Clinical impact of sirolimus-eluting stent in ST-segment elevation myocardial infarction: a meta-analysis of randomized clinical trials

Drug-Coated Balloons for Treatment of Internal Carotid Artery Restenosis After Stenting: A Single-Center Mid-Term Outcome Study

PURPOSE

Endovascular and surgical treatments of stenosis of the extracranial internal carotid artery (ICA) are common procedures, yet both introduce a risk of restenosis due to endothelial hyperplasia. Drug-coated balloons (DCBs) are designed to decrease neointimal hyperplasia, however rarely used in the neurovascular setting. This study retrospectively analyzes mid-term results of DCB-treated in-stent restenosis (ISR) of the ICA.

MATERIALS AND METHODS

The medical history, comorbidities, and periprocedural data of patients receiving DCB treatment for > 50% ISR of the ICA after carotid artery stenting were analyzed. Follow-up after DCB treatment was performed with Doppler ultrasound. Suspicious cases were checked with CT- or MR-angiography and-if there was agreement between the modalities-validated with digital subtraction angiography. Potential risk factors for restenosis and differences in outcomes after PTA with three types of DCB balloons were evaluated.

RESULTS

DCB treatment was performed in 109 cases, 0.9% of which involved in-hospital major stroke; no minor strokes occurred. A total of 17 patients (15.6%) had recurrent ISR after DCB treatment, after a mean time of 30.2 months (7-85 months). Tobacco use was significantly associated with a higher incidence of recurrent ISR.

CONCLUSION

DCB angioplasty for ISR is an effective treatment that may delay and decrease restenosis. Treating comorbidities and adopting lifestyle changes may additionally help prevent ISR.

Ultrathin Struts Drug-Eluting Stents: A State-of-the-Art Review

New-generation drug-eluting stents (DESs) represent the standard of care for patients undergoing percutaneous coronary intervention (PCI). Recent iterations in DES technology have led to the development of newer stent platforms with a further reduction in strut thickness. This new DES class, known as ultrathin struts DESs, has struts thinner than 70 µm. The evidence base for these devices consists of observational data, large-scale meta-analyses, and randomized trials with long-term follow-up, which have been conducted to investigate the difference between ultrathin struts DESs and conventional new-generation DESs in a variety of clinical settings and lesion subsets. Ultrathin struts DESs may further improve the efficacy and safety profile of PCI by reducing the risk of target-lesion and target-vessel failures in comparison to new-generation DESs. In this article, we reviewed device characteristics and clinical data of the Orsiro (Biotronik, Bülach, Switzerland), Coroflex ISAR (B. Braun Melsungen, Germany), BioMime (Meril Life Sciences Pvt. Ltd., Gujarat, India), MiStent (MiCell Technologies, USA), and Supraflex (Sahajanand Medical Technologies, Surat, India) sirolimus-eluting stents.

Prognostic Analysis of Patients with Acute Myocardial Infarction Undergoing Implantation of Different Stents for the First Time

For patients with acute myocardial infarction scheduled to undergo percutaneous coronary stent implantation, in most cases a drug-eluting stent is recommended as the first choice for treatment. However, there is a lack of research on the effectiveness of bare-metal stents and drug-eluting stents on patients with different types of myocardial infarction. Our objective was to explore the effects of bare-metal stents and drug-eluting stents on patients with different types of myocardial infarction in terms of major cardiovascular incidents. This retrospective cohort study included 934 patients with myocardial infarction undergoing coronary artery stent implantation for the first time at the cardiac catheter room of the Tri-Service General Hospital in the Neihu District between 2014 and 2018. Patients’ information, including demographic data, laboratory data, cardiac echocardiography results, and angiocardiography results, was collected by reviewing medical records. Cox proportional hazards regression was used to adjust the potential confounding factors, and the adjusted data were then used to compare the correlation between different types of stents and major cardiovascular incidents in patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction. After the confounding factors were adjusted, in patients with ST-elevation myocardial infarction receiving a drug-eluting stent compared with those receiving a bare-metal stent, it was found that the mortality risk was lower in terms of all causes of death (Adj-HR = 0.26, 95% CI = 0.14–0.48, p < 0.001) and cardiogenic death (Adj-HR = 0.20, 95% CI = 0.08–0.55, p = 0.002), the risk of non-fatal myocardial infarction was lower (Adj-HR = 0.17, 95% CI = 0.04–0.73, p = 0.017), and there was no difference in the risk of revascularization at the lesion site (Adj-HR = 0.59, 95% CI = 0.24–1.43, p = 0.243). It terms of the findings in patients with non-ST-elevation myocardial infarction, those receiving a drug-eluting stent had a lower risk of revascularization at the lesion site (Adj-HR = 0.48, 95% CI = 0.24–0.97, p = 0.04); however, there was no difference in the mortality risk in terms of all causes of death (Adj-HR = 0.71, 95% CI = 0.37–1.35, p = 0.296) or cardiogenic death (Adj-HR = 0.59, 95% CI = 0.18–1.90, p = 0.379),or in the risk of non-fatal myocardial infarction (Adj-HR = 0.27, 95% CI = 0.06–1.25, p = 0.093). Compared with bare-metal stents, drug-eluting stents provide better protection against death to receivers with ST-elevation myocardial infarction; however, this protection is decreased in receivers with non-ST-elevation myocardial infarction. It is recommended that for patients with non-ST-elevation myocardial infarction who are indicated to receive a drug-eluting stent, the clinical effectiveness of the treatment must be considered.

Sirolimus-Eluting Electrospun-Produced Matrices as Coatings for Vascular Stents: Dependence of Drug Release on Matrix Structure and Composition of the External Environment

Although a number of drug-eluting coatings for vascular stents (VSs) have been developed and are in commercial use, more efficient stent coatings and drug delivery systems are needed. Sirolimus (SRL) is a clinically important drug with antiproliferative and immunosuppressive activities that is widely used for coating stents. Here, we characterized SRL-enriched matrices, intended for coating vascular stents, that were produced by electrospinning (ES) on a drum collector from a solution of polycaprolactone (PCL) and human serum albumin (HSA), 1,1,1,3,3,3-hexafluoroisopropanol (HFIP), dimethyl sulfoxide (DMSO), and SRL. The release of tritium-labeled SRL (³H-SRL) from matrices in phosphate-buffered saline (PBS) or human blood plasma (BP) was studied. The introduction of DMSO in the ES blend decreased SRL release. The use of BP significantly accelerated SRL release through binding with serum biomolecules. The exchange of PBS or BP after every time point also increased SRL release. The maximum SRL release in BP was observed at 3 days. The matrices produced from the ES solution with DMSO and HSA released no more than 80% SRL after 27 days in BP, even under medium exchange conditions. Therefore, PCL-based matrices containing HSA, SRL, and DMSO can be used for coating VSs with prolonged SRL delivery.

The Ultimaster Biodegradable-Polymer Sirolimus-Eluting Stent: An Updated Review of Clinical Evidence

The Ultimaster coronary stent system (Terumo Corporation, Tokyo, Japan) represents a new iteration in drug-eluting stent (DES) technology that has recently received the Conformité Européenne (CE) mark approval for clinical use. The Ultimaster is a thin-strut, cobalt chromium, biodegradable-polymer, sirolimus-eluting coronary stent. The high elasticity of the biodegradable-polymer (PDLLA-PCL) and the abluminal gradient coating technology are additional novel features of this coronary device. The Ultimaster DES has undergone extensive clinical evaluation in two studies: The CENTURY I and II trials. Results from these two landmark studies suggested an excellent efficacy and safety profile of the Ultimaster DES across several lesion and patient subsets, with similar clinical outcomes to contemporary, new-generation DES. The aim of this review is to summarize the rationale behind this novel DES technology and to provide an update of available evidence about the clinical performance of the Ultimaster DES.

Ultrathin Strut Biodegradable Polymer Sirolimus-Eluting Stent Versus Durable-Polymer Everolimus-Eluting Stent for Percutaneous Coronary Revascularization: 2-Year Results of the BIOSCIENCE Trial

Background

No data are available on the long‐term performance of ultrathin strut biodegradable polymer sirolimus‐eluting stents (BP‐SES). We reported 2‐year clinical outcomes of the BIOSCIENCE (Ultrathin Strut Biodegradable Polymer Sirolimus‐Eluting Stent Versus Durable Polymer Everolimus‐Eluting Stent for Percutaneous Coronary Revascularisation) trial, which compared BP‐SES with durable‐polymer everolimus‐eluting stents (DP‐EES) in patients undergoing percutaneous coronary intervention.

Methods and Results

A total of 2119 patients with minimal exclusion criteria were assigned to treatment with BP‐SES (n=1063) or DP‐EES (n=1056). Follow‐up at 2 years was available for 2048 patients (97%). The primary end point was target‐lesion failure, a composite of cardiac death, target‐vessel myocardial infarction, or clinically indicated target‐lesion revascularization. At 2 years, target‐lesion failure occurred in 107 patients (10.5%) in the BP‐SES arm and 107 patients (10.4%) in the DP‐EES arm (risk ratio [RR] 1.00, 95% CI 0.77–1.31, P=0.979). There were no significant differences between BP‐SES and DP‐EES with respect to cardiac death (RR 1.01, 95% CI 0.62–1.63, P=0.984), target‐vessel myocardial infarction (RR 0.91, 95% CI 0.60–1.39, P=0.669), target‐lesion revascularization (RR 1.17, 95% CI 0.81–1.71, P=0.403), and definite stent thrombosis (RR 1.38, 95% CI 0.56–3.44, P=0.485). There were 2 cases (0.2%) of definite very late stent thrombosis in the BP‐SES arm and 4 cases (0.4%) in the DP‐EES arm (P=0.423). In the prespecified subgroup of patients with ST‐segment elevation myocardial infarction, BP‐SES was associated with a lower risk of target‐lesion failure compared with DP‐EES (RR 0.48, 95% CI 0.23–0.99, P=0.043, P_interaction=0.026).

Conclusions

Comparable safety and efficacy profiles of BP‐SES and DP‐EES were maintained throughout 2 years of follow‐up.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01443104.

Pharmacotherapeutic Considerations for the Use of Prasugrel and Ticagrelor to Reduce Stent Thrombosis in Patients With Acute Coronary Syndrome

Despite the improvement in stent technology, stent thrombosis (ST), a potentially catastrophic event, still occurs. Among several risk factors for ST, high on-treatment platelet reactivity to clopidogrel has been demonstrated to play a role, occurring in about one-third of the patients. In order to overcome this limitation, prasugrel and ticagrelor, newer P2Y12 inhibitors, have been developed and approved for clinical use. Two large clinical trials, TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet inhibitioN with prasugrel-thrombolysis in myocardial infarction (TRITON-TIMI) 38 and Study of Platelet Inhibition and Patient Outcomes (PLATO), evaluated these drugs in patients with acute coronary syndrome (ACS), showing a significant improvement in efficacy end points (including a prominent reduction in ST occurrence) compared to clopidogrel. In contrast, the TRILOGY ACS trial found no benefit with prasugrel compared to clopidogrel in patients with medically treated ACS. The aim of this review is to consider decision-making strategies between prasugrel and ticagrelor in daily clinical practice.

Long-term clinical outcomes following sirolimus-eluting stent implantation in patients with acute myocardial infarction. A meta-analysis of randomized trials

OBJECTIVES

The aim of this study was to perform a meta-analysis of randomized trials, evaluating the long-term outcomes of sirolimus-eluting stents (SES) versus bare-metal stents (BMS) in patients with ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Despite short-term outcomes of patients with STEMI undergoing primary percutaneous coronary intervention indicate a benefit of SES in terms of reintervention, several concerns remain on the long-term safety and efficacy of SES.

METHODS

A systematic literature search of electronic resources, through October 2011, was performed using specific search terms. Included trials were randomized studies comparing SES to BMS in STEMI patients, with a follow-up ≥3 years.

RESULTS

Seven trials were included, with a total of 2,364 patients. At a median follow-up of 3 years, SES significantly reduced the risk of target-vessel revascularization when compared with BMS [odds ratio (OR), 0.44; 95 % confidence interval (CI), 0.34-0.57; p < 0.0001], without increasing the risk of mortality (OR 0.78; 95 % CI, 0.57-1.08; p = 0.14), reinfarction (OR 0.91; 95 % CI, 0.61-1.35, p = 0.64) and early to late stent thrombosis (OR 0.77; 95 % CI, 0.49-1.20; p = 0.25). However after the first year, SES did not further reduce target-vessel revascularization (OR 1.06; 95 % CI, 0.64-1.74; p = 0.83) and increased the risk of very late stent thrombosis (OR 2.81; 95 % CI, 1.33-5.92; p = 0.007).

CONCLUSIONS

At long-term follow-up, SES compared to BMS use in STEMI patients reduces the risk of target-vessel revascularization, without increasing the risk of death and reinfarction. However, the strong SES efficacy is counterbalanced by a significant risk of very late stent thrombosis.