Tips and tricks from DES to BRS - Khôi Minh Lê

Tips and Tricks 
From DES to BRS 
Khôi Minh Lê, MD, FACC, FSCAI 
Co-Director Cardiac Cath Lab 
Eisenhower Medical Center 
Rancho Mirage, CA 
Absorb GT1 
Only BRS currently available in the US 
Absorb: What’s Different? 
Absorb polymer ≠ Cobalt alloy 
1. Strut size 
a. Thickness 157 (vs 89 μm for Xience) 
b. Width 190.5 – 215.9 μm (vs 90 μm for Xience) 
2. Crossing profile A-BVS 1.42 mm (vs Xience 1.07 mm) 
3. Does not score the vessel like a metallic stent and therefore 
requires more thorough lesion preparation 
4. Absorb’s maximum expansion range (≤0.5 mm) is less than that 
of current metallic stents 
5. Radiolucent, cannot be visualized with x-ray equipment. 
Lesion Selection 
• De novo native lesion 
• 24 mm or less 
• 2.5 to 3.75 mm reference vessel diameter 
• Non-ostial 
• Avoid jailing side branches ≥2.0 mm 
• Avoid heavily calcified, eccentric lesions 
Recognize the Differences Between 
CoCr and PLLA 
• The Absorb polymer is viscoelastic which means it is 
temperature and rate sensitive. The Absorb scaffold needs to 
expand slowly to optimally realign the polymer chains. 
• After reaching the desired atmosphere it is important to hold 
for 30 seconds in order for the polymer to reset its memory 
from being in the crimped state. If the “hold time” is too short 
the scaffold may experience slight recoil. 
Deployment Procedure 
• Deploy the scaffold slowly, in 2-atm increments, over 5 seconds, 
until scaffold is completely expanded 
– Use a constant, slow inflation 
– Count (“1, 2, 3, 4, 5” while going up 2 atm) and repeat 
– [Not cutting balloon technique of quickly going up to 2 atms] 
• Nominal pressures: 
– 6 atm for 2.5 and 3.5 mm 
– 7 atm for 3.0 mm 
• Deployment pressures should range from 10 – 16 atm 
• Hold maximum pressure for 30 seconds (if tolerated) 
Puricel et al. J Am Coll Cardiol. 2016; 67(8): 
921-931. 
Ellis et al. N Engl J Med. 2015; DOI: 
10.1056/NEJMoa150938. 
*<2.4 for 2.5 and 3.0; <2.8 for 3.5 
Early Experience and Absorb-Specific 
Protocol 
1. Oversized scaffolds* 
2. Incomplete deployment 
“Absorb-Specific Protocol” 
Improved 1 year Scaffold Thrombosis 
3.0% 
Pre-dilatation 
Using the device 
only in vessels 
where it could be 
fully deployed 
Implanting the 
device only in 
reference vessels of 
the same size 
Post dilatation 
1.0% 
“Absorb-Specific Protocol” 
Improved 1 year Scaffold Thrombosis 
3.0% 
Pre-dilatation 
Using the device 
only in vessels 
where it could be 
fully deployed 
Implanting the 
device only in 
reference vessels of 
the same size 
Post dilatation 
1.0% 
“P P” 
Prepare 
lesion 
Size 
P t dil te 
Prepare the Lesion 
Fail to prepare, prepare to fail 
• Full expansion of pre-dilatation balloon 
(noncompliant balloon sized 1:1) 
• [Consider contrast injection with balloon 
expanded to confirm proper sizing] 
• Maximum 20-40% residual stenosis after pre-
dilatation 
Resistant Fibrocalcific Lesions 
• High pressure NC balloon 
• “Cutting wire” angioplasty 
• Cutting/scoring balloon 
• Rotational/orbital atherectomy 
Delivering the Scaffold 
• Guide catheter selection 
– Coaxial alignment 
– Larger French sizes more supportive 
• Buddy wires 
• Anchor wire or catheter 
Size Appropriately 
• IC Nitroglycerin 
• Compare to expanded pre-dilatation balloon 
• Use alternative sizing/imaging tools 
– QCA 
– IVUS 
– OCT 
Vessel sizing 
Visual estimate of vessel diameter (mm) 
2.5 2.7
5 
3.5 3.7
5 
AVOID 
BORDERLINE 
Consider QCA, IVUS 
Sizing Guidelines 
• Scaffolds used in tapered vessels should be sized 
to the larger/proximal vessel 
• When in doubt, size up because the stent cannot 
be further expanded more than 0.5 mm 
Post Dilate 
Goals 
1. Embed scaffold struts into the vessel wall 
2. Achieve <10% final residual stenosis 
3. Ensure full strut apposition 
Non-Compliant Post-Dilatation Balloon 
Size Recommendations 
• Post dilate with noncompliant balloon sized ≤ 0.5 
mm over scaffold diameter. 
• Recommended pressure >16 atm 
SPECIAL SITUATIONS 
Overlapping Stents 
Farooq et al JACC Intv 2013;6:523-32 
Overlapping Absorb Struts 
• Strut thickness 
0.16 mm 
• Struts will take 
up 0.64 mm of 
vessel diameter 
in overlap zone 
Luminal area 
Expansion of outer struts 
Overlapping Scaffolds 
• Minimize amount of 
overlap (single marker) 
• Consider end-to-end with 
no overlap in vessels <3.0 
mm 
• High pressure post-dilation 
prior to deploying 
subsequent scaffolds 
Overlapping Scaffolds 
SPECIAL SITUATIONS 
Side Branches/Bifurcations 
Suggested Algorithm for Side 
Branches/Bifurcations 
• Provisional SB 
treatment 
• Max 2.5 mm side 
dilatation 
• DES preferred for SB 
• Always finish with 
high pressure MB 
• Simultaneous 
“snuggle” rather 
than “kiss” 
Ielasi et al EMJ Int Cardiol 2014;1:81-90 
Bifurcation BVS Stenting 
Seth et al Catheter Cardiovasc Interv 
2014;84:55-61 
BVS Bifurcation OCT 
Seth et al Catheter Cardiovasc Interv 
2014;84:55-61