Thursday, June 01, 2006

The Chill in Paris

It is end spring and early summer in Paris, and the temperature should be warming up. The EuroPCR, one of the biggest showcase of Interventional Cardiology, is currently on (16th-19th May) in Paris. But a distinct chill is felt at the interventional climate.

Two years ago, the same meeting was full of enthusiasm about the revolutionary Drug-Eluting Stent (DES), which seemed then like the answer to all our interventional problem. "Restenosis is defeated" we proudly proclaimed. DES usage climbed from 30-40% usage to almost 100% usage in some laboratories. Then reports of the downside of DES began to appear. Late stent thrombosis. That terrible, life-threatening problem. This problem had autopsy evidence, thanks to the sobering work of Dr R Virmani, and clinical trial evidence, the LATE-BASKET study. So the chills sets in to interventional cardiology. The enthusiasm is tempered by more realism.

Many labs are beginning to re-think their strategy. The 100% DES usage labs begin to have 80-90% usage. Looking at this another way, (and we have seen this many times before with rotablator, artherectomy devices, laser angioplasty, cutting balloons, even bare metal stents), there was the initial enthusiasm with over-enthusiastic use of the particular technology, before the sobering realism sets in, and finally settles down to more rational usage. The pendulum swings to the left, then right and finally settles at the center. With DES two years ago, there was the fantastic enthusiasm with a new revolution, now the pendukum is swinging to the right (let us hope not too much) and soon it will settle to the center. Put another way, some are advocating that we should be stricter in our use of DES (better have restenosis with the use of bare metal stents, then run the life-threatening risk of DES late stent thrombosis). I don't think that is right. What we need are better DESes with almost no late stent thrombosis. There is a suggestion that stents with more late loss, may have less late stent thrombosis. Meaning that higher late loss in the DES, may somewhat protects against late stent thrombosis. Interesting. In Paris, as the meeting closes, I am sure that wisdom will prevail. DES is here to stay. I am sure that better DESes will appear, and late stent thrombosis will be further minimised (literally to zero or almost zero).

Science must often be tempered with the wisdom of man, for good practical application.

1 comment:

Jan said...

Lately I have seen some tendency to use bare metal stents rather than DES in patients that are pre-op or have an anticipated procedure such as EGD w/ dilation.
(We refer our PCI patients to a tertiary facility - only do diagnostic cath).
Many of my DES patients are told (erroneously) by their GI doc or dentist or PCP that it is OK to stop both ASA and Plavis peri-procedurally. One of my biggest teaching points with patients is to tell them never to stop both drugs during the first 6 months post PCI, and that doing so after 6 mos is not without risk.
Innovations that reduce the risk of thrombosis would be welcome indeed.