Clinical, physiologic, anatomic and procedural factors predictive of restenosis after percutaneous transluminal coronary angioplasty

One-Year Outcomes of Long Coronary Drug-Eluting Stents (≥40 MM) in Patients With Diffuse Coronary Artery Disease: Findings From a Tertiary Care Hospital in North India

Background and objective Diffuse coronary artery disease (CAD) is associated with extensive involvement of coronary arteries, necessitating the use of long (≥40 mm) drug-eluting stents (DES) based on the lesion length. However, these long DES can lead to complications such as in-stent restenosis (ISR) and stent thrombosis. This study aimed to assess the safety, efficacy, and one-year clinical outcomes of using long DES in patients with diffuse CAD undergoing PCI at a tertiary care hospital in north India. Methodology Patients with diffuse CAD undergoing PCI with long DES between January 2017 and June 2022 were included in the study. Baseline characteristics were recorded, and patients were followed up telephonically or in the outpatient department (OPD) at one, three, six, and 12 months following the PCI. The primary endpoint was the target lesion failure (TLF) rate, with secondary endpoints constituting all-cause mortality, major adverse cardiovascular events (MACE), subacute stent thrombosis, and ISR. Results A total of 200 patients were recruited and followed up for one year. The median age of the patients was 58 years (range: 48.25-63 years), and 82% were men. The most frequently stented artery was the left anterior descending (LAD, 48%), followed by the right coronary artery (RCA, 36%). A total of 388 stents (mean: 1.94 ±0.79) were implanted, including both long and short stents. The mean length and diameter of long stents were 43.64 ±3.58 mm and 3 ±0.37 mm, respectively. At the one-year follow-up, patients undergoing PCI with long DES ≥40 mm had an overall TLF rate of 5%, all-cause mortality of 6% (12 patients), MACE of 6% (12 patients), subacute stent thrombosis of 4% (eight patients), and ISR of 1% (two patients). A large proportion of patients (90%) had an uneventful follow-up of up to a year. At the one-year follow-up, all 10 (5%) patients with a primary outcome had a smaller stent diameter than those without a primary outcome (2.5 ±0.25 mm vs. 3.03 ±0.35 mm, p=0.015). Conclusions Our results suggest that using extremely long stents (>40 mm) for diffuse coronary lesions is safe, efficacious, and associated with relatively low event rates. In addition, the stent diameter has a substantial correlation with the primary outcome. Further studies with larger sample sizes as well as longer follow-up periods are required to validate our findings.

Comparative treatment outcomes of a single long stent vs. overlapped short stents in acute myocardial infarction

Objectives

There is no consensus regarding the optimal choice between single long stent (SLS) and overlapped double short stents (DSS) in patients with acute myocardial infarction (AMI). Therefore, we aimed to compare treatment outcomes among patients with AMI treated with these two different stenting methods.

Methods

In total, 537 patients with AMI from a single tertiary center were categorized into two groups: (1) those who received an SLS (stent length ≥38 mm) (n = 254; 47.3%) and (2) those who received overlapped DSS (individual stent lengths <38 mm) (n = 283; 52.7%). The primary outcome was the incidence of major adverse cardiac and cerebrovascular events (MACCEs) within 1 year.

Results

The mean age of participants was 65.4 years, and 75.0% were male. Patients receiving an SLS had a higher rate of serum creatinine level ≥1.5 mg/dl (16.3% vs. 8.9%, p = 0.009) but a lower rate of hypertension (46.8% vs. 55.8%, p = 0.038), lesser total stent length (38.26 ± 1.31 vs. 45.20 ± 9.25 mm, p < 0.001), total procedure time (41.40 ± 15.74 vs. 53.31 ± 21.75 min, p < 0.001) and total contrast volume (134.13 ± 30.72 vs. 160.57 ± 39.77 ml, p < 0.001) than in those receiving DSS. One-year MACCEs were comparable between the two groups before [hazard ratio (HR), 1.33; 95% confidence interval (CI), 0.80-2.24] and after adjusting for covariates (HR, 1.21; 95% CI, 0.67-2.19).

Conclusions

Stenting with an SLS demonstrated similar outcomes compared to those achieved when using stenting with overlapped DSS in patients with AMI. Therefore, if the deliverability is acceptable, stenting with an SLS appears to be a safe and effective strategy for AMI treatment.

Ultra-thin everolimus-eluting stents in atherosclerotic lesions: Three years follow-up with subgroup analysis of ultra-long stents

OBJECTIVES

To assess the long-term (3 years) safety and efficacy of Tetrilimus everolimus-eluting stent (EES) and subgroup analysis of outcomes of ultra-long (44/48 mm) Tetrilimus EES implantation in patients with long coronary lesions.

MATERIAL AND METHODS

In this observational, single-centre, single-arm, investigator-initiated registry, 558 patients who underwent implantation of Tetrilimus EES for the treatment of coronary artery disease were retrospectively included. The primary endpoint was occurrence of any major adverse cardiac event (MACE) at 12 months follow-up (composite of cardiac death, myocardial infarction [MI], and target lesion revascularization [TLR]) and we hereby report 3 years follow-up data. Stent thrombosis was assessed as a safety endpoint. A subgroup analysis of patients with long coronary lesions is also reported.

RESULTS

A total of 558 patients (57.0 ± 10.2 years) received 766 Tetrilimus EES (1.3 ± 0.5 stents/patient) to treat 695 coronary lesions. In subgroup analysis of 143 patients implanted with ultra-long EES, 155 lesions were intervened successfully with only one Tetrilimus EES (44/48 mm) implanted per lesion. At 3 years, event rates of 9.1% MACE with predominance of MI (4.4%), followed by 2.9% TLR and 1.7% cardiac death, and only 1.0% stent thrombosis were reported in overall population, while in a subgroup of patients implanted with ultra-long EES, 10.4% MACE and 1.5% stent thrombosis were reported.

CONCLUSIONS

Three years clinical outcomes showed favourable long-term safety and excellent performance of Tetrilimus EES in high-risk patients and complex coronary lesions in routine clinical practice, including a subgroup of patients with long coronary lesions, with acceptable primary and safety endpoints.

Coronary In-Stent Restenosis: Predictors and Treatment

BACKGROUND

Despite the use of modern drug-eluting stents (DES), in-stent restenosis (ISR) may still occur in as many as 2-10% of percutaneous coronary interventions (PCI) in certain lesion/patient subsets. ISR causes increased morbidity after stent implantation; acute myocardial infarction is a frequent correlate to a clinical ISR, arising in 5-10% of cases. Compared to de novo stenosis, patients with ISR also present more frequently with symptoms of unstable angina pectoris (45% versus 61%). In this article, we discuss the risk factors for ISR and the corresponding diagnostic measures and effective treatment strategies.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, with special attention to current international guidelines and specialist society recommendations.

RESULTS

The type of implanted stent, the presence of diabetes mellitus, previous bypass surgery, and small vessel caliber are predictors for ISR. In their guidelines, the European specialist societies (ESC/EACTS) recommend repeated PCI with DES implantation or drug-coated balloon (DCB) angioplasty as the methods of choice for the treatment of ISR. This approach is supported by evidence from meta-analyses. The RIBS-IV trial showed that revascularization treatment of the target lesion is needed less often after everolimus-eluting stent (EES) implantation than after DCB dilatation (11 [7.1%] versus 24 [15.6%]; p = 0.015; hazard ratio: 0.43; 95% confidence interval: [0.21; 0.87]).

CONCLUSION

Because the pathogenesis of ISR is multifactorial, differentiated risk stratification is necessary. The identification of patient-, stent-, and lesion-related predictors is particularly important, as the most effective way to combat ISR is to prevent it.

A Non-inferiority, Randomized Clinical Trial Comparing Paclitaxel-Coated Balloon Versus New-Generation Drug-Eluting Stents on Angiographic Outcomes for Coronary De Novo Lesions

Background

Drug-coated balloon (DCB) has been proved efficacy for coronary small vessel disease, but data regarding outcomes of DCB in common de novo lesions (including reference vessel diameter more than 3.0mm) compared with new-generation drug-eluting stent (DES) are lacking. We hypothesized that a DCB-only strategy for coronary de novo lesions would be non-inferior to DES treatment on angiographic outcomes.

Methods

In this randomized controlled trial, we compared the effect of DCB with DES on late lumen loss (LLL) at 9-month angiographic follow-up and 12-month major adverse cardiac events (MACEs), including death, non-fatal myocardial infarction, target lesion revascularization (TLR), and target vessel revascularization (TVR).

Results

From July 2017 to July 2018, 288 consecutive patients with reference vessel diameter (RVD) between 2.25 and 4.0mm were screened. After proper pre-dilation, 170 patients were enrolled and randomized to the DCB and the DES groups at 1:1 ratio. Seven patients withdrew the consent forms during hospital stay (1 in DCB group, 6 in DES group). Two patients in DCB group underwent bailout stenting due to severe dissection after DCB release. The primary endpoint of 9-month LLL was −0.19±0.49mm with the DCB versus 0.03±0.64mm with the DES. The one-sided 97.5% upper confidence limit of the difference was −0.04mm, achieving non-inferiority of the DCB compared with the DES (P=0.019). The 12-month cumulative MACE rate was similar in the DCB and DES groups (2.44% vs. 6.33%, P=0.226).

Conclusions

In this prospective study, the DCB only strategy for de novo lesion was non-inferior to the new-generation DES in terms of 9-month late lumen loss.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10557-021-07172-4.

Evaluation of relationship between common carotid artery intima-media thickness and coronary in-stent restenosis: A case-control study

Aim

The study was intended to evaluate relationship of common carotid artery intima-media thickness (CIMT) with coronary in-stent restenosis (ISR) and to assess clinical profile of patients to determine the predictors of coronary ISR.

Methods

This was a single-center, case-control study performed between December 2012 and February 2015 in India. The study population consisted of PCI-treated patients with ISR (n = 32) and those without any post-PCI symptoms at least 6 months prior to the study period (n = 40). Quantitative coronary angiography was performed in patients to determine ISR.

Results

Average CIMT for cases and controls was 0.96 ± 0.23 and 0.66 ± 0.09 mm (OR = 57, p < 0.001), respectively. CIMT was <0.8 mm in 25% of cases and 95% of controls. On multivariate analysis, presence of hypertension (OR = 10.79, p = 0.026) and higher stent diameter (OR = 14.87, p = 0.039) were independently associated with increased presence of ISR. CIMT <0.8 mm (OR = 0.03, p = 0.025), STEMI (OR = 0.03, p = 0.004), and estimated glomerular filtration rate >50 ml/min (OR = 0.005, p = 0.014) were independently associated with lower presence of ISR.

Conclusions

Elevated CIMT appears to be an independent risk indicator for increased ISR. As CIMT is a non-invasive parameter, post-PCI follow-up measurements of CIMT in routine clinical practice will provide potential benefits to predict the restenosis rates.

Treatment of large de novo coronary lesions with paclitaxel-coated balloon only: results from a Chinese institute

BACKGROUND

To evaluate the efficacy of paclitaxel-coated balloons (SeQuent Please^®) for large de novo coronary lesions with diameters greater than 2.8 mm.

METHODS

We performed a retrospective study of 527 consecutive patients with 595 de novo lesions (222 lesions) that comprised the large vessel disease (LVD) group, with a reference diameter (RD) ≥ 2.8 mm; the other 373 lesions comprised the small vessel disease (SVD) group, with a RD < 2.8 mm who received drug-coated balloon (DCB) angioplasty at the Beijing Hospital, Beijing, China. Sixty-eight patients with 91 lesions, including 45 LVD lesions, underwent coronary angiography at an average 10.7 months after DCB intervention. Clinical characteristics were recorded, and coronary angiograms were analysed with Quantitative Coronary Angiography (QCA) software.

RESULTS

The patients in the LVD group were much younger than those in the small vessel group (61.7 ± 11.3 vs. 63.8 ± 11.7, P = 0.003), and fewer LVD patients had diabetes (27.0 vs. 57.8%, P = 0.001), three-vessel disease (37.5 vs. 52.6%, P = 0.003) and complex lesions (37.8 vs. 48.8%, P = 0.009) than those in the SVD group. Lesion preparations for LVD were more complicated than for SVD, such as 40.1% of lesions required the additional use of a cutting or scoring balloon (P = 0.004), and 21.2% lesions required non-compliant (NC) balloons (P < 0.001). Coronary dissections occurred in 63(28.3%) lesions in the LVD group but bail-out drug-eluting stent (DES) implantation was required only in one lesion (0.5%), which were both comparable with those in the SVD group. The success rate of DCB intervention was quite high and also similar in the LVD group and SVD group (99.5 vs. 99.7%, P > 0.05). QCA analysis showed that the follow-up minimal lumen diameter (MLD) was significantly increased compared with the MLD immediately post angioplasty both in the SVD group (1.75 ± 0.48 vs. 1.58 ± 0.31 mm, P = 0.008) and the LVD group (2.26 ± 0.66 vs. 2.09 ± 0.40 mm, P = 0.067). At an average of 10.1 months of clinical follow-up, the major adverse cardiovascular event (MACE) rate was 0% in the LVD group and 1.4% in the SVD group, with target lesion revascularization (TLR) rates of 0% and 1.1%, respectively. No death was observed in either group.

CONCLUSIONS

DCB for de novo coronary lesions with diameters greater than 2.8 mm was as safe and effective as for small vessel lesions, suggesting that the DCB-only strategy is also feasible in large de novo lesions intervention.

Impact of stent length and diameter on short term clinical outcomes of drug eluting stents in patients with stable coronary artery disease

Background & Objective:

The risk of restenosis and other adverse cardiovascular events with bare-metal stents have increased with smaller stent diameters and longer stent lengths. However, the exact impact of stent size on the short-term outcomes of drug-eluting stent (DES) implantations has not been much classified in Pakistani population. This study was designed to evaluate the impact of size (length and diameter) of Drug Eluting Stents on Clinical outcomes in patient with stable coronary artery disease at three months of implantation in Pakistani Population.

Methods:

This is a prospective study which was carried out in the Department of Cardiology, Lady Reading Hospital Peshawar from April 2011 and July 2012. All consecutive patients with stable coronary disease undergoing Percutaneous Intervention (PCI) with DES implantation at Cardiology Unit Lady Reading Hospital, were included prospectively. Clinical outcomes (Myocardial infarction [MI], unstable angina[UA], and positive ETT) at three months stratified by 3 tertiles of stent length and diameter each, were measured in patients who underwent PCI with DES for coronary artery lesions. All patients were followed and reassessed after three months from the index procedure. Exercise Tolerance Test(ETT) was performed on every patient and recorded on proforma. Data analysis was done using SPSS software version 16.

Results:

A total of 376 patients were included prospectively in this study. The mean age was 57±9.313 years. Male patients were 271(72.1%). Mean length of drug eluting stent was 27.313±7.235 mm while mean diameter of stent was 2.90±0.2483mm. There were slightly higher rates of MI, U.A and positive ETT in the longest stent length tertile(>28mm) compared with the shortest stent length tertile (<22mm) at three months, but they were statistically not significant. We also observed that for DES, there was no clear relationship between stent diameter and outcome for any of the clinical outcome variables.

Conclusion:

In our single-center prospective study, stent length and diameter defined in tertiles, had no impact on the short-term clinical outcomes of DES in patients with stable coronary artery disease.

Percutaneous revascularization strategies in small-vessel disease

Percutaneous coronary intervention (PCI) of small coronary vessels represents a real challenge for myocardial revascularization because of the high risk of stent-restenosis and increased risk of adverse clinical events. Moreover, small coronary arteries supply small myocardial territories therefore questioning the clinical significance of small-vessel stenoses. The definition of small-vessel disease and PCI-strategies used are very heterogeneous across studies. The present review will focus on percutaneous coronary revascularization in patients with small vessel coronary artery disease.

Degenerated Saphenous Vein Graft Intervention: Should We Target the Native Vessel instead?

Coronary interventions of degenerated saphenous vein grafts (SVGs) continue to present a management challenge. Although repeat coronary artery bypass grafting (CABG) remains a significant risk factor for operative mortality, percutaneous coronary intervention (PCI) is still associated with a high risk for periprocedural events. There is a lack of consensus on the optimal treatment strategy for patients with severe stenosis of SVGs. It is imperative to review the characteristics of native versus SVG disease, risk factors for complications after SVG intervention, procedural treatment strategies important to the decision on which therapeutic strategy to follow, and measures to mitigate the risks of periprocedural complications.

A comparative study of restenosis rates in bare metal and drug-eluting stents

BACKGROUND

Various studies have been performed throughout the world on the rate of restenosis using bare metal stents (BMS) and drug-eluting stents (DES). The prohibitive costs associated with DES generally dictate the type of stent used, especially in developing countries. Therefore, there was a need for a study to assess the effect of various risk factors on restenosis in BMS and DES in the Indian context. A study was performed in the premier institution of the Indian Armed Forces, the Army Hospital (Research and Referral), New Delhi, India, under the aegis of the Indian Council of Medical Research (New Delhi). The profile of patients in the armed forces is inherently diverse in terms of demography, ethnicity, genetics, etc, which reflects the diverse and varied nature of the population in India.

METHODS AND RESULTS

A total of 130 patients were included in the present study. Follow-up after stent implantation was scheduled for six to nine months following the procedure to assess symptoms, drug compliance, and treadmill test and coronary angiography results, and to ascertain the incidence of restenosis. However, only 80 patients returned for follow-up and, therefore, the final analysis was based on these patients. They were segregated into BMS (n=41) and DES (n=39) groups. Restenosis occurred in 29 patients (36.3%). Nine of 39 patients with DES (23.1%) and 20 of 41 patients with BMS (48.8%) developed restenosis. There was a statistically significant relationship between restenosis and female sex, clinical presentation before intervention and at the time of follow-up evaluation (unstable angina), hypertension, positive stress test and compliance with medical therapy (P<0.05). No statistically significant relationship was observed between restenosis and age, diabetes, smoking, obesity and diet (P>0.05).

CONCLUSIONS

DES appear to reduce the restenosis rate and clinical end points, and appear to be more cost effective than BMS. Patient-related factors (eg, sex, hypertension and unstable angina) are important variables that affect the restenosis rate. Noninvasive stress testing had high positive and negative predictive values. Therefore, based on the present study, noninvasive stress testing is suggested before routine angiography at follow-up, which will reduce the need for repeat coronary angiography.

Long-term clinical outcome after fractional flow reserve-guided percutaneous coronary revascularization in patients with small-vessel disease

BACKGROUND

Small coronary vessels supply small myocardial territories. The clinical significance of small-vessel stenoses is therefore questionable. Moreover, percutaneous coronary intervention (PCI) of nonfunctionally significant lesions does not improve clinical outcome and might be associated with potential procedural or stent related risks. The aim of this study was to assess the clinical outcome of fractional flow reserve (FFR)-guided PCI in the treatment of small coronary vessel lesions as compared with an angio-guided PCI.

METHODS AND RESULTS

From January 2004 to December 2008, all patients treated with PCI for stable or unstable angina in small native coronary vessels (reference vessel diameter and stent size <3 mm) were retrospectively analyzed. Patients were divided into angio-guided and an FFR-guided PCI groups. A total of 717 patients were enrolled (495 angio-guided, 222 FFR-guided). End points were death, nonfatal myocardial infarction (MI), combined death or nonfatal MI, target vessel revascularization (TVR), and procedure costs. Major adverse cardiac events (MACE) were defined as death, nonfatal MI, and TVR. Clinical follow-up was obtained in 97.5% (median follow-up: 3.3 [from 0.01-5] years) of the patients. Seventy-eight patients (35%) had a significant FFR (<0.80) and underwent PCI. Using a propensity score adjusted Cox analysis, patients treated with FFR-guided PCI had significantly lower combined death or nonfatal MI (hazard ratio [HR], 0.413; 95% confidence interval [CI], 0.227-0.750; P=0.004), nonfatal MI (HR, 0.063; 95% CI, 0.009-0.462; P=0.007), TVR (HR, 0.517; 95% CI, 0.323-0.826; P=0.006), and MACE (HR, 0.458; 95% CI, 0.310-0.679; P<0.001). No difference was observed in mortality alone (HR, 0.684; 95% CI, 0.355-1.316; P=0.255). Procedure costs were also reduced in the FFR guided strategy (3253±102 Euros versus 4714±37 Euros, P<0.0001).

CONCLUSIONS

FFR-guided PCI of small coronary arteries is safe and results in better clinical outcomes when compared with an angio-guided PCI.

A genome-wide association study identifies a region at chromosome 12 as a potential susceptibility locus for restenosis after percutaneous coronary intervention

Percutaneous coronary intervention (PCI) has become an effective therapy to treat obstructive coronary artery diseases (CAD). However, one of the major drawbacks of PCI is the occurrence of restenosis in 5-25% of all initially treated patients. Restenosis is defined as the re-narrowing of the lumen of the blood vessel, resulting in renewed symptoms and the need for repeated intervention. To identify genetic variants that are associated with restenosis, a genome-wide association study (GWAS) was conducted in 295 patients who developed restenosis (cases) and 571 who did not (controls) from the GENetic Determinants of Restenosis (GENDER) study. Analysis of ~550 000 single nucleotide polymorphisms (SNPs) in GENDER was followed by a replication phase in three independent case-control populations (533 cases and 3067 controls). A potential susceptibility locus for restenosis at chromosome 12, including rs10861032 (P(combined) = 1.11 × 10(-7)) and rs9804922 (P(combined) = 1.45 × 10(-6)), was identified in the GWAS and replication phase. In addition, both SNPs were also associated with coronary events (rs10861032, P(additive) = 0.005; rs9804922, P(additive) = 0.023) in a trial based cohort set of elderly patients with (enhanced risk of) CAD (PROSPER) and all-cause mortality in PROSPER (rs10861032, P(additive) = 0.007; rs9804922, P(additive) = 0.013) and GENDER (rs10861032, P(additive) = 0.005; rs9804922, P(additive) = 0.023). Further analysis suggests that this locus could be involved in regulatory functions.

Long-term clinical outcome in patients with small vessel disease treated with drug-eluting versus bare-metal stenting

BACKGROUND

DES is superior to BMS in reducing restenosis and repeat revascularization. Available data are less convincing in small vessel disease. Aim of our study is to assess long-term clinical outcome of drug-eluting stents (DES) vs. bare-metal stents (BMS) in small coronary vessel disease.

METHODS

Procedural and long-term clinical outcomes were assessed in consecutive patients (pts) treated with stenting of native small coronary arteries (reference vessel diameter and implanted stent < 3mm).

RESULTS

Pts enrolled were 645: DES group (n = 277) presented more frequently diabetes (173 [62%] vs. 32 [9%], P < .0001), higher body mass index (27 ± 5 vs. 26 ± 4, P = .01) and with previous PCI (115 [42%] vs. 118 [32%], P = .01) as compared to BMS group (n=368). DES group presented more frequently with unstable angina (46 [17%] vs. 38 [10%], P = .02); BMS group presented more frequently with myocardial infarction (103 [28] vs. 43 [15], P = .0002). Reference vessel (2.27 ± 0.36 vs. 2.24 ± 0.36, P = .29), minimal lumen (0.81 ± 0.32 vs. 0.80 ± 0.31, P = .84) and stent diameter (2.59 ± 0.17 vs. 2.60 ± 0.15, P = .69) did not differ between the 2 groups. Lesion length was significantly higher in DES group (15.85 ± 6.81 vs. 13.66 ± 7.18, P = .01). At a median clinical follow-up of 3.0 years (IQR range 2.2-4.6), pts with DES showed significantly lower major adverse cardiac events (MACE, HR 0.51, 95%CI 0.33-0.78) and target vessel revascularization (TVR, HR 0.44, 95%CI 0.25-0.78). No differences were observed between the two groups as to death, myocardial infarction and stent thrombosis.

CONCLUSIONS

In small vessel disease, DES was more frequently implanted in pts at higher risk of restenosis, though it demonstrated to be more effective than BMS in reducing MACE and TVR at long-term follow-up.

Clinical and angiographic comparison of everolimus-eluting and paclitaxel-eluting stents in small coronary arteries: a post hoc analysis of the SPIRIT III randomized trial

BACKGROUND

Drug-eluting stents with low late loss may be particularly beneficial in small coronary arteries. We therefore examined whether the everolimus-eluting stent is superior to the paclitaxel-eluting stent in patients treated with 2.5-mm stents in the SPIRIT III trial.

METHODS

The SPIRIT III trial was a prospective, multicenter, randomized (2:1; XIENCE V: TAXUS Express) trial in which 1002 patients were enrolled. One or more 2.5-mm stents were implanted in 160 patients in the XIENCE V arm, and 59 patients, in the TAXUS arm. Mean vessel diameter was 2.36 +/- 0.30 and 2.34 +/- 0.33 mm in the XIENCE V and TAXUS groups, respectively (P = .69).

RESULTS

At 9 months, XIENCE V compared to TAXUS reduced the rates of major adverse cardiac events (cardiac death, myocardial infarction, or ischemic target lesion revascularization) from 12.5% to 3.2% (P = .02) and target vessel failure (cardiac death, reinfarction, or ischemic target vessel revascularization) from 16.1% to 5.2% (P = .02), the differences being driven primarily by reductions in target lesion revascularization (12.5% vs 1.3%; P = .002). In-stent late loss was significantly reduced by XIENCE V when compared to TAXUS (0.54 +/- 0.74 vs 0.11 +/- 0.43 mm, P = .01), as was In-segment binary angiographic restenosis (20.8% vs 4.1%, P = .02).

CONCLUSIONS

In this post hoc analysis from the SPIRIT III trial, the XIENCE V 2.5-mm stent significantly reduced clinical and angiographic restenosis compared to the TAXUS 2.5-mm stent, further supporting the hypothesis that lower late loss is beneficial in small vessel disease.

A genome wide association analysis in the GENDER study

Percutaneous coronary intervention (PCI) has become an effective therapy to treat coronary artery diseases. However, one of the major drawbacks of PCI is the occurrence of restenosis in 8 to 40% of all treated patients. The GENetic Determinants of Restenosis (GENDER) project was designed to study the association between genetic polymorphisims and clinical restenosis. The discovery of genetic variants associated to the occurrence of restenosis after PCI may provide a more tailored therapy and may serve as rationale for new antirestenotic therapies. So far, several candidate gene approaches had already been performed in the GENDER samples but a Genome Wide Association Scan (GWAS) was still lacking. Here, we present preliminary results from the GWAS we are currently carrying out in the GENDER population. (Neth Heart J 2009;17:262-4.).

Overcommitment predicts restenosis after coronary angioplasty in cardiac patients

The objective of this study is to examine the role of a particular stress-enhancing psychosocial risk factor, termed overcommitment, in predicting restenosis after successful percutaneous transluminal coronary angioplasty (PTCA). Overcommitment defines a personal pattern of coping with demands characterized by excessive striving in combination with a strong desire of being approved and esteemed. One hundred six consecutive male patients with coronary artery disease who underwent PTCA were followed over a mean of 12 months. The restenosis rate as defined by quantitative angiography was 34%. Multivariate analysis revealed independent effects of high density lipoprotein cholesterol (odds ratio [OR] 3.19), age (OR 3.43), and overcommitment (OR 2.86) on risk of restenosis. In conclusion, a stress-enhancing psychosocial person characteristic termed overcommitment acts as an independent predictor of coronary restenosis after PTCA. As overcommitment is subject to cognitive-behavioral intervention, results have implications for a more comprehensive approach to secondary prevention in cardiac patients.

Drug-Eluting Coronary Stents

The introduction and widespread use of coronary stents have been the most important advancement in the percutaneous treatment of coronary artery disease since the introduction of balloon angioplasty. Coronary artery stents reduce the rate of angiographic and clinical restenosis compared to balloon angioplasty. This angiographic restenosis was further reduced with the introduction of drug-eluting stents and hence further reduction in the frequency of major adverse cardiac events. Herein we present a comprehensive and up-to-date review about the use of drug-eluting stents in the treatment of coronary artery disease.

The SV stent study: a prospective, multicentre, angiographic evaluation of the BiodivYsio phosphorylcholine coated small vessel stent in small coronary vessels

OBJECTIVE

To evaluate the use of the phosphorylcholine (PC) coated BiodivYsio small vessel (SV) stent in native coronary vessels of small calibre.

DESIGN AND SETTING

Prospective, multi-centre, multi-national registry with 6-month clinical and core-lab angiographic follow-up. Adverse events were adjudicated by a Clinical Events Committee (CEC) and included peri-procedural analysis of cardiac enzymes.

PATIENTS

Patients with signs or symptoms of ischaemia with an identified target lesion in an epicardial vessel with reference diameter 2.0-2.75 mm were enrolled. Intervention in other epicardial territories in the same patient was permitted.

RESULTS

Recruitment of 150 consecutive lesions (in 143 patients) was completed in 19 centres in Europe and Israel. The stent was deployed successfully in all but one lesion. At 6 months, 1 patient (1%) had experienced sudden cardiac death, 4 further patients (3%) had a non-Q wave MI, and a further 24 patients (17%) had repeat revascularisation of a study target vessel. The mean reference vessel diameter prior to stenting was 2.2 mm (S.D. 0.4). Mean minimal luminal diameters at pre-procedure, post procedure and follow-up were 0.6 mm (S.D. 0.3), 2.0 mm (S.D. 0.4) and 1.2 mm (S.D. 0.6), respectively. The late lumen loss index was 0.55 (S.D. 0.53) with a binary restenosis rate of 32%.

CONCLUSIONS

In stenting of selected lesions in small vessels, the BiodivYsio SV stent demonstrated high rates of implant success. The rates of major adverse cardiac events (MACE), angiographic restenosis and repeat revascularisation are similar to those reported in other small vessel bare metal stent studies.

New approaches to long lesions

Long coronary lesions, comprising up to 20% of the interventional practice, pose a significant challenge to the interventionalist. Several approaches have been described to treat long coronary lesions with long-term suboptimal outcomes. Atherectomy and laser treatments with or without adjunctive balloon angioplasty have not been shown to be superior to conventional balloon angioplasty alone. Preliminary data with the use of drug-eluting stents in the treatment of long coronary lesions appears to be promising even in small vessels and may eventually become the mainstay treatment of long lesions.

Prevention of restenosis after coronary angioplasty

PURPOSE OF REVIEW

Despite numerous advances in coronary interventional techniques, the frequent occurrence of restenosis continues to plague interventional cardiology. With the widespread use of drug-eluting stents, there is a need to reexamine critically the roles of the various interventional techniques currently available.

RECENT FINDINGS

Drug-eluting stents have dramatically reduced the rates of restenosis and target vessel revascularization in a wide spectrum of patients with varying lesion morphologies. However, when restenosis does occur, it still tends to be dependent on the same factors that predict restenosis with bare metal stenting. The routine use of drug-eluting stents entails high initial costs to the health care system. Debulking as a means to improve outcomes after angioplasty has not lived up to expectations. Gene therapy is rapidly evolving into a viable means to reduce neointimal proliferation after angioplasty.

SUMMARY

Careful patient selection and attention to the procedure of stent deployment optimize the results of angioplasty with drug-eluting stents. Because of cost considerations, drug-eluting stents should be used in patients who are expected to have the greatest absolute benefit. In this context, when judiciously used, conventional balloon angioplasty and bare metal stenting still have a definite role in the management of patients with obstructive coronary artery disease.

Restenosis in Intervened Coronaries with Hyperhomocysteinemia (RICH)

BACKGROUND

Controversy exists regarding the contribution made by elevated serum homocysteine evels in raising the risk of restenosis after percutaneous coronary interventions. The objective of this study was to determine whether elevated homocysteine evels increase the risk of restenosis.

METHODS

Two hundred and two consecutive patients undergoing percutaneous coronary intervention with stents on previously nonintervened native coronary arteries were eligible for enrollment in the study. Before the percutaneous coronary intervention, a fasting serum homocysteine evel was drawn. Patients were followed-up by their primary cardiologists for recurrence of symptoms. Those patients who had a recurrence of anginal symptoms consistent with clinical restenosis were referred for a repeat angiogram. All other patients were followed-up medically. The homocysteine evels of the patients who had repeat angiography for recurrent symptoms were compared to those who were followed-up medically.

RESULTS

Age, stent ength, stent diameter, and homocysteine evels were all associated with an increased risk of restenosis in the univariate analysis. In the multiple ogistic regression model, the only variable that remained significant in relation to an increased risk of restenosis was homocysteine. There was a significant difference in the mean homocysteine evels between the restenosis group (13.7 micromol/L) and those without restenosis (9.6 micromol/L; P <.0001). A homocysteine evel > or =11.1 micromol/L was identified as the best threshold for an increased risk of restenosis with a sensitivity of 75.0% and specificity of 76.9% (OR 6.5, CI 2.3-18.6; P =.0004).

CONCLUSION

This study demonstrates that elevated homocysteine evels strongly correlate with an increased risk of restenosis.

Predictors of repeat revascularization after nonemergent, first percutaneous coronary intervention in the community

BACKGROUND

We sought to determine the incidence of and risk factors for repeat revascularization after nonemergent, first percutaneous coronary intervention (PCI) performed in contemporary community practice.

METHODS

We analyzed a prospective registry of consecutive patients undergoing isolated PCI in the state of Washington. Multivariate Cox regression analysis was used to determine predictors of repeat revascularization (by PCI or bypass surgery) within 1 year after first PCI.

RESULTS

Between January 1, 1999, and December 31, 1999, there were 3571 nonemergent first PCIs, 87.7% of which involved stent placement. Repeat revascularization occurred in 577 (16.2%) patients. Repeat revascularization was predicted by multivessel disease (hazard ratio [HR] 1.36, 95% CI 1.12-1.66), stable versus no angina (HR 1.27, 95% CI 1.03-1.57), and maximum stent length used (per 1 mm longer: HR 1.01, 95% CI 1.002-1.02), while prior myocardial infarction (HR 0.77, 95% CI 0.62-0.96) and creatinine >1.2 mg/dL (HR 0.74, 95% CI 0.56-0.98) were associated with lower risk of repeat revascularization. Diabetes was a significant predictor only when the outcome was limited to revascularization by coronary artery bypass surgery (HR 1.52, 95% CI 1.03-2.23). Although glycoprotein IIb/IIIa inhibitor use was a significant univariate predictor of freedom from early repeat revascularization (within 60 days after first PCI), after controlling for potential confounders, it was no longer significant.

CONCLUSIONS

In this contemporary, community-based registry of patients undergoing nonemergent first PCI, clinical practice and outcomes are consistent with evidence from clinical trials and previous controlled studies. Results from controlled studies may reasonably be extrapolated to such a community setting.

Current status of rotational atherectomy

Despite the increasing use of percutaneous transluminal coronary angioplasty and intracoronary stent placement for the treatment of obstructive coronary artery disease, a large subset of coronary lesions cannot be adequately treated with balloon angioplasty and/or intracoronary stenting alone. Such lesions are often heavily calcified or fibrotic and undilatable with the present balloon technology and attempts to treat them with balloon angioplasty or intracoronary stent placement often lead to vessel dissection or incomplete stent deployment with resultant adverse outcomes. Rotational atherectomy remains a useful niche device for the percutaneous treatment of such complex lesions, usually as an adjunct to subsequent balloon angioplasty and/or intracoronary stent placement. In contrast to balloon angioplasty or stent placement that widen the coronary lumen by displacing atherosclerotic plaque, rotational atherectomy removes plaque by ablating the atherosclerotic material, which is dispersed into the distal coronary circulation. Other lesion subtypes amenable to treatment with this modality include ostial and branch-ostial lesions, chronic total occlusions, and in-stent restenosis. This review discusses the technique and principles of rotational atherectomy, the various treatment strategies for its use (including adjunctive pharmacotherapy), the lesion-specific applications for this device, and the complications unique to this modality. Recommendations are also made for its use in the current interventional era.

Coronary stenting after rotational atherectomy in diffuse lesions of the small coronary artery: comparison with balloon angioplasty before stenting

The purpose of this randomized trial was to evaluate the role of debulking and balloon predilation on acute and long-term results of stent implantation in diffuse stenosis of small vessels. Patients with symptomatic diffuse stenosis of the native left anterior descending coronary artery between 2 and 2.9 mm in size were randomly assigned to rotational atherectomy (group I, n = 21) or balloon dilation (group II, n = 20) before stenting. The primary end point of the study was the incidence of angiographic restenosis at follow-up; adverse clinical events, such as death, myocardial infarction, stroke, or target vessel revascularization, were assessed as secondary end points. Acute gain was significantly greater in group I than in group II (p = 0.038), but net gain at follow-up was similar in both groups (p = 0.24). There was no significant difference in angiographic restenosis rate (33.3% vs 31.3%, p = 0.80), target vessel revascularization (23.8% vs 15%, p = 0.21) or 1-year event-free survival rate (72.8% vs 84.6%, p = 0.28). In conclusion, rotational atherectomy before stenting showed no additional benefit over balloon dilation with stenting in the management of diffuse lesions in small coronary vessels.

Stenting for restenotic lesions with the BARD XT stent

BACKGROUND

Conventional PTCA for the treatment of restenotic lesions is associated with a high rate of recurrence (30-50%). Primary stenting decreases the restenosis rate at long-term follow-up.

METHODS

One-hundred consecutive patients with restenosis received a Bard XT stent. Follow-up angiography was performed after 6 months. Angiograms were compared by means of computed quantitative analysis.

RESULTS

The mean pretreatment reference diameter was 2.88 +/- 0.51 mm. The mean minimal luminal diameter (MLD) increased from 1.09 +/- 0.57 mm to 2.70 +/- 0.44 mm. The percent diameter stenosis decreased from 66 +/- 13% to 15 +/- 10%. The procedural success rate was 99%. At 6 month follow-up repeat angiography was performed in 86 patients. The mean MLD was 1.74 +/- 0.67 mm with a mean diameter stenosis of 41 +/- 20%. Residual anginal complaints were reported in 29% of patients. In-stent restenosis (defined as diameter stenosis of more than 50%) occurred in 18% of the patients.

CONCLUSION

Placement of the Bard XT stent in restenotic lesions is feasible, has an excellent short term outcome and yields a favorable result at 6 month follow-up angiography.

Comparison of rotational atherectomy with conventional balloon angioplasty in the prevention of restenosis of small coronary arteries: results of the Dilatation vs Ablation Revascularization Trial Targeting Restenosis (DART)

BACKGROUND

The optimum treatment of obstructive coronary disease in small (<3.0 mm diameter) arteries remains unknown. Rotational atherectomy is an approved treatment that might reduce the vascular injury during percutaneous coronary intervention compared with angioplasty. We report on a multicenter, randomized, blinded end point trial comparing rotational atherectomy with balloon angioplasty in the prevention of restenosis of obstructed small coronary arteries.

METHODS

A total of 446 patients with myocardial ischemia associated with an angiographic stenosis in a native coronary artery 2 to 3 mm in diameter and < or =20 mm in length without severe calcification were randomly assigned to receive rotational atherectomy (n = 227) or balloon angioplasty (n = 219). The primary end point was target vessel failure at 12 months (defined as the composite of death, Q-wave myocardial infarction, and clinically driven repeat revascularization of the target vessel).

RESULTS

The mean reference vessel diameter was 2.46 +/- 0.40 mm, the mean lesion length was 9.97 +/- 5.59 mm, and the prevalence of diabetes mellitus was 32%. Acute procedural success (91.6% for rotational atherectomy, 94.1% for balloon angioplasty, P =.36) and target vessel failure at 12 months were not significantly different (30.5% vs 31.2%, P =.98). At 8 months, there were no significant differences in minimum lumen diameter (1.28 +/- 0.63 mm vs 1.19 +/- 0.54 mm, P =.26), percent diameter stenosis (28% +/- 12% vs 29% +/- 15%, P =.59), binary restenosis rate (50.5% vs 50.5%, P = 1.0), or late loss index (0.57 vs 0.62, P =.7). No Q-wave myocardial infarctions occurred in either arm of the study, and non-Q-wave myocardial infarctions (defined as creatine kinase level >2 times normal with an elevated creatine kinase-myocardial band isoenzyme level) occurred in 2.2% and 1.4% of the patients in the rotational atherectomy and balloon angioplasty groups, respectively (P =.72).

CONCLUSION

Rotational atherectomy was found to be safe in the treatment of obstructed small arteries, but lower rates of target vessel failure were not achieved compared with balloon angioplasty. Because the acute gain and loss index ratios of the 2 treatments were similar, there was no evident beneficial antirestenosis mechanism seen for rotational atherectomy.

Exercise stress testing, myocardial perfusion imaging and stress echocardiography for detecting restenosis after successful percutaneous transluminal coronary angioplasty: a review of performance

When chest symptoms recur in a patient who underwent percutaneous transluminal coronary angioplasty (PTCA), it is necessary to rule out restenosis (R). Three main noninvasive tests suggest the presence of R: exercise stress test (XT), myocardial perfusion imaging (MPI) and stress echocardiography (s-echo). The objectives of this review were: (1) to estimate the pretest probability of R as a function of time after PTCA in symptomatic patients and (2) to obtain an approximation of the diagnostic parameters of the XT, MPI and s-echo for detecting R. A MEDLINE search (English-language, years: 1980-2001) was conducted to identify studies examining post-PTCA functional testing for diagnosing R. Data from the studies were pooled. Comparing studies was often difficult due to varying methodology in the studies. Pretest probability of R in symptomatic patients increases in a nonlinear fashion from 20% or less at 1 month, to nearly 90% at 1-year postangioplasty. The approximated accuracy of the XT, MPI, and s-echo for detecting R was 62, 82 and 84%, respectively. During the first month after PTCA, none of the noninvasive modalities is able to accurately detect R. Late (7-9 months) after PTCA, the pretest probability of R is high and therefore the noninvasive measure may be spared. Our analysis suggests that MPI and s-echo should be preferred over the XT for diagnosing R.

Intravascular ultrasound guidance improves angiographic and clinical outcome of stent implantation for long coronary artery stenoses: final results of a randomized comparison with angiographic guidance (TULIP Study)

BACKGROUND

Long coronary lesions treated with stents have a poor outcome. This study compared the 6-month outcome of stent implantation for long lesions in patients randomized to intravascular ultrasound (IVUS; n=73) or angiographic guidance (n=71).

METHODS AND RESULTS

Stenoses >20 mm in length and a reference diameter that permitted a stent diameter > or =3 mm were eligible. Primary end points were 6-month minimal lumen diameter (MLD) and the combined end point of death, myocardial infarction, and target-lesion revascularization (TLR). Baseline clinical and angiographic data were comparable in both groups. At 6 months, MLD in the IVUS group (1.82+/-0.53 mm) was larger than in the angiography group (1.51+/-0.71 mm; P=0.042). TLR and combined end-point rates at 6 months were 4% (n=3) and 6% (n=4) in the IVUS group and 14% (n=10) and 20% (n=14) in the angiography group, respectively (P=0.037 for TLR and P=0.01 for combined events). Restenosis (>50% diameter stenosis) was found in 23% of the IVUS group and 45% of the angiography group (P=0.008). At 12 months, TLR and the combined end point occurred in 10% (n=7) and 12% (n=9) of the IVUS group and 23% (n=17) and 27% (n=19) of the angiography group (P=0.018 and P=0.026), respectively.

CONCLUSIONS

Angiographic and clinical outcome up to 12 months after long stent placement guided by IVUS is superior to guidance by angiography.

Beta-radiation therapy for long lesions in native coronary vessels: a matched comparison between de novo and in-stent restenotic lesions

OBJECTIVE

The purpose of this study was to evaluate effectiveness and to compare clinical outcome of intracoronary beta-radiation to treat long lesions (>20 mm) in patients with de novo stenosis vs. patients with in-stent restenosis (ISR).

METHODS

A matched comparison of 44 patients with 63 de novo lesions and 48 patients with 63 ISR lesions (>20 mm) treated with intracoronary beta-radiation was performed.

RESULTS

Stents were implanted in 65.1% of de novo and 19% of ISR lesions (P=.001). Radiation doses delivered were 17.2+/-3.0 vs. 20.3+/-3.0 Gy at 2 mm from the source center for de novo and ISR lesions. There was no difference in the incidence of in-hospital events. Clinical follow-up at 16.4+/-6.7 months showed no difference in major adverse cardiac events (MACE) between de novo and ISR patients (27.3% vs. 25%, P=.8). Late total occlusions (LTOs) occurred in eight patients (four in each group) treated with stents at the time of radiation and after discontinuation of ticlopidine. By multivariate analysis, stent implantation was the only predictor of late occlusions (OR 8.25, 95% CI 1.73-38.46, P<.008). Restenosis rates were similar for de novo and ISR lesions (29.3% vs. 23.2%, P=.46), as well as target lesion revascularization (TLR) and target vessel revascularization (TVR) rates (22.7% vs. 22.9% and 29.5% vs. 29.2%, respectively).

CONCLUSIONS

Intracoronary beta-radiation gives comparable results when used to treat de novo or ISR lesions provided new stent implantation can be avoided. Long-term combined antiplatelet therapy is mandatory for patients who receive new stents at the time of radiation treatment.

Long balloon angioplasty with focal stenting for the treatment of diffuse coronary artery disease

The objective of this study was to evaluate the efficacy of treating long coronary lesions (> 30 mm) with either a 40 or a 60 mm long Scimed Cobra balloon followed by focal (contingency) stenting of areas with suboptimal results. Diffuse lesion length is a morphological characteristic associated with a poorer clinical outcome after balloon angioplasty with or without stenting. Patients were enrolled in a prospective randomized fashion to have initial PTCA with either a 40 or a 60 mm long balloon followed by focal stenting in areas with suboptimal results. The MACE rate at 6-month follow-up was collected from all patients and was the primary endpoint of the study. A total of 41 patients were enrolled into the study. The acute procedural success rate was 97.5% with a 6-month MACE rate of 9.8%. The use of long balloons with contingency stenting is a highly effective strategy for the treatment of diffuse coronary lesions.

Cutting balloon angioplasty for the prevention of restenosis: results of the Cutting Balloon Global Randomized Trial

The cutting balloon (CB) is a specialized device designed to create discrete longitudinal incisions in the atherosclerotic target coronary segment during balloon inflation. Such controlled dilatation theoretically reduces the force needed to dilate an obstructive lesion compared with standard percutaneous transluminal coronary angioplasty (PTCA). We report a multicenter, randomized trial comparing the incidence of restenosis after CB angioplasty versus conventional balloon angioplasty in 1,238 patients. Six hundred seventeen patients were randomized to CB treatment, and 621 to PTCA. The mean reference vessel diameter was 2.86 +/- 0.49 mm, mean lesion length 8.9 +/- 4.3 mm, and prevalence of diabetes mellitus in patients was 13%. The primary end point, the 6-month binary angiographic restenosis rate, was 31.4% for CB and 30.4% for PTCA (p = 0.75). Acute procedural success, defined as the attainment of <50% diameter stenosis without in-hospital major adverse cardiac events, was 92.9% for CB and 94.7% for PTCA (p = 0.24). Freedom from target vessel revascularization was slightly higher in the CB arm (88.5% vs 84.6%, log-rank p = 0.04). Five coronary perforations occurred in the CB arm only (0.8% vs 0%, p = 0.03). At 270 days, rates of myocardial infarction, death, and total major adverse cardiac events for CB and PTCA were 4.7% versus 2.4% (p = 0.03), 1.3% versus 0.3% (p = 0.06), and 13.6% versus 15.1% (p = 0.34), respectively. In summary, the proposed mechanism of controlled dilatation did not reduce the rate of angiographic restenosis for the CB compared with conventional balloon angioplasty. CB angioplasty should be reserved for difficult lesions in which controlled dilatation is believed to provide a better acute result compared with balloon angioplasty alone.

Randomized comparison of success and adverse event rates and cost effectiveness of one long versus two short stents for treatment of long coronary narrowings

Long stents of high flexibility and low profile have become widely available. Treatment of long coronary lesions by 1 long stent may require less interventional efforts and reduce the rate of restenosis due to a lack of overlapping stent segments. This study sought to evaluate the use of 1 long stent compared with 2 short stents for treatment of long coronary lesions. One-hundred twenty-four patients with a coronary lesion 20 to 40 mm in length, in a vessel 2.5 to 4.0 mm in diameter, were randomly assigned to treatment with 1 long stent (GFX II stents or S670 of 24, 30, or 40 mm lengths; n = 62) or 2 stents (GFX II or S670 stents, n = 62) of equal length. Procedural success, interventional costs, as well as long-term clinical and angiographic outcomes were evaluated. Lesion characteristics were similar for the 2 treatment groups. Stent placement was possible as assigned by randomization in 61 of 62 cases (98%) in the 1-long-stent group and 100% of cases in the 2-short-stents group. There was crossover to successful short-stent placement in 1 case. The in-hospital success rate was 97% for the 1-long-stent group and 98% for the 2-short-stents group. Acute angiographic results were similar for both groups after intervention. The angiographic restenosis rate at 6 months was 38.5% in the 1-long-stent group and 37.5% in the 2-short-stents group (p = 0.919). Intervention time was less, and the need for a contrast agent had a tendency to be lower in the long-stent group. Procedural costs were significantly less in the long-stent group. In conclusion, 1 long stent can be used with identical procedural success and adverse event rates as 2 short stents in long, atherosclerotic coronary lesions. The restenosis rate is not reduced by the use of 1 long stent compared with 2 stents. However, long stent placement is highly cost effective.

Failure of prolonged dilation to improve long-term patency of femoropopliteal artery angioplasty: results of a prospective trial

PURPOSE

To determine long-term patency of femoropopliteal artery percutaneous transluminal angioplasty (PTA) in a prospective trial during which prolonged balloon inflation was used for optimization of initial results.

MATERIALS AND METHODS

Femoropopliteal PTA was performed in 112 limbs of 97 patients. The mean total length of the treated segments was 7.2 cm (95% CI: 5.99-8.46; median: 5.5 cm). In cases of unsatisfactory primary results after standard dilation for 1-3 minutes, the procedure was continued with prolonged dilation (93 limbs; mean balloon inflation time: 31 min; 95% CI: 24.2-37.7; median: 15 min) with use of the same balloon catheter (77 limbs) or a perfusion balloon catheter (35 limbs). Thirty-four proximal infrapopliteal artery stenoses were treated to improve peripheral runoff and 12 short stents were placed because of flow-limiting dissections.

RESULTS

Primary hemodynamic success established by Doppler ultrasound (US) criteria was achieved in 92.9% (104 of 112) of the limbs. Three major complications were encountered; none were related to prolonged balloon inflation. The primary patency rate according to Kaplan-Meier analysis was 42% (+/-5% SE) at 1 year and 39% (+/-5%) at 2 and 3 years. The corresponding secondary patency rates were 51% (+/-5%) and 47% (+/-5%). Large numbers of diseased vessels in the treated limb (four to 10 instead of one to three), eccentric lesions (as opposed to concentric morphology), and additional treated segments (instead of only femoropopliteal lesions) were associated with poorer long-term patency. The duration of balloon dilation was not a determinant of long-term patency.

CONCLUSION

Although prolonged dilation is safe and feasible in femoropopliteal artery PTA, its routine use is not warranted because it does not result in superior long-term patency rates.

A randomised trial of endoluminal reconstruction comparing the NIR stent and the Wallstent in angioplasty of long segment coronary disease: results of the RENEWAL Study

BACKGROUND

The role of coronary stents in reducing the incidence of acute complications and late restenosis after angioplasty has been established in randomized studies focusing on simple, short coronary lesions. The development of long coronary stents has provided a safe and predictable means of treating long coronary lesions, but this carries with it a higher risk of restenosis. By comparing the outcome of treating long lesions with two different stent types, we aimed to assess the influence of stent design rather than the nature of long lesions per se on the relatively high restenosis rates in this subgroup.

METHODS

This study was designed to assess procedural complications and 6-month restenosis rates in a randomized trial comparing a slotted tube stent with a self-expanding stent for the treatment of long coronary lesions. Randomization of vessels to either stent occurred after successful balloon angioplasty. Intravascular ultrasound (IVUS) was used to assess and optimize stent deployment. The patients were restudied angiographically and by IVUS at 6 months.

RESULTS

A total of 82 patients (85 vessels) were recruited (slotted tube stent, n = 44 vessels; self-expanding stent, n = 41 vessels). Successful deployment occurred in 41 (100%) of 41 of the self-expanding stent group and 41 (93%) of 44 of the slotted tube stent group. There was no difference in lesion length between the two groups (slotted tube stent, 26.6 +/- 6.9 [SD] mm; self-expanding stent, 28.7 +/- 9.8 [SD] mm; P = .2), but the mean length of the self-expanding stent was greater than that of the slotted tube stent (41.6 +/- 18.8 [SD] mm vs 35.4 +/- 16.2 [SD] mm, respectively; P < .05). There was no significant difference in the rate of major events between the two groups at 6-month follow-up. The angiographic restenosis rate at follow-up was less in the slotted tube stent group, but this did not reach statistical significance (26% vs 46%, respectively; P = .1) and the target lesion revascularization rate was similar for both groups (7.9% vs 7.7%, respectively; P = .8). IVUS assessment of plaque/stent ratios suggested a greater plaque burden in the self-expanding stent compared with the slotted tube stent at follow-up (0.42 +/- 1.2 [SD] vs 0.3 +/- 0.08 [SD]), but this was not statistically significant (P = .1).

CONCLUSIONS

Long stents can be safely and successfully deployed in long segment coronary disease, with an acceptable 6-month target lesion revascularization rate. Our results showed a trend toward lower angiographic restenosis and a lesser in-stent plaque burden at follow-up in the slotted tube stent compared with the self-expanding stent. This suggests that stent design may influence the restenotic process in long coronary lesions.

Achieving optimal results with standard balloon angioplasty: can baseline and angiographic variables predict stent-like outcomes?

OBJECTIVES

To predict which patients might not require stent implantation, we identified clinical and angiographic characteristics associated with repeat revascularization after standard balloon angioplasty.

BACKGROUND

Stents reduce the risk of repeat revascularization but are costly and may lead to in-stent restenosis, which remains difficult to treat. Identification of patients at low risk for repeat revascularization may allow clinicians to reserve stents for patients most likely to benefit.

METHODS

Data from five interventional trials (5,146 patients) were pooled for analysis. We identified patients with optimal angiographic results (final diameter stenosis < or =30% and no dissection) after balloon angioplasty and determined the multivariable predictors of repeat revascularization.

RESULTS

Optimal angiographic results were achieved in 18% of patients after angioplasty. The repeat revascularization rate at six months was lower for patients with optimal results (20% vs. 26%, p < 0.001) but still higher than observed in stent trials. Independent predictors of repeat revascularization were female gender (odds ratio [OR] 1.67, p = 0.01), lesion length > or =10 mm (OR 1.62, p = 0.03) and proximal left anterior descending coronary artery lesions (OR 1.62, p = 0.03). For the 8% of patients with optimal angiographic results and none of these risk factors, the repeat revascularization and target vessel revascularization rates were 14% and 8% respectively, similar to rates after stent implantation. Cost analysis estimated that $78 million per year might be saved in the U.S. with a provisional stenting strategy using these criteria compared with elective stenting.

CONCLUSIONS

A combination of baseline characteristics and angiographic results can be used to identify a small group of patients at very low risk for repeat revascularization after balloon angioplasty. Provisional stenting for these low risk patients could substantially reduce costs without compromising clinical outcomes.

A randomized trial comparing stenting with balloon angioplasty in small vessels in patients with symptomatic coronary artery disease. ISAR-SMART Study Investigators. Intracoronary Stenting or Angioplasty for Restenosis Reduction in Small Arteries

BACKGROUND

More than 30% of the lesions currently treated with interventional approaches are situated in vessels smaller in size than those representing an established indication for stenting. The objective of this randomized trial was to assess whether compared with PTCA, stenting of small coronary vessels is associated with a reduction of restenosis.

METHODS AND RESULTS

Patients with symptomatic coronary artery disease with lesions situated in native coronary vessels between 2 and 2.8 mm in size were randomly assigned to be treated with either stenting (n=204) or PTCA (n=200). Adjunct therapy consisted of abciximab, ticlopidine, and aspirin. Repeat angiography at 6-month follow-up was performed in 83% of the patients. The primary end point of the study was the incidence of angiographic restenosis (>/=50% diameter stenosis) at follow-up; adverse clinical events, such as death, myocardial infarction, stroke, or target vessel revascularization, were assessed as secondary end points. After 7 months, there were no significant differences in the infarct-free survival rates between the 2 study groups: 96.6% for stent patients, and 97.0% for PTCA patients (P:=0. 80). Target vessel revascularization was needed in 20.1% of the stent patients and 16.5% of the PTCA patients (P:=0.35). The primary end point of angiographic restenosis was found in 35.7% of the stent patients and 37.4% of the PTCA patients (P:=0.74). The net lumen gain observed at follow-up was identical (0.76+/-0.78 in the stent group versus 0.76+/-0.63 mm in the PTCA group, P:=0.93).

CONCLUSIONS

Stenting and PTCA are associated with equally favorable results when used for treating lesions in small coronary vessels.

Long-term outcome of coronary balloon angioplasty in diabetic patients

Diabetes is recognised to increase morbidity and mortality after coronary revascularization. We compared clinical outcomes in mean 5-year-long follow-up of coronary balloon angioplasty in diabetic and non-diabetic patients. We studied 621 patients undergoing elective angioplasty from 1987 to 1996. There were 60 (9.7%) patients with diabetes who were compared with 561 non-diabetic patients. Diabetics were older, more often obese, less frequently were current smokers, and less frequently had hypercholesterolaemia. Diabetic patients in comparison with non-diabetics had lower ejection fraction and more frequently had angioplasty of complex (B2 or C) lesions, but there were no differences between both groups in the other clinical and angiographic risk factors. Clinical success of angioplasty, as well as complications rate were similar in both groups. In follow-up restenosis occurred more frequently in diabetics (46.3 vs. 32.2%, P=0.03), resulting in significantly higher re-intervention rate (50.0 vs. 35.4%, P=0.03). Especially diabetic patients were more frequently referred to CABG (20.4 vs. 9. 9%, P=0.02). There were no significant differences in deaths (1.9 vs. 2.8%) and myocardial infarction (3.7 vs. 4.4%). Diabetics presented worse CCS status at the end of observation (Class 0 and I - 61.1 vs. 74.4%, P=0.037). Angioplasty proved to be a safe procedure in diabetic patients. Despite higher restenosis and re-intervention rate in diabetics, mortality as well as myocardial infarction rate was the same in both groups during mean 5-year follow-up.

Importance of lesion length on new device angioplasty of native coronary arteries. NACI Investigators. New Approaches to Coronary Interventions

The influence of lesion length on early and late outcomes after new device angioplasty has not been well documented. We reviewed the clinical and angiographic outcomes of 2,980 patients (3,902 lesions) undergoing new device angioplasty of native vessels enrolled in the New Approaches to Coronary Interventions (NACI) Registry. Patients were divided into three groups according to the longest lesion length (< 10, 10-20, and > 20 mm) treated. Patients with the longest lesions had more multivessel disease (56.9% vs. 49.0%, P<0.05), right coronary artery disease (52.7% vs. 32.0%, P<0.001), and total occlusions (19.1% vs. 2.5%, P<0.001) than patients with shorter lesions. Longest lesions had the smallest minimal lumen diameter (P<0.001) at baseline and at the end of the procedure. Although in-hospital events were similar, there were differences in clinical outcomes at 1 year due mainly to more target lesion revascularization in the longest lesion group (P<0.01). Multivariate analysis showed that each 1-mm increase in lesion length was associated with an increase relative risk of 1.014 (95% CI, 1.004-1.025) for target lesion revascularization at 1 year. We conclude that despite similar early clinical events, patients undergoing new device angioplasty of longer lesions have more target lesion revascularization at 1 year.

Relation of coronary artery size to one-year clinical events after new device angioplasty of native coronary arteries (a New Approach to Coronary Intervention [NACI] Registry Report)

The influence of vessel size on clinical and angiographic outcomes after new device angioplasty has not been well documented. We reviewed clinical and angiographic outcomes of 2,044 patients undergoing new device angioplasty of native vessels enrolled in the New Approaches to Coronary Interventions (NACI) Registry. Quantitative angiography was performed using standard methods. Patients were divided into 3 groups according to reference vessel diameter (RVD) (<2.75, 2.75 to 3.25, and >3.25 mm). Patients with the smallest vessels had a higher incidence of diabetes (26% vs. 16%, p<0.01), multivessel disease (50% vs. 45%, p<0.01), left anterior descending coronary artery disease (61% vs. 39% p<0.01), and in general, more severe baseline lesion characteristics than patients with larger (>3.25 mm) vessels. Absolute baseline and final minimal lumen diameter (MLD) was also smaller in patients with RVD <2.75 mm despite similar final percent diameter stenosis. Although in-hospital events were similar, patients who underwent interventions in vessels <2.75 mm had an increased incidence of death (p<0.01), surgical revascularization (p<0.05), and target lesion revascularization (TLR) (p<0.01) at 1 year. Multivariate analysis by vessel size showed a stepwise increase in the risk of TLR by 1 year in patients with the smaller RVD (p = 0.0001) and the combined end point of 1 year death/Q wave-myocardial infarction/TLR (p = 0.02). Thus, despite similar early clinical events among patients undergoing new device angioplasty, patients who underwent treatment of smaller vessels had a significantly increased risk of major adverse clinical events and particularly TLR by 1 year after new device angioplasty of native coronary arteries.

Short- and long-term evolution of unstented nonocclusive coronary dissection after coronary angioplasty

OBJECTIVES

We assessed the short- and long-term clinical and angiographic outcome of nonocclusive unstented dissection after percutaneous transluminal coronary angioplasty (PTCA) and its correlation with restenosis.

BACKGROUND

The use of stents has dramatically increased both the number and the cost of coronary revascularization procedures. However, this technique is not completely risk free, and its benefits have not been fully demonstrated in uncomplicated dissections.

METHODS

We studied 129 consecutive patients with 49 nonocclusive dissections after PTCA (grades A to D of National Heart, Lung, and Blood Institute classification) and good distal flow (TIMI [Thrombolysis in Myocardial Infarction] flow grade 3). All patients underwent coronary angiography at 24 h and at six months post-PTCA. Clinical status was assessed every three months in the outpatient clinic. Study subjects were matched with 60 other patients in whom stenting was performed for the presence of dissection.

RESULTS

In the former group, all but two patients (with type E dissection, which evolved to coronary occlusion and myocardial infarction) improved their dissection score during follow-up: at six months only 18 dissections were still angiographically visible, and no clinical adverse events were recorded. In the dissected vessels, the restenosis rate was significantly lower than in those without dissection (12% vs. 44%, p < 0.001); in the stented vessels, the restenosis rate was 25% (15/60).

CONCLUSIONS

In the presence of TIMI flow grade 3, coronary dissection is associated with a favorable outcome and predicts a low restenosis rate. These results caution against the indiscriminate use of intravascular prostheses in the event of nonocclusive coronary dissection.

Comparison of immediate and follow-up results of the short and long NIR stent with the Palmaz-Schatz stent

The intrinsic characteristics of a stent including stent length may affect both procedural success and long-term outcome. The present study evaluated the immediate and follow-up results after implantation of the short and long NIR stent and compared these results with the Palmaz-Schatz stent. Between July 1995 and December 1996, stenting with a 16-mm NIR stent (NIR-16), a 32-mm NIR stent (NIR-32), or a Palmaz-Schatz stent (PS) was performed in 68, 57, and 155 lesions, respectively. There were no significant differences in the incidences of delivery failure (PS, 2.6%: NIR-16, 4.4%; NIR-32, 5.3%; p = NS) and procedural success (PS, 92%; NIR-16, 93%; NIR-32, 93%; p = NS) among the 3 groups. The reference vessel diameter was smaller in lesions with a 32-mm NIR stent than in those with a Palmaz-Schatz stent (PS, 3.14+/-0.58, NIR-16, 3.00+/-0.50; NIR-32, 2.90+/-0.47 mm; p <0.05). The lesion length was longer in lesions with a 32-mm NIR stent than in those with a Palmaz-Schatz or a 16-mm NIR stent (PS, 8.9+/-5.0; NIR-16, 11.0+/-4.1; NIR-32, 26.1+/-9.7 mm; p <0.01). After the procedure, the lesions with a 32-mm NIR stent had a smaller minimal lumen diameter than those with a Palmaz-Schatz stent (PS, 3.17+/-0.61; NIR-16, 2.99+/-0.51; NIR-32, 2.89+/-0.49 mm; p <0.01). At follow-up, a smaller minimal lumen diameter was observed in lesions with a 32-mm NIR stent than in those with a Palmaz-Schatz or a 16-mm NIR stent (PS, 2.32+/-0.98; NIR-16, 2.25+/-0.80; NIR-32, 1.68+/-0.79 mm; p <0.01). Restenosis rates were 16.5% in lesions with a Palmaz-Schatz stent, 13.3% in those with a 16-mm NIR stent, and 47.4% in those with a 32-mm NIR stent (p <0.01). Although stent delivery and procedural success of a long NIR stent were acceptable, the restenosis rate of a long NIR stent was high compared with a short NIR stent or a Palmaz-Schatz stent.

Restenosis, late vessel occlusion and left ventricular function six months after balloon angioplasty in diabetic patients

OBJECTIVES

We studied angiographic outcome and its predictors after traditional coronary balloon angioplasty in diabetics. We further examined whether changes in ejection fraction were influenced by the status of the dilated site(s) at follow-up.

BACKGROUND

Recent studies have suggested that diabetics have a particularly poor outcome after balloon angioplasty. The reasons for this observation are not known.

METHODS

We investigated procedural and six-month angiographic outcome, analyzed by quantitative coronary angiography, and left ventricular function in 485 consecutive diabetics (627 lesions) treated by balloon angioplasty without stent implantation.

RESULTS

The procedure was successful in 455 (94%) patients; angiographic follow-up was available in 377 patients (83%). At follow-up, the rates of restenosis and total occlusion were 62% and 13%, respectively. Five independent predictors of restenosis were identified: the presence of organ damage, a saphenous vein graft (SVG) angioplasty, a bifurcation lesion, a Thrombolysis in Myocardial Infarction (TIMI) flow <3 preprocedure and the degree of residual stenosis. Four independent predictors of vessel occlusion were identified: treatment with insulin, a SVG angioplasty, a TIMI flow <3 preprocedure and the degree of residual stenosis after angioplasty. Late vessel occlusion at angioplasty site(s) was observed in 15% of patients, ranging from 11% for a one-site procedure to 37% for a three-site procedure. This complication was associated with a decrease in ejection fraction at follow-up (-6.2 +/- 9.9%, p = 0.0001), whereas no significant change was observed in patients without occlusion.

CONCLUSIONS

This study shows that late vessel occlusion is a frequent mode of restenosis in diabetic patients and is associated with a significant decrease in ejection fraction. This could partly explain the poor long-term clinical outcome reported in such patients after traditional balloon angioplasty.

Clinical and angiographic outcome of stenting following suboptimal results of percutaneous transluminal coronary angioplasty in small (<2.5 mm) coronary arteries

The purpose of the present study was to evaluate the feasibility and efficacy of stenting following suboptimal percutaneous transluminal coronary angioplasty (PTCA) in angiographically small coronary arteries. The clinical and angiographic outcome of unplanned stenting in 33 patients with coronary arteries <2.5 mm in diameter was studied. Procedural success was achieved for 97.0% with a greater initial gain (1.79 +/- 0.60 vs. 1.34 +/- 0.58 mm, P < 0.05) and larger postprocedural minimal luminal diameter (2.19 +/- 0.43 vs. 1.57 +/- 0.57 mm, P < 0.001) than that in the size-matched elective PTCA patients. Trends toward a lower restenosis rate and a significant reduction in target lesion revascularization (7.1% vs. 41.9%, P < 0.01) were observed in the stented patients, suggesting the feasibility and efficacy of stenting following suboptimal PTCA in small coronary arteries. Cathet. Cardiovasc. Intervent. 47:269-276, 1999.