EuroPCR 2013 – samorozprężalne stenty wieńcowe u pacjentów z zawałem.

EuroPCR 2013 – samorozprężalne stenty wieńcowe u pacjentów z zawałem.

Czerwiec 26, 2013  |  Udostępnij  | 
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Niedawno przedstawiliśmy wyniki nowych badań dotyczących TAVI, jakie prezentowano podczas paryskiej konferencji EuroPCR 2013. Podczas największego w Europie forum kardiologii inwazyjnej nie mogło jednak zabraknąć także doniesień dotyczących najnowszych osiągnięć w dziedzinie przezskórnego leczenia choroby niedokrwiennej. W poniższym artykule przyjrzymy się szczególnie jednemu z nich – wynikom rocznej obserwacji pacjentów z rejestru APPOSITION III, czyli kolejnego etapu badań nad nitinolowym, samorozprężalnym stentem wieńcowym firmy Stentys.

Poprzednie testy tego nowego narzędzia – APPOSITION I oraz II, a także badanie OPEN I, potwierdziły słuszność założeń jego konstruktorów. Jak wiadomo, ocena wielkości naczynia dozawałowego, objętego skurczem, w którego świetle znajduje się skrzeplina, nie należy do zadań łatwych, a jest kluczowa dla doboru stentu o odpowiedniej średnicy. Zastosowanie stentu zbyt małego wiąże się ze zwiększonym ryzykiem zakrzepicy i restenozy, podczas gdy zbyt agresywne poszerzanie zwiększa groźbę rozwarstwienia tętnicy lub jej perforacji. Stąd idea konstrukcji stentu samorozprężalnego, dopasowującego się do średnicy i kształtu naczynia, rozszerzającego się wraz ustąpieniem jego skurczu i rozpuszczaniem skrzepliny, bez konieczności doprężenia balonem. O tym, że to nie tylko teoria, mogliśmy się przekonać już w ubiegłym roku, po ukazaniu się wyników badania APPOSITION II[1]. Wzięło w nim udział 80 chorych z zawałem serca z uniesieniem odcinka ST (STEMI), których losowo podzielono na dwie grupy. Pierwszej z nich implantowano stent samorozprężalny, drugiej natomiast klasyczny, rozszerzany balonem. Po trzech dniach od przeprowadzenia procedury oceniano z zastosowaniem optycznej tomografii koherencyjnej dopasowanie wszczepionych rusztowań. Co najmniej 5% źle ulokowanych ogniw przyjęto jako kryterium niezadowalającej apozycji stentu. W grupie kontrolnej odsetek takich nieudanych implantacji wyniósł 28%, podczas gdy wśród pacjentów, u których zastosowano stenty samorozprężalne, nie było choćby jednego takiego przypadku.

Wyniki te, choć obiecujące, były dopiero wstępem do uznania nowego produktu firmy Stentys za wartościowy klinicznie. Przede wszystkim nie pozwoliły one na rozstrzygnięcie, w jakim stopniu ulepszone dopasowanie stentu przełoży się na rokowanie u pacjentów. Odpowiedzi dostarczyło dopiero badanie APPOSITION III, którego roczne wyniki przedstawiono podczas EuroPCR. W eksperymencie wzięło udział 965 pacjentów ze STEMI, z 50 ośrodków, w tym 5 polskich. Wśród kryteriów włączenia znalazły się – zmiana powstała de novo oraz średnica naczynia pomiędzy 2,5, a 4,5 mm. Wyłączeniu z badania podlegali natomiast chorzy ze zwężonym pniem lewej tętnicy wieńcowej, we wstrząsie kardiogennym, a także osoby z przeciwwskazaniami do podwójnej terapii przeciwpłytkowej. Protokół nie zakładał próby kontrolnej – wszystkim zakwalifikowanym pacjentom wszczepiano samorozprężalny stent Stentys w wersji powlekanej lub niepowlekanej w zależności od decyzji operatora. Obserwacja trwała 12 miesięcy. Częstość zgonów sercowych w tym czasie wyniosła 2%, a odsetek powtórnych zawałów spowodowanych zmianą w naczyniu poddanym interwencji 1,3%. Łącznie u 9,3% badanych wystąpiła któraś ze składowych złożonego punktu końcowego (poza zdarzeniami opisanymi wyżej, tworzyły go pilna, powtórna angioplastyka przezskórna oraz konieczność rewaskularyzacji chirurgicznej). Wobec braku grupy kontrolnej uzyskane rezultaty odniesiono do wyników przeprowadzonych w ostatnim czasie (od 2006 roku) podobnych badań u pacjentów w ostrej fazie zawału. Porównanie wypadło korzystnie dla nowego produktu firmy Stentys – 11,1% vs. przytaczane już 9,3%, jeśli chodzi o główne zdarzenia niepożądane, oraz odsetek zgonów sercowych 3,9% vs. 2%.

Podsumowując, należy stwierdzić, że samorozprężalny stent Stentys jest narzędziem godnym uwagi. Wyniki badania APPOSITION III są kolejnym argumentem potwierdzającym jego przydatność u pacjentów z ostrym zespołem wieńcowym.

1. RJ van Geuns et al., Self-expanding versus balloon-expandable stents in acute myocardial infarction: results from the APPOSITION II study: self-expanding stents in ST-segment elevation myocardial infarction. JACC Cardiovasc Interv. 2012 Dec; 5(12):1209-19



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