Gli stent riassorbibili: indicazioni e limiti in Geriatria. Roberto Violini Cardiologia Interventistica AO S.Camillo Forlanini Roma

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1 Gli stent riassorbibili: indicazioni e limiti in Geriatria Roberto Violini Cardiologia Interventistica AO S.Camillo Forlanini Roma

5 RESTENOSI 30-40% solo pallone 15-20% stent < 6 % stent medicato

g. atrial fibrillation), have a higher probability of invasive procedure within months following stent implantation, and have a

10 elderly patients might benefit from DES to avoid repeat hospitalization or revascularization related to re-stenosis,.. but these patients also have a higher bleeding risk on prolonged DAPT, more frequently have an indication for anticoagulation (e.g. atrial fibrillation), have a higher probability of invasive procedure within months following stent implantation, and have a higher risk of poor compliance to treatment..newgeneration DES, allowing shorter duration of DAPT, might extend the use of DES in this population.

11 IN ACS PTS

12 BMS 1 st DES 2 nd DES 3 th DES BVS

13 caffold Stent = scaffold + cage = BVS = Scaffold

Absorb BVS: The First Drug Eluting Bioresorbable Vascular Scaffold Bioresorbable Scaffold Poly (L-lactide) (PLLA) Based on proven MULTI-LINK pattern Naturally resorbed, fully

14 Absorb BVS: The First Drug Eluting Bioresorbable Vascular Scaffold Bioresorbable Scaffold Poly (L-lactide) (PLLA) Based on proven MULTI-LINK pattern Naturally resorbed, fully metabolized* Bioresorbable Coating Poly (D,L-lactide) (PDLLA) Naturally resorbed, fully metabolized Everolimus Similar dose density and release rate to XIENCE V Polimero Rivestimento Farmaco

15 Scaffold Conformability Gli stent riassorbibili: indicazioni e limiti in Geriatria - Roberto Violini Absorb BVS BVS provides better conformability compared to metallic platforms

16 Scaffold Strut Lactic Acid DIFFUSION Lactic Acid Lactate Intracellular Mitochondrion H 2 O CO 2 Lactate Krebs Cycle Lactic acid is readily converted to lactate, a common fuel source for multiple metabolic pathways

evidence of natural vessel function Resorbs leaving no scaffold

17 Vascular Reparative Therapy Revascularizes Restores Resorbs Revascularizes like a best-in-class DES, XIENCE Preliminary evidence of natural vessel function Resorbs leaving no scaffold behind* Absorb Bioresorbable Vascular Scaffold: Three Phases of Functionality

From BVS to VRT Restoration and Resorption Restoration Resorption Returning to a natural vessel Transition from scaffolding to discontinuous structure Become structurally discontinuous Gradually lose

18 From BVS to VRT Restoration and Resorption Restoration Resorption Returning to a natural vessel Transition from scaffolding to discontinuous structure Become structurally discontinuous Gradually lose radial strength Struts must be incorporated into the vessel wall (strut coverage) Implant is discontinuous and inert Resorb in a benign fashion Allow the vessel to respond naturally to physiological stimuli Complete resorption of the scaffold Lumen preservation Late lumen enlargement Potential restoration of vasomotion Plaque modification

19 AREA LUMINALE AREA LUMINALE/AREA RIF Variazione sisto diastolica

21 Plaque regression and positive remodeling 6 to 24 months: 0.90 mm 2 ; p < to 24 months: 0.41 mm 2 ; p < to 24 months: 0.66 mm 2 ; p < to 24 months: 0.49 mm 2 ; p = 0.01 Baseline 6 Months 24 Months Ormiston JA et al. Circ Cardiovasc Interv. 2012;5:

22 Serruys PW. et al. Eur Heart J. 2012;331(1):16-25

24 in Vessel Diameter (mm) (pre-drug infusion to post-drug infusion) Vasoconstriction Vasodilation Gli stent riassorbibili: indicazioni e limiti in Geriatria - Roberto Violini ABSORB Vasomotor Function Testing 1 6 Months 1 12 Months 2 24 Months 3 ABSORB Cohort B1 ABSORB Cohort B2 ABSORB Cohort A (n=15) (n=6) (n=19) (n=13) (n=9) (n=7) Acetylcholine Methergine

25 ABSORB A vasomotor functiont 2 years Acetylcholine (Vasodilator) Methergine (Vasoconstrictor) Vasodilation Vasoconstriction The reappearance of vasomotion in the proximal, distal, as well as treated segments in response to methergine or acetylcholine suggests that vessel vasoreactivity has been restored and that a physiological response to vasoactive stimulus might occur anew. Serruys, PW, et al. Lancet 2009; 373: as well as treated segments

27 150 ACS pts MACE: death, non fatal MI, re-interv EuroIntervention2014;9:

34 ABSORB EXTEND Compared to SPIRIT IV Site-Reported Angina Outcomes at 1 Year Preliminary Observation Population Site-reported Angina Events Through 1 Year Absorb BVS (EXTEND) (N=322) XIENCE V (SPIRIT IV) (N=1999) Unadjuste d P-value 16.5% 25.8% Site reported angina for the TAXUS arm (N=1005) in SPIRIT IV: 26.1%

35 I BVS (Bioresorbable vascular scaffold) costituiscono una promettente innovazione, che realizza una vera terapia riparativa vascolare, con incremento del lume vasale, riduzione della placca e ripresa dell attivita vasomotoria. Devono essere dimostrati i vantaggi clinici di queste modificazioni fisiopatologiche e deve essere definita l incidenza reale di trombosi intrastent

36 I vantaggi ed i limiti dei BVS (Bioresorbable vascular scaffold) nel paziente anziano devono essere ancora studiati specificamente. Comunque i tempi lunghi di evoluzione della terapia riparativa vascolare (2 anni) costituiscono un limite per l utilizzo dei device attuali nel grande anziano

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