Outcomes of First- Versus Second-Generation Drug-Eluting Stent Implanted for Right Coronary Artery Ostial Narrowing

Three-Dimensional CT for Preprocedural Planning of PCI for Ostial Right Coronary Artery Lesions: A Randomized Controlled Pilot Trial

BACKGROUND

Geographic stent-ostium mismatch is an important predictor of target lesion failure after percutaneous coronary intervention of an aorto-ostial right coronary artery lesion. Optimal visualization of the aorto-ostial plane is crucial for precise stent implantation at the level of the ostium. This study investigates whether preprocedural 3-dimensional computed tomography (3DCT), with determination of the optimal viewing angle, would allow for more precise stent implantation and reduce procedure time, contrast, and radiation dose.

METHODS

In this single-center, prospective, open-label, core-laboratory blinded trial, a total of 30 patients with an aorto-ostial right coronary artery lesion were randomly assigned to either percutaneous coronary intervention with a preprocedural 3DCT or angiography-guided percutaneous coronary intervention. The optimal working view angle was determined by 3DCT in the intervention group and by the operators' discretion in the control group. The primary end point was the percentage of patients without geographic mismatch, as determined by intravascular ultrasound.

RESULTS

3DCT-determined C-arm angles were heterogenous but, in general, more extreme left anterior oblique projections were used (P<0.0001). While stent implantation was in the optimal position in all patients randomized to the intervention group, geographic mismatch was present in 5 (33%) patients randomized to the control group (P=0.06). The mean amount of procedural contrast (P<0.0001), mean radiation (P=0.03), and median procedure time (P=0.03) were significantly lower in the intervention group. The 3DCT scan was able to predict the calcium arc (P<0.0001) and minimal lumen area by intravascular ultrasound (P=0.003).

CONCLUSIONS

Preprocedural 3DCT planning for percutaneous coronary intervention of aorto-ostial right coronary artery lesions allows for optimal stent positioning while reducing procedure time, contrast, and radiation dose.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05172323.

Full-metal jacket technique using second-generation drug-eluting stent: clinical and angiographic follow-up in 2 years

The aims of this study are to evaluate the efficacy of percutaneous coronary intervention (PCI) using full-metal jacket (FMJ) with second-generation drug-eluting stents (DES). A single-center, non-randomized, retrospective study was performed from May 2005 to February 2014 at Miyazaki Medical Association Hospital, Japan. PCI using FMJ with DES was performed to treat 240 very long lesions (> 60 mm) in 240 patients. Subjects were divided into a first-generation or second-generation DES group. The primary endpoint was the incidence of major adverse cardiac events (MACE) at 2 years. MACE included all-cause death, myocardial infarction (MI), cerebrovascular event, and target vessel revascularization. The secondary endpoint was binary restenosis (> 50% stenosis) assessed by angiography at 1 year of follow-up. Second-generation DES were implanted to treat 121 lesions, and the first-generation DES were implanted to treat 119 lesions. Since 35 patients were lost to follow-up, the final analysis included 102 patients with second-generation DES and 103 with first-generation DES. At the 2-year follow-up, the incidence of MACE was significantly less in the second-generation DES group (9.8% vs. 20.4%, p = 0.03). The incidence of binary restenosis at 1 year was also significantly lower in the second-generation DES group (6.7% vs 29.1%, p < 0.01). When PCI was performed using FMJ with DES to treat very long lesion, the angiographic and clinical outcomes were better with second-generation than first-generation DES.

Rotational atherectomy and new-generation drug-eluting stent implantation

OBJECTIVES

The aim of this study was to evaluate the clinical outcomes of rotational atherectomy (RA) followed by new-generation drug-eluting stent (DES) implantation in patients with an extensive amount of calcified and fibrotic plaque.

BACKGROUND

RA followed by new-generation DES implantation for complex lesions has not been thoroughly evaluated.

METHODS

A total of 744 consecutive patients (770 lesions) treated with new-generation DES implantation following RA for de novo lesions between January 2013 and November 2015 were retrospectively identified using our institutional database. Clinical outcomes at 12 months were evaluated and the independent predictors of all-cause death and target vessel failure (TVF) were assessed using Cox regression models.

RESULTS

Target lesion revascularization occurred in 22 lesions (2.9%) and TVF occurred in 51 lesions (6.6%). In a multivariate analysis, hemodialysis, non-ST-segment elevation acute coronary syndrome, low ejection fraction, and HbA1c ≧ 7% were associated with 12-month mortality. Hemodialysis and right coronary artery were identified as independent predictors of TVF (hazard ratio (HR) 4.107, 95% confidence interval (CI) 2.194-7.685, P < .001; HR 2.491, 95% CI 1.023-6.062, P = .044, respectively).

CONCLUSIONS

A good debulking with RA followed by new-generation DES implantation is recommended for patients with an excessive amount of calcified and fibrotic plaque, as this will likely improve the clinical outcomes.

Independent predictors of in-stent restenosis after drug-eluting stent implantation for ostial right coronary artery lesions

OBJECTIVES

We evaluated the angiographic patterns and predictors of in-stent restenosis (ISR) for ostial lesions of the right coronary artery (RCA) to clarify the mechanism of insoluble restenosis.

BACKGROUND

Although ISR of the RCA still occurs, limited data is available regarding the associated angiographic findings.

METHODS

Between January 2005 and September 2013, we recruited consecutive patients undergoing routine angiography 6-18months after implantation of a drug-eluting stent (DES). Multiple logistic regression analysis was used to determine the independent predictors of ISR, and the adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were calculated.

RESULTS

Routine angiography revealed that 45 of 131 patients (34.3%) had RCA-ISR, which were classifiable by occlusion type into ostial (24 cases), proximal (17 cases), diffuse (3 cases), and total (1 case). By multivariable analysis, early generation DES was the only independent predictor of overall ISR (aOR, 3.54; 95% CI, 1.59-7.87; p=0.002). In a subgroup analysis of each focal ISR pattern, early generation DES (aOR, 7.76; 95% CI, 2.15-28.0; p=0.002) was associated with increased risk of ostial ISR. On the contrary, larger stent (aOR, 0.21; 95% CI, 0.05-0.84; p=0.027) was associated with decreased risk of ostial ISR. Furthermore, a ratio of the stent to post-balloon size >1.10 (aOR, 3.93; 95% CI, 1.30-11.8; p=0.002) and good left ventricular contractility (ejection fraction >60%) (aOR, 8.27; 95% CI, 1.76-39.0; p=0.008) were associated with increased risk of proximal ISR when stent fracture was observed.

CONCLUSION

The focal pattern of RCA-ISR was mostly observed after DES implantation, and the mechanisms of proximal and ostial ISR differed.