Stents são para a vida toda: análise crí4ca de resultados tardios de stents na circulação pulmonar na idade pediátrica Célia Maria Camelo Silva Declaro não haver conflito de interesse nesta minha apresentacão Tipos Estenose de artéria pulmonar : -­‐ Congênita (isolada ou associada outras lesões) -­‐ Pós-­‐operatório Qual o racional para indicar stent Vantagens: •  Fornece suporte – previne efeito “recoil” e compressão Ainda: •  Menor risco de ruptura •  Consolidar “flaps” da ín4ma •  Super:cie regular ↓ proliferação neoin4mal •  Previne formação de pseudo aneurisma Problemas em potencial: • Hiperplasia in>mal • Expansão limitada quando usado stents pequenos • Oclusão ou limitação de fluxo em sub-­‐ramos • Fratura do stent O que sabemos: Mullins et al(1988) -­‐ Eficácia clínica imediata – terapêu>ca estabelecida estenose ramos pulmonares – Circula9on 1988;77:188 -­‐99. Úl9mos 25 anos: •  ampliação experiência clínica usando vários >pos de stents •  poucos estudos avaliaram o impacto do uso de stents nos ramos pulmonares O,Laughlin at al Circula4on 1991; 83: 1923 -­‐1939 Fogelman R et al-­‐ Circula4on 1995; 92:881 -­‐885 A longo prazo: o que precisamos saber • Taxa de pacientes sem re-­‐intervenção • Fatores de risco para estenose intrastent e fraturas • A redilatação de stent é segura • Impacto do stent na evolução clínica • O que acontece ao adulto com C.C que teve stent implantado quando criança Protocolo uso stent em CC 200 pacientes 347 stents Período de 6 anos Stents: P308 ( 12-­‐18mm) e P204 (8 -­‐10mm) Shaffer, MF et al -­‐1998 diameter plots reflects measurements
available for individual stents, whereas
“n” in the RV/FA ratio plots refers to
patients (mean ! SEM, *p " 0.001).
Estenose pulmonar Pós-­‐operatório Congênita 71 ± 45 mmHg para 15 ± 21 mmHg 46 ± 25 mmHg para 10 ± 13 mmHg 6 ± 3 mm para 12 ± 3 mm The RV/FA systolic pressure ratio improved in both groups.
The RV systolic pressure in the postoperative PA stenoses
group decreased to less than half systemic (RV/FA: from
0.63 ! 0.2 to 0.41 ! 0.02, p " 0.001). This decrease persisted
at follow-up catheterization (0.45 ! 0.01, p # 0.002). In
patients who required further stent dilation, the RV/FA pressure ratio decreased again (from 0.48 ! 0.14 to 0.38 ! 0.09,
p # 0.2). (Fig. 2C). In the congenital PA stenoses group, a
drop in the RV/FA pressure ratio also occurred, although this
change was not statistically significant (from 0.71 ! 0.3 to
0.55 ! 0.35, p # 0.04) (Fig. 2F). At follow-up catheterization,
the RV/FA pressure ratio in the congenital PA stenoses group
increased to 0.65 ! 0.3 (p # 0.8). Further dilation of stents in
a limited number of the patients with congenital PA stenoses
decreased the ratio from 0.74 ! 0.15 to 0.70 ! 0.14 (p # 0.2),
which was not statistically significant.
Venous stenoses. The systemic vein stenoses/venous anastomoses group included patients with stents placed in low
pressure–low velocity flow locations. These locations included
P< 0.001 clinically and/or hemodynamically significant stenoses in systemic veins, in atrial baffles or conduits or in the branch PAs
and veno-pulmonary artery anastomoses of the patient with a
postoperative cavopulmonary anastomosis. Eighty stents were
placed in 49 patients. Although initial pressure gradients in the
venous stenoses were much lower than those in both the
postoperative and congenital stenoses, after stent implantation
there was still a statistically significant decrease in the pressure
gradient (from 7 ! 6.4 to 1 ! 1.9 mm Hg, p " 0.001). At
follow-up catheterization of 13 patients (22 stents), there was
no statistically significant difference in the gradient (1 !
2.2 mm Hg, p # 0.9). Five stents were further dilated; the
gradient decreased (from 4 ! 3.3 to 1 ! 0.8 mm Hg), but
this change did not reach statistical significance (p # 0.06)
(Fig. 3A).
The diameter of the stenotic segment increased dramatically after venous stent implantation (from 2.8 ! 3.6 to 12.5 !
3.9 mm, p " 0.001). Twelve of the venous stenoses (18%) were
totally occluded vessels before stent implantation. Stent im-
3 ± 1 mm para 12 ± 4 mm 31 ± 17 % para 46 ± 14% P< 0.001 P< 0.001 CINTILOGRAFIA PULMONAR: OBSTRUÇÃO UNILATERAL Endovascular Stents in the Pulmonary Circula9on Clinical Impact on Management and Medium-­‐term Follow-­‐up Rami Fogelman et al. Circula9on 1995 92: 881 -­‐885. Obje>vos: Avaliar benebcios e potencial de reestenose 109±79% p=0.001 ↓Gradiente 74±26% p=0.001 Necessidade de reintervenção 15/55 pacientes 1 ano após implante de stent Estenose intra-­‐stent Pós redilatação com balão Rami Fogelman et al. Circula9on 1995 92: 881 -­‐885 thrombosed stent was not included in the
group and one patient was lost to follow
remaining 22 (26 successfully implante
patients form the long-term follow-up group.
Miami, FL 33155. E-mail: [email protected]
operator experience has grown and advances
in cathe- *Correspondence to: Evan M. Zahn, MD, Miami Children
younger children and infants has emerged [12–14].
ter and stent technology have facilitated
stent 19delivery,
Received
November 2007;
Revision accepted
12 January
tal, Ambulatory
Care Building,
31002008
SW 62nd Ave., Seco
Although the acute results appear comparable to those
a growing experience with stent implantation in Miami, FL 33155. E-mail: [email protected]
in older children, little is known about the long-term DOI 10.1002/ccd.21526
younger children and infants has emerged [12–14].
fate of these vascular
prostheses when placed into the Published online
Received
2007; Revision
accepted 12 Januar
14 April
200819inNovember
Wiley InterScience
(www.
Although the acute results appear comparable
to those
circulation of a small
child.
Important
long-term
folinterscience.wiley.com).
in older children, little is known about the long-term
fate of these vascular prostheses when placed into the
circulation of a small child. Important long-term fol-
' 2008 Wiley-Liss, Inc.
DOI 10.1002/ccd.21526
Published online 14 April 2008 in Wiley InterScienc
interscience.wiley.com).
' 2008 Wiley-Liss, Inc.
Stanfill, R et al. POSSIBILIDADE DE EXPANSÃO DO STENT Long-Term
Follow-Up
Crianças < 2 anos Recatheterization. Between November
September 2006, all 22 patients underwent a
Catheterization and Cardiovascular Interventions DOI 10.10
Published on behalf of The Society for Cardiovascular Ang
Stent em crianças pequenas é uma alterna]va importante para evitar cirurgias de emergências em neonatos. Várias redilatações foram necessárias pulmonary arteries of canines [5] and then humans in DOI 10.1002/ccd.22356
an FDA IDE protocol from 1989–92 were in
tion data
were evaluated. Patients were inc
Therefore,
18
patients
with
no
known
late
complication
s
the late 1980s [6], numerous studies have reported Published online 10 November 2009
InterScience
(www.
able inorWiley
if mortality
occurred
following the
short to
of stents
interscience.wiley.com)
four due to progression of their
orintermediate-term
death andeffectiveness
less than
5 years
follow-updeaths:
were
excluded
complication during a follow-up catheteriza
demonstrated 39 patients (91%) are in NY
surgical intervention during the follow-up p
sions), but none addressed PA stenosis. Fi
in 36 patients (55 stents) 7.2 6 4.3 years
procedures with stent dilations. In this
increased from 4.7 6 1.8 to 13.4 6 2.4 m
improved from 41 6 25 to 9 6 11 mm H
smaller balloons were associated with a fi
and 0.046). Jailed vessels occurred in 49%
in 18/55. Six repeat catheterizations resulte
cedural death. Conclusion: Stents implants
ment in vessel caliber in the long-term. Al
this procedure reduces RV pressure and p
C 2009 Wiley-Lis
V
for residual PA obstruction.
from further analysis. Fifty patients (71 stents), includ- c
ing five patients who died, met inclusion criteria for p
the study with a mean follow-up time of 13.2 ! 2.3 !
years (See Table I). The average age at stent placement d
was 12.6
! 7.1 years
withprazo an average
weight of 25 ! q
Primeiro seguimento a longo > 15 anos 13 kg. Tetralogy of Fallot, single ventricle, and truncus a
arteriosus comprised 84% of the patients’ diagnosis.
te
During the study period, Palmaz ‘‘3 series’’ stents u
INTRODUCTION
(Johnson and Johnson, Interventional
Systems,
Branch pulmonary
artery (PA) Warren,
stenosis is commonlys
many congenital heart defects. UnilatNJ) P-308 (3 cm length " 3.4associated
mmwithnominal
diameter, w
eral stenosis causes significant imbalance in right verleft PA blood flow [1] and potentially worsen pulexpandable to 12 to 18 mm) sus
were
the only large size im
monary insufficiency in patients with repaired tetralogy
of Fallot [2]. With limited human data, recent reports
stents available. Smaller Palmaz
‘‘4 series’’ stents (e.g., d
in animal models also suggest that stenosis can worsen
pulmonary valve insufficiency
[3]. The long-termim
P204) were avoided due to a suboptimal
final diameter
sequelae of branch PA stenosis with pulmonary insufficiency result in RV dysfunction, ultimately increasingy
of 10 mm.
the risk of ventricular arrhythmias and sudden death
C 2009 Wiley-Liss, Inc.
V
Key words: congenital heart disease; pediat
[4].
Since endovascular stents were first implanted in the
pulmonary arteries of Published
canines [5] andon
thenbehalf
humans of
in
the late 1980s [6], numerous studies have reported
short to intermediate-term effectiveness of stents
C 2009 Wiley-Liss, Inc.
V
(Johnson and Johnson, Interventional Systems,
NJ) P-308 (3 cm length " 3.4 mm nominal d
expandable to 12 to 18 mm) were the only la
stents available. Smaller Palmaz ‘‘4 series’’ ste
P204) were avoided due to a suboptimal final
of 10 mm.
Publish
arteriosus comprised 84% of the patients’ diagno
During the study period, Palmaz ‘‘3 series’’
(Johnson and Johnson, Interventional Systems, W
NJ) P-308 (3 cm length " 3.4 mm nominal dia
expandable to 12 to 18 mm) were the only larg
stents available. Smaller Palmaz ‘‘4 series’’ stent
P204) were avoided due to a suboptimal final di
of 10 mm.
Published
the study with a mean follow-up time of 13
years (See Table I). The average age at stent p
was 12.6 ! 7.1 years with an average weight
13 kg. Tetralogy of Fallot, single ventricle, an
arteriosus comprised 84% of the patients’ diag
During the study period, Palmaz ‘‘3 serie
(Johnson and Johnson, Interventional Systems
NJ) P-308 (3 cm length " 3.4 mm nominal
expandable to 12 to 18 mm) were the only l
stents available. Smaller Palmaz ‘‘4 series’’ st
P204) were avoided due to a suboptimal final
of 10 mm.
Publis
Gender (% male)
Age at stent placement (years)
Weight at stent placement (kg)
Baseline gradient (mm Hg)
Baseline pulmonary artery size (mm)
Baseline percent stenosis (%)
Baseline RV:FA ratio
Pulmonary artery side (% right)
Maximum balloon diameter
PA < 14 mm
PA > 14 mm
n ¼ 29 (stent)
n ¼ 21 (stent)
69
10.9 # 6.4
35.3 # 20.4
49 # 24
4.6 # 1.7
60 # 13
68 # 19
55
15.6#2.1
31
13.1 # 5.4
39.6 # 20.4
32 # 25
4.9 #2.1
66 # 14
58 # 22
45
16.7#1.5
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Oclusão de sub-­‐ramos (“jailed vessels”) 49% oclusão parcial ou total do fluxo 16% -­‐preservado 24% -­‐ reduzido 9% -­‐ ausente Aceitável – risco x bene`cio Oclusão inevitável de sub-­‐ramos – opção escolha de stent com célula aberta para permi4r dilatação dos subramos para restaurar o fluxo Quanto a fratura Stent fractures in congenital heart disease Breinholt et al . Catheteriza>on and Cardiovasc Interv 2008 72; 977 -­‐982 10/395 – 2,5% -­‐ sem embolizacão Fatores de risco: • Localizacao proximal • Stent de grande diâmetro REINTERVENÇÃO > CHANCE ARTERIOPLASTIA CIRURGICA Período: 807 ± 415 dias Cirurgia x Stent Pacientes 9/18 (50%) 1/19(5,3%) Período (médio) 272±162 dias 150 dias p=0,002 Definição não padronizada Angiográfica estreitamento > 25% 24% -­‐ 104 pacientes Fatores que influenciam: • Técnica de implantação • Lesão endotelial • Localização • Tipo de stent Sd. Williams Sd. Alagille Desafio -­‐ crianças pequenas Stern, HJ et al Crianças pequenas -­‐ Procedimento híbrido -­‐ Dilatação por balão -­‐ Stents pequenos Edwards Valeo Lifestent 10 x 26 mm2 Implanta9on and preliminary follow-­‐up of the Bard Valeo stent in pulmonary artery stenosis Kudumula ,V et al
Catheteriza9on and Cardiovascular Interven9ons 2014; 84: 197 -­‐203 Parece ser o stent ideal Vantagens: Baixo perfil Flexível Liberação fácil Conclusões: Força radial adequada para tratamento de estenose de artéria pulmonar Mínimo “recoil “ Manutenção de sua geometria a médio prazo em lesões complacentes Lesões rígidas podem distorcer o stent Conclusões •  O stent como tratamento de estenose de artéria pulmonar é efe]vo, tem impacto clínico, ganho luminal man]do na maioria das vezes, reduz a pressão do VD e cons]tue uma alterna]va a cirurgia • Redilatacão é efe]va, é necessária na maioria dos pacientes para acompanhar o crescimento somá]co •  Fraturas e complicações por redilatação são raras • Oclusão de sub-­‐ramos é aceitável, o uso de stent de célula aberta permite dilatação do ós]o do ramo Futuro Terapia an9-­‐prolifera9va – stents farmacológico para uso nos grupos de risco para EIS Muito Obrigada !!!!!!!