b.honton clinique pasteur toulouse - high tech...
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Les nouveaux outils qui nous font rêver
Les lésions calcifiées
B.Honton
Clinique Pasteur
Toulouse
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• None
Disclosure
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Sous estimée :
36 % en angiographie – 74% en IVUS1
1Bahtt et al. Cardiovascular Revascularization Medicine 20012Wiemer et al. CCI 2010
Altération du polymère2
Calcifications coronaires
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1 Vavanurakis et al. CCI 20012Generaux et al. J Am Coll Cardiol 2014
Stent Expansion after Stent
inflation at 16 ATM1
R=-0.8 ; p < 0.0001 Arc of CA2+
Stent
Expansion
Majoration TLR – Thrombose de stent
DC cardiaque et toute cause
2.81.8
7.36.0
1.7
12.9
4.2
2.8
7.68.2
3.4
15.3
6.3
4.0
9.48.7
2.4
19.9
0
10
20
Death Cardiac death MI TLR ARC Definite ST MACE
NONE/MILD MODERATE SEVERE
p = 0.01
p = 0.003
p = 0.0001
p = 0.22 p = 0.002
p = 0.002
6,855 ACS pts pooled from HORIZONS-AMI and ACUITY trials
1-Year Ischemic Outcomes by
Calcification*
Calcifications coronaires
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Calcifications coronaires
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My New Tool Box …
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Atherectomie Rotative : ROTAPROTM
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Pas de changement
Bouton de
libération du frein
Bouton d’activation
temporaire du Dynaglide
Bouton ON / OFF du
mode Dynaglide
Bouton d’activation du fraisage
sur le curseur de l’Advancer
Fraise – KT guide : identiques
Atherectomie Rotative : ROTAPROTM
Advancer
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Atherectomie Rotative : Console
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Tomey et al. JACC Cardiovasc interv 2014
Barbato et. Al. EuroInterv 2015
Atherectomie Rotative : Données Cliniques
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Traiter à 360° la paroi de l’artère
Préserver un flot continu durant l’intervention
Vaisseaux de 2 à 4 mm avec une seule reference de bague
Compatible guiding catheter 6F
Bague de 1.25 mm excentrique en diamant
Force Centrifuge = Diamètre d’abrasion selon la vitesse
80000 à 120000/min
Atherectomie Orbitale : Diamondback 360°
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Atherectomie Orbitale : Diamondback 360°
ViperWire
Advance®0.012
ViperSlide®
Lubrifiant
Pompe OAS
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Lee et al. Cardiovasc Revasc Med. 2017
Prospective – Single Arm
N= 443
49 US Site
49 US Site
Données Cliniques : ORBIT II Trial
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Co-Primary Endpoints
* MLA Stent / OCT lors de l’implantation
* Target vessel failure (TVF) à 12 mois :
Critère composite associant décès
d’origine cardiaque, Revascularisation du vaisseaux cible (Myocardial infaction ou
ischemia driven)
150 US
Site150 US
Site
Données Cliniques : Eclipse Trial
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Post RA
Effet Guide
Limite de l’atherectomie
Médiacalcose
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GénérateurRechargeable / secteur
ConnecteurPlug magnétique
CathéterUsage unique
EmetteurPulse 1/s – Max 80 pulses
Lithotripsie intracoronaire : Shockwave IVL
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Diamètre (mm)
Long. (mm)
Impulsion Max.
Compatibilité Guide
Compatibilité Cath. Guide
Long. Utile (cm)
Profil de l’Extremité*
Profil de Franchissement
2.5
12 80 0.014” 6F 138 0.023” 0.042”±0.002
3.0
3.5
4.0
Marque CE Avril 2017
Ballon de 12mm Semi-compliant
IVL =4 atm - Nominal =6 atm - Rupture =10 atm
2 marqueurs radio-opaques
2 émetteurs
Monorail
Shockwave Cathéter IVL C2
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Energie Electrique transmisse à
l’émetteur
Formation d’une bulle de vapeur qui se
dilate puis s’effondre
Création d’une Onde Acoustique
Shockwave Cathéter IVL C2
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Onde Acoustique Pulsatile Circonférentielle
Interagit avec les tissus calciques de haute densité
Lithotripsie endovasculaire = Lithoplastie
Shockwave IVL C2
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Shockwave Cathéter IVL C2
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Ali et al. JACC : Cardiovascular Imaging 2017
Lithoplastie : Effet sur la plaque
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Pre
Market
Study
Pre
Market
Study
Données clinique : Disrupt CAD I
Brinton T. EuroPCR 2017
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Brinton T. EuroPCR 2017
Données clinique : Disrupt CAD I
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Données Cliniques : Disrupt CAD I
Brinton T. EuroPCR 2017
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Ali et al. JACC : Cardiovascular Imaging 2017
Lithoplastie : effet sur la plaque
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Perspectives cliniques CAD II et III
50 centres (US – EU)
N= 392 (Dont 50% US)
Lésion < 40 mm ; 2.5 à 4 mm
FU : 30 jours – 6 , 12 et 24 mois
Post
Market
Registry
Post
Market
Registry
DISRUP CAD II
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Schockwave IVL Off Label !
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60 centres (US – EU)
N= 400 pour bras randomisé et N= 500 All comers
Lithoplasty + DCB vs DCB
Perspectives cliniques : Périphérique
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Transfemoral aortic valve implantation following lithoplasty of iliac artery in a patient with poor vascular access
Gorla et al. CCI 2018
Perspectives cliniques : Structurel
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Transfemoral aortic valve implantation following lithoplasty of iliac artery in a patient with poor vascular access
Gorla et al. CCI 2018
Perspectives cliniques : Structurel
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Shockwavemedical.com
Perspectives cliniques : Structurel
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Conclusion
Calcium en 2019 : Toujours un problème …
… qui va aller en s’accroissant
New Tools for New Results ?
Technologie séduisante – En cours d’évaluation
Eviter le « Rota Regret »