Heartfelt with Dr Melissa Walton-ShirleyView all posts »
A rose is a rose is a rose-but not so in the DES worldOct 13, 2008 22:43 EDT
In an intriguing series of presentations today, we learned that no longer do we describe stents just based on their drug coating or steerability. There are obvious differences and even concerns that surround N.O. metabolism and production. Each time proximal or distal endothelial function was assessed with either Acetylcholine, exercise or nitroglycerin infusion, CYPHER performed more poorly than all other stents. Xcience and bare metal stents were a close finish for best yet, no one could prove any clinical outcomes based on these findings. DRIVER and ENDEAVOR both demonstated better endothelial fct than cypher or taxus. I was amazed at how exercise was performed "during" a cardiac cath whereas other studies employed atrial pacing at rates of 20 -150 bpm above baseline. Talk about your courageous study subjects.
Causes for these differences in stent performance are pure speculation but include polymer influence and with regard to poor distal vessel vasodiliation, down stream eluding was thought to account for it.
Dr. Virmani is always stimulating and entertaining in her presentations and today was no different. She discussed pathology findings in 7 patients who died with evidence for hypersensitivity rxn from CYPHER stents. Frightening as always as well as disappointing, there was a case report that was 720 days post implant and one case as early as 4 months. Taxus stents produced higher fibrin scores whereas Cypher begats more eosinophilic and giant cell infiltration. One particularly concerning story was of a 40 year old patient who died 5 days after a melanoma resection that of course required d/c of clopedigrel. She had 5 prior stents and 8 bouts with restenosis. A severe hypersensitivity rxn was noted at post, much like a Latex allergy would appear. Her theory is that the "polymer is the culprit" in all likelihood. My theory is that in a patient like this, a bridging anticoagulation plan is a must. Hind sight is 20/20 but with these reports, we can now use a little foresight to help protect our patients.
I gained a whole new respect today for stent "physiology". Obviously , it's not true that a stent by any other name will smell as sweet.