Coronary Restenosis Clinical Trial
Official title:
Evaluation of Neointimal Healing of Endothelial Progenitor Cell Capturing Sirolimus-Eluting (COMBO) Stent by Optical Coherence Tomography: the EGO-COMBO Pilot Study
All subjects requiring percutaneous coronary intervention (PCI) and stenting are eligible to participate in the study. Restudy coronary angiogram with Optical Coherence Tomography (OCT) would be performed between 1 to 5 months at the time of a staged PCI procedure (for remaining coronary disease) or as clinically indicated, and then at 9 months. At the time of the 9-month restudy (a proper time window for drug eluting stent to develop into restenosis should it occur), any new disease detected or restenosis will be treated. The reported incidence of drug eluting stent restenosis is around 10% in simple lesions and is expected to be higher in diabetic patients, long lesions and multi-vessel diseases; a restudy at 9 months actually confers better protection to the patients with advanced disease and any restenosis can be treated timely. All data on clinical events and progress will be monitored and regular follow-ups will be carried out.
The GENOUS Stent (the EPC Capturing R-stent, OrbusNeich Medical Inc., Fort Lauderdale, FL)
is commercially available and has been extensively used in standard coronary intervention
procedures treating >200 patients with critical coronary stenoses at Queen Mary Hospital.
The COMBO Stent (OrbusNeich Medical Inc., Fort Lauderdale, FL) is a hybrid version of the
GENOUS Stent with an abluminal sirolimus coating, and is currently under the investigational
use for clinical research in the REMEDEE Study; over 20 patients have been treated and all
remained in good condition since the treatment.
The GENOUS Stent is a bio-engineered 316L stainless steel coronary stent with a
biocompatible circumferential coating of anti-CD34 antibody, and will bind to and therefore
capture the circulatory endothelial progenitor cells (EPC) which have CD34 antigen on the
surface. Immobilization of EPCs on the stent surface will encourage differentiation and
proliferation of the EPCs into endothelial and neointimal layer. Animal model has
demonstrated that a functional endothelial layer could be formed as soon as 24 to 48 hours
after GENOUS stent implantation (1). The HEALING-FIM registry has shown that GENOUS stent is
clinically safe and effective in the treatment of coronary stenosis (2). Recent reports have
further confirmed its efficacy in patients with acute coronary syndrome requiring urgent
revascularization (3,4).
The COMBO Stent is a hybrid version of the GENOUS Stent, with an additional abluminal, drug
eluting sirolimus coating, targeted to reduce excessive neointima formation, while
maintaining the EPC capturing capacity and therefore continue to promote healing after stent
injury. The hybrid function of these two technologies in this new COMBO stent is expected to
produce better clinical results in terms of accelerated healing, less stent thrombosis and
less restenosis; these are being investigated in the current REMEDEE Study.
Animal study has shown the COMBO Stent promotes endothelialization and reduces neointima
formation, as assessed by both optical coherence tomography (OCT) and histopathology (5).
Even though COMBO Stents have been used and found to be safe in over 180 patients world-wide
and in about 30 patients at Queen Mary Hospital under the REMEDEE Study Protocol, such
benefits of "early" endothelial coverage as assessed by OCT has never been fully documented
in human subjects.
The current EGO-COMBO study protocol is designed based on the approved protocols of the
ongoing REMEDEE Study (IRB: UW 09-384) and the EGO Study (IRB: UW 10-256); both are still
active in this Hospital. In the multi-center REMEDEE Study, the COMBO stent is compared to
the TAXUS stent (Boston Scientific) in patients with coronary artery disease requiring stent
implantation, looking at the 9 months late loss results. This EGO-COMBO Study is different
from the REMEDEE Study and focuses mainly on the very early time frames assessing the degree
of early neointimal healing (enhanced endothelialization) between 2nd to 5th months, and the
subsequent neointimal proliferation at 9 months after the COMBO Stent implantation, as
assessed by the very high resolution of the frequency domain optical coherence tomography
(OCT) used in the existing EGO study. This is a single centre, non-randomized, open-label
study.
Intracoronary frequency domain optical coherence tomography (FD-OCT) is a simple
catheter-based imaging technique using optic fibre to achieve very detailed assessment
(resolution down to 10 microns) of the stents, in terms of stent apposition, early
neointimal coverage (enhanced endothelialization) and late stent neointimal growth
(restenosis). It is performed as part of the routine cardiac catheterization procedure and
provides high-resolution cross sectional images of the coronary arteries. OCT has been shown
to be safe in clinical practice (6, 7). The LightLab C7XR OCT System (Frequency Domain OCT)
is a commercially available product with CE Mark and FDA approval, and is being used in our
EGO Study. The Dragonfly OCT catheter used is a non-occlusive optic fibre which is extremely
small and flexible, and will pose absolutely no additional risk to the patient under
treatment, other than those inherent risks of a standard angioplasty procedure.
In this prospective, pilot study, OCT is used to image the COMBO Stent after implantation to
evaluate both the early healing (stent apposition, neointimal coverage) and late lumen loss
(neo-intimal thickness and neo-intimal area). Clinical outcomes will also be monitored as
secondary end points. The OCT analyses will be performed by an USA based core laboratory,
which is blinded from the time frame of the OCT pullbacks and the clinical details.
;
Allocation: Non-Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Single Group Assignment, Masking: Single Blind (Outcomes Assessor), Primary Purpose: Treatment
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