Salil Patel, MD, interventional cardiologist, talks about a new stent designed for use in large, proximal vessels close to the aorta.
Interview conducted by Ivanhoe Broadcast News in November 2021.
We might as well just come out and say it, Synergy Megatron. What is it?
SALIL PATEL: Synergy Megatron is a new stent by Boston Scientific. A stent is a kind of a metal scaffold that you put into the arteries of the heart when there’s a blockage. Synergy Megatron is just one of their newest stents that they’ve just rolled out into the market and is available for us to use.
Everybody will want one, but no, this is for very specific problems. Can you tell me what this would be used for?
SALIL PATEL: This particular stent is stronger than the standard stent, and it comes in different sizes. They intend for it to be used in arteries that are much more calcified and closer to the aorta. The beginning part of the arteries are bigger and more calcified. They’re more rigid. [This stent] can do a better job in some of those locations. They’ve [the manufacturer]created it to satisfy a need in those locations where the arteries are a little bit different than in other areas.
This goes in when arteries are blocked with plaque. But how do you do it? You first kind of Roto-Rooter out the plaque, right?
SALIL PATEL: Often times we do in the more complex patients. In a basic cardiac catheterization, we access the artery through the wrist or the groin. We run a small catheter tube to the heart, inject dye into the arteries and we take pictures. If we see a blockage, we typically open it with a stent, and that’s done by inserting a wire into the artery and then advancing a stent on a balloon. We inflate the stent at the site of the blockage, and it’s like a metal scaffold that holds the artery open. This particular stent, the Synergy stent, is again more rigid and stiffer and it’s capable of holding open the artery in these areas where there’s intense calcification. A lot of times in those arteries, we have to do a Roto-Rooter type procedure. We drill some of the calcium out of the way just to be able to expand the balloon and stent in those places, and then the strength of the stent helps to keep that area open.
Since it’s so much stronger, does it mean that it will hold for longer? That you may not have to replace it?
SALIL PATEL: Hopefully, yes. These arteries where there is a lot of calcium, sometimes it’s hard to expand the artery fully and get those stents to expand. Once they’re open, there’s less chance of it recoiling or narrowing back down, but part of the process is prepping the artery properly in the beginning when we put it in. Again, these are designed to go in areas where the vessels are larger and more calcified.
Let’s say what if you don’t catch this type of buildup in that artery, what happens?
SALIL PATEL: If we don’t catch it?
Yeah.
SALIL PATEL: If we don’t identify that they have a blockage, then that can lead to chest pain symptoms and potentially heart attacks down the road.
Would you say out of all the stents that you do, like, is it more common to have the larger arteries build up with plaque?
SALIL PATEL: It’s maybe not more common, but we’re having to address this more frequently nowadays because we’ve gotten better and better at putting stents in, and some of the patients, some of these arteries, are very diseased and calcified. There are things that we might not have done 10 years ago. A lot of times we’re doing these in patients that we would have typically sent for surgery, but they’re too sick for surgery. That was the issue in this particular patient’s case. We watched her for over a week in the hospital, and they declined to take her to the operating room because she was too sick. They didn’t think she’d make it. Maybe 10 or 15 years ago, this patient would have had no options and, in fact, some of these patients, we refer them to hospice. The family sometimes doesn’t want to do that. [They say,] ‘We want you to do whatever you can’. Nowadays, with the newer technology, we’re able to do this successfully.
Is there going to be a time where, you know, like open surgeries for any of this is going to be kind of like the rare thing instead?
SALIL PATEL: There’s always going to be a need for surgery because there are some things that, quite frankly, we just may never be able to fix with a stent. But there are a lot of things that we can fix that we didn’t do before. Even if we did them before, the technology wasn’t good enough for those procedures to last very long. Now with these better stents, we’re more comfortable because we may not have been able to put stents in these arteries five, ten years ago, but they’d re-narrow, or we’d be facing the same problem a year or two down the road. Now that the technology is better, we can do this and have some confidence that this will work and have a more lasting effect. We’re already seeing it in the valve cases. A lot of these valves are getting put in with a percutaneous approach or a catheter approach. A lot of the things that we used to do surgery for are transitioning to a more of a catheter-based technique.
How long is this stent supposed to last?
SALIL PATEL: Typically, when you put a stent in, the objective is that it lasts forever. The stents are never removed. They’re in permanently, but you can have a re-narrowing or plaque buildup inside of a stent and that’s re-stenosis. Typically, as generations of new stents and new designs [appear], the percentage of the re-stenosis goes down each time. So, the re-stenosis rates for these stents are less than ten percent, and it gets better each time, but obviously, the more complex the artery is, the higher the chance of re-narrowing. The idea is that we don’t have to do that again.
Can you kind of go over again how this stent works? Do you always put it through the groin? Can it go through the wrist?
SALIL PATEL: This stent goes in pretty much like any other stent, and we can do most of the procedures through the wrist. It just depends on the patient and their anatomy whether we can or can’t do that, but otherwise it typically goes in like a routine stent. The stents are basically metal that’s crimped down into a balloon, which is advanced over wire. To get that into the area where the blockage is, you just inflate it and the balloon. The stent expands, they deflate the balloon, and the stent is pressed up against the artery wall. They remove the balloon, and then the stent is left there.
Is there any more risk to this one since it is kind of a harder material than it would – than a normal stent?
SALIL PATEL: Probably not more risk, but it may not be as flexible as some of the other ones. It’s also designed for bigger arteries. So, you wouldn’t put this one in a small artery because it doesn’t come in those small sizes. It can be expanded to six millimeters, which is pretty large. The only area where those arteries are typically that large is at the beginning of the arteries where it comes off the aorta.
Is it more of a risk because it is a little bit harder of a stent, like when you’re putting it in to maybe dislodge some plaque?
SALIL PATEL: Putting the stent in is probably not the riskier part. It’s just when you’re probably putting it in vessels that are much more diseased. That vessel itself is kind of a complicated vessel. In general, when you’re dealing with the locations that are near the aorta that’s usually the beginning of the stent arteries, and those are kind of dangerous locations because if something goes wrong with the artery, typically the whole vessel shuts down.
Now because of technology, I mean, you are getting to save so much more, so many more people than you would have had the chance to do before because there was just no option for them. Like this woman was not going to go into surgery. No one was going to touch her.
SALIL PATEL: Exactly. Part of that is with this piece of equipment and other equipment that we use in tandem, we’re able to do sicker and sicker patients. I did a patient yesterday who was in the same situation. She was turned down by surgery. We actually tried to enroll her into hospice, and she came to the hospital. This is the third time she was readmitted within a two-week period. They chose not to do hospice, and said ‘we want to do this,’ even though we told them if something goes wrong, you might not make it out of the procedure room. Everything went fine, but because we have some of this technology and these newer techniques, we’re able to do some of these procedures, whereas in the past we wouldn’t even try them.
END OF INTERVIEW
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