While cheering FDA approval of the Absorb bioabsorbable stent, many cardiovascular interventionalists anticipate using it in only a minority of their patients as they wait for more data and advancing technology.
The major selling point of the dissolving stent is that it is absorbed by the body in 3 years. It was shown non-inferior to the Xience everolimus-eluting stent in the ABSORB trials — albeit with a disturbing trend of more scaffold thrombosis (1.54% versus 0.74% for Xience).
“This is an innovative and transformational new technology that we are eager on using,” Etisham Mahmud, MD, of University of California San Diego told MedPage Today. Nevertheless, he estimated that his group will only be implementing the technology in 15% to 20% of interventional procedures.
Ajay Kirtane, MD, SM, of Columbia University Medical Center/New York-Presbyterian Hospital, also told MedPage Today that while he would be using the Absorb stent, it won’t be for many cases.
“I do think that this will be a minority of our patients … given the excellent performance of the current generation of metallic drug-eluting stents [DES]. At least based upon experience outside the United States, the current generation of metallic DES do have advantages (e.g., in deliverability due to strut thickness) which are likely to be more manifest in more complex lesion subsets.”
“Remember also that while the potential advantage of Absorb may present a compelling story, this story is as yet unproven, and we await the longer term results of ABSORB II, III and IV to provide these data,” he wrote in an email.
Cindy Grines, MD, of Detroit Medical Center, came in at the high end of interventionalists contacted by MedPage Today but still didn’t anticipate use in a majority of patients. “I like the device and anticipate using it in about 50% of cases,” she said.
While calling the bioabsorbable stent a “paradigm shift in stent technology” that “hasn’t happened since the introduction of DES,” Sripal Bangalore, MD, MHA, of New York University School of Medicine, fell somewhere in the middle in his use estimate, at 20% to 30%.
“I think it’s a step in the right direction. I am excited for the next-generation scaffolds and the things to come in the next decade or so,” he told MedPage Today.
A common refrain among the clinicians interviewed was their expected use of Absorb in younger patients and those with selected less complex lesions.
Vessel size has been an important issue for Absorb, with poor outcomes seen in vessels smaller than 2.5 mm and a label “strongly” recommending quantitative coronary angiography or intravascular imaging to confirm appropriate vessel sizing for small vessels.
Grines said that she would simply avoid bioabsorbable stent placement in small vessels as well as those with heavy calcification and proximal tortuosity.
Bangalore added he would most likely use Absorb for “patients who need long stents, primarily in the left anterior descending but also in other arteries.”
“I cannot emphasize enough the importance on appropriate patient and lesion selection, and how important it will be to revisit good fundamental PCI [percutaneous coronary intervention] technique when implanting this device,” said Kirtane. “To my eye, this first-generation device has less tolerance to variability in technique than other contemporary metallic DES, which is why optimization of stenting technique is so critical.”
Annapoorna S. Kini, MD, of Mount Sinai Hospital in New York City, also emphasized techniques to make sure the bioabsorbable stent is expanded. The three steps of pre-dilatation, scaffold placement, and post-dilatation can reduce the risk of scaffold thrombosis to that of “any other stent,” she suggested.
“I have always been able to deliver” the Absorb stent after adequate lesion prepping, Grines told MedPage Today. “The hardest issues for me is to remember to inflate slowly and to visualize the small scaffold markers to perform post dilation without geographic miss.”
Bangalore and Grines declared serving on the advisory board for Abbott Vascular.
Kini disclosed no relevant conflicts of interest.
Kirtane reported receiving institutional research grants from Abbott Vascular, Medtronic, Boston Scientific, Abiomed, and St. Jude Medical.
Mahmud disclosed consulting and serving on the speakers bureau for Abbott Vascular.