Long-term clinical outcomes of direct absorb bioresorbable vascular scaffold implantation in acute coronary syndrome

BACKGROUND

Preferred technique for bioresorbable vascular scaffold (BVS) implantation included high pressure predilation. Data about direct BVS implantation in acute coronary syndrome (ACS) patients are scarce.

METHODS

Analysis of 90 consecutive patients with acute myocardial infarction (MI) treated with primary PCI with Absorb deployment between 2013-2016 in a single center. In 45 patients, scaffolds were implanted in the direct technique, other 45 patients underwent Absorb deployment after balloon predilation.

RESULTS

Follow-up was available in 100% of patients with mean duration of 32±11 months. No cardiac death or scaffold thrombosis were observed in both groups. In the direct group, no target lesion revascularization (TLR) was reported. In the predilation arm, TLR occurred in 4 (9%) patients (P=0.12). Target vessel revascularization (TVR) was observed in 1 (2%) case in the direct group and in 6 (13%) patients from the predilation group (P=0.11). Target vessel MI was reported in one patient from each group. In an intention to treat analysis, we observed significantly higher rates of TVR (15% vs. 2%; P<0.043) and TLR (10% vs. 0%; P=0.038) in the predilation arm. Kaplan-Meier survival analysis did not show significant differences in TLR, TVR and device oriented composite endpoint (a combination of cardiac death, target vessel MI and ischemia driven TLR) between patients treated with both methods.

CONCLUSIONS

Direct Absorb implantation in patients with ACS may be feasible and safe.

Angiographically Based Direct Implantation of the Bioresorbable Vascular Scaffold in Non-ST Segment Elevation Acute Coronary Syndrome: Feasibility and Outcome

BACKGROUND:

Direct implantation of metallic drug-eluting stents is recommended for lesions with high thrombotic burden; however, this can’t be applied to bioresorbable scaffold for which adequate lesion preparation is recommended.

AIM:

We aimed at assessing the feasibility and safety of direct scaffold implantation based only on angiographic assessment in patients presented with non-ST segment elevation acute coronary syndrome.

METHODS:

The study was a retrospective two-centre study conducted over patients diagnosed with NSTE-ACS presented to cardiology department at Juan Ramon Hospital, Spain and critical care department, Cairo University in the period between February 2016 to May 2017. We included patients for whom we depend only on angiographic assessment for decision making whether to directly implant the scaffold or predilate the lesion and we excluded patients for whom intracoronary imaging was used at the index procedure either for pre or post-implantation. The primary outcome of interest was the device-oriented composite endpoints (DOCE) including cardiac death, and MI attributed to the target vessel and TLR. The secondary endpoints were the broader patient-oriented composite outcome (POCE) and scaffold/stent thrombosis. POCE includes all-cause mortality, any MI and any revascularisation (including TLR, TVR and revascularisation of non- target vessel)

RESULTS:

Among 46 patients with NSTE-ACS treated with BVS, we did direct implantation in 20 patients (group A), and we used pre dilatation in 26 patients (group B). The two groups have similar demographics and clinical criteria. Procedural success was obtained in all study population. Mean follow up duration was 12 months. We have total of 10% device-oriented composite endpoints in group A versus 15% in group B (p-value = 0.684). We didn’t document any cardiac death in both groups. In group B we had one (3.8%) non-fatal MI while there was no MI in group A (P-value = 1). In group A we had 2 cases (10%) of TLR while in group B there were 3 cases (11.5%) TLR (P-value = 1). We have two cases (7.7%) of TVR in group B and one in group A p-value = 1. All cases were planned staged PCI. Scaffold thrombosis occurred in one case in group A (5%) and two cases in group B (7.7%) p-value = 1.

CONCLUSION:

With proper lesion selection, direct BVS implantation in all-comers NSTE-ACS patients is feasible and safe even without the aid of intracoronary imaging.

Clinical outcomes of bioresorbable vascular scaffold to treat all-comer patients. Are patients with acute coronary syndrome better candidates for bioresorbable vascular scaffold?

BACKGROUND

Scaffold thromboses (ST) and adverse events and have been associated with bioresorbable vascular scaffolds (BVS) at long-term, but their mechanism remains unclear. We sought to evaluate patient and lesion characteristics associated with mid- to long-term outcomes in patients treated with BVS.

METHODS

This is an observational single-center, single-arm, retrospective study evaluating the performance of BVS in an all-comer population, including complex lesions (chronic total occlusions, long lesions), small vessels, and acute coronary syndromes (ACS).

RESULTS

From May 2013 to June 2015, we included 482 patients (580 lesions) that were treated with BVS implantation including 71.2% treated for ACS in the present analysis. Mean follow-up period was 816.2 ± 242.6 days. The primary endpoint was device oriented cardiac events (DOCE), defined as a composite of target-lesion revascularization (TLR), ST, target vessel myocardial infarction (TVMI) and cardiac death. Using Kaplan-Meier methods, the DOCE and ST rates at 36 months were 9.4% and 2.3%, respectively. No ST occurred between 2 and 3 years and ST occurred after 3 years, in one patient. Using multivariate analysis, ACS was the only significant predictor of lower rates of DOCE (p = 0.04, HR: 0.47, 95% CI: 0.23-0.96).

CONCLUSIONS

In this large all-comers real-world cohort, lesions treated with BVS had non-negligible rates of DOCE and ST, in line with previous published randomized trials. The occurrence of very late event was very low after 24 months. ACS patients had lower rates of DOCE.

Hybrid Percutaneous Coronary Intervention With Bioresorbable Vascular Scaffolds in Combination With Drug-Eluting Stents or Drug-Coated Balloons for Complex Coronary Lesions

Bioresorbable vascular scaffolds (BVS) have become an attractive option in the percutaneous coronary intervention field due to the potential advantages associated with the complete resorption process that occurs within a few years. However, current-generation BVS have several limitations including thicker struts, reduced radial strength, and limited expansion capability when compared with drug-eluting stents (DES). As a result, complex coronary disease often contains BVS-inappropriate/unfavorable segments. This does not necessarily mean that BVS use must be completely avoided, and minimizing the length of permanent metallic caging may still be advantageous. Operators should fully understand the limitations of current BVS, and when to consider a hybrid strategy of BVS in combination with DES or drug-coated balloons.

Bioresorbable vascular scaffold to treat in-stent restenosis: Single-center experience

AIMS

The management of patients with in-stent restenosis (ISR) is still a major clinical challenge even in the era of drug-eluting stents (DES). Recent studies have demonstrated acceptable clinical outcomes for the everolimus-eluting bioresorbable vascular scaffold (BVS) ABSORB™ in patients with stable coronary artery disease but data are scarce on its use in patients with ISR. We report the long-term results of our preliminary experience with this novel approach at our institution.

METHODS AND RESULTS

We investigated the safety and efficacy of BVS implantation to treat ISR. 34 consecutive patients (37 lesions) underwent PCI for ISR with BVS implantation between May 2013 and June 2015 at our institution and were included in the current analysis. Follow-up was available in 91.9% of the patients. Mean follow-up period was 801.9 ± 179 days. One patient had definite scaffold thrombosis (ScT) 2 months after stent implantation which was treated with DES. Five patients (six lesions) experienced target lesion revascularization (TLR). The composite endpoint rate of TLR, ScT, myocardial infarction, and death occured in 6/37 lesions at follow-up (16.2%).

CONCLUSIONS

These real-world data using BVS in patients with ISR demonstrates that ISR treatment with ABSORB™ BVS is feasible but could have slightly higher target lesion failure rates as compared to DES. This proof of concept could be hypothesis-generating for larger randomized controlled studies.

Effect of strut distribution on neointimal coverage of everolimus-eluting bioresorbable scaffolds: an optical coherence tomography study

The thick struts of bioresorbable vascular scaffolds (BRS) are associated with changes in wall shear stress and contribute to neointimal proliferation. We aimed to evaluate the relationship between the BRS strut distribution and the neointimal proliferation. 50 lesions underwent optical coherence tomography, 12 months after BRS implantation. Scaffold area and neointimal thickness were evaluated in each cross-sectional area (CSA). Scaffold eccentricity was defined as follows: (maximum diameter - minimum diameter) × 100/maximum diameter. CSAs of BRS were divided into four quadrants. The maximal neointimal thickness (Maximal-NIT), Minimal-NIT and the number of struts in each quadrant were measured. The number of struts were classified as 1, 2, 3 and ≥ 4. Furthermore, the mean-NIT acquired in each quadrant was divided by the average-NIT of all struts in the same CSA, which was defined as the unevenness score. In addition, Maximal-NIT minus Minimal-NIT was divided by the average-NIT of all struts in the same CSA, which was defined as heterogenicity of neointimal proliferation. There was a significant difference in the association between the number of struts and not only the unevenness score (no. of strut = 1 (N = 440), unevenness score 1.04 ± 0.34; 2 (N = 696), 0.98 ± 0.27; 3 (N = 994), 0.96 ± 0.23; ≥4 (N = 1202), 1.04 ± 0.22, P < 0.01) but also Maximal-NIT and Minimal-NIT. Furthermore, a significant correlation was observed between scaffold eccentricity in each CSA and the heterogeneity of neointimal proliferation in the same CSA (N = 892, R = 0.38, p = 0.01). Crowding of struts is associated with increased neointimal proliferation after BRS implantation. The scaffold eccentricity causes heterogeneity of neointimal proliferation.