Bioresorbable scaffolds for the treatment of complex lesions: are we there yet?

Abstract

The introduction of bioresorbable vascular scaffolds (BRS) is changing the landscape of percutaneous coronary revascularization and is considered by many the 4th revolution in interventional cardiology. To date, BRS have shown promising short-and long-term results in the treatment of simple de novo lesions. Even though the feasibility, efficacy and safety of BRS implantation for more complex lesion subsets remain unknown, reports are emerging aiming to identify the role of BRS in everyday practice. In the current review we are aiming to summarize the results from 'all-comer' BRS studies and identify strengths and limitations of BRS when tackling specific complex lesion subsets. Keywords: acute coronary syndrome • bifurcation • bioresorbable scaffold • BRS • BVS • calcific • complex • left main • ostial • outcomesThe introduction of bioresorbable vascular scaffolds (BRS) is changing the landscape of percutaneous coronary revascularization and is considered by many the 4 th revolution in interventional cardiology. The emergence of drug-eluting stents (DES) and more potent antiplatelet drugs has improved patient outcomes by reducing the incidence of restenosis and stent thrombosis [1,2]. Despite improvements in the safety profile of DES [3], late lumen loss, late stent thrombosis and permanent vessel caging are bitter reminders of the inherited limitations of inserting a foreign material in the walls of the coronary arteries. BRS are the product of the attempts to overcome these limitations by temporarily providing support to the vessel wall with a scaffold that will subsequently disappear in 2-4 years' time. Even though increases in the plaque size in the first couple of years post implantation compared with their metallic counterparts have been observed, bioresorbable scaffolds compensate by facilitating plaque regression [4] and by promoting expansive remodeling [5] at long-term follow-up. Despite the positive early experience with BRS in de novo simple lesions, the efficacy and long-term behavior of BRS implanted in complex lesions remains unknown. In recent days several real-world registries have published their early experiences with BRS and will be discussed in the current review. Bioresorbable vascular scaffolds clinical studiesThe initial experience with BRS implantation in de novo simple lesions has proven remarkable. Excellent long-term outcomes (major adverse cardiovascular events 3.4%) have been demonstrated in the 5-year follow-up of the ABSORB (Bioresorbable Everolimus Eluting Vascular Scaffold) Cohort A [6] where 30 patients with single simple de novo lesions were treated with the Absorb version v1.0. From 6-months to 2-year, the luminal dimensions in vessels treated with BRS Absorb v1.0 were increased [7] due to a decrease in plaque size without change in vessel size suggestive of positive remodeling. The Absorb v1.1 [8] multi-imaging modality study revealed unchanged late luminal loss after the first year, whereas on intravascular ultrasound (IVUS), mean lumen, scaffold, plaque and vessel area show...

Use of Bioresorbable Vascular Scaffold technology in treating coronary bifurcation lesions: A report about long-term clinical results and review of available literature

“…Ormiston et al (23) reported on a "snuggling" technique, where only a small portion of SB balloon comes back in MB, and is infl ated at 5 atm, to avoid BVS scaffold fracture. The use of hybrid techniques, where DES is used to treat SB is advised in complicated bifurcations where single provisional stenting with BVS is not enough (22,25). In another case report, Okamura et al (24) describes a patient with an initially peri-proceduraly obstructed SB.…”

Clinical Outcomes After Implantation of Overlapping Bioresorbable Scaffolds vs New Generation Everolimus Eluting Stents

“…Real-world BRS registries 22 have demonstrated overall acceptable mid-term outcomes, albeit with some worrying signs of increased stent thrombosis. Ishibashi et al 9 summarized the stent thrombosis experience with BRS in various settings (stable angina, ACS, STEMI).…”

Everolimus-eluting stent platforms in percutaneous coronary intervention: comparative effectiveness and outcomes

“…Definite/probable thrombosis rate in the BVS group was numerically higher at both 30 days (2.1% vs 0.3% [ P =0.059] vs 1.0% [ P =0.324], respectively) and 1 year (2.4% vs 1.4% [ P =0.948] vs 1.7% [ P =0.825], respectively), as compared with the EES or BMS groups. Several smaller registries have demonstrated the feasibility of implantation of BVS in more complex lesions, 75 such as calcified lesions 76 or ISR. 77 Table 2 shows the landmark studies in patients treated with EESs/everolimus-eluting scaffolds.…”