : Same DES : Different DES VBT CABGHEART INSTITUTE 24. Algorithm for the Treatment of DES RestenosisDangas et al. J Am Coll Cardiol. 2010;56(23):1897-1907HEART INSTITUTE 25. Conclusion Though DES has lowered the restenosis rates of PCI, theincreased complexity of lesions being treated has resulted inDES ISR being an important problem. The predictors of restenosis in DES era are similar to the BMSera, but DES ISR can occur later and tends to be more focal andthis has a better prognosis than BMS ISR. Diffuse DES ISR is a very difficult animal as the pathophysiologyand causative mechanism of DES ISR are in many cases unclearand hence treatment options are hit and trial. Further studies new DES and Bioresorbable stents are on theway to overcome this important problem.HEART INSTITUTE