Comparison of Sirolimus-Eluting Stenting With Minimally Invasive Bypass Surgery for Stenosis of the Left Anterior Descending Coronary Artery

Percutaneous Coronary Intervention or Minimally Invasive Coronary Bypass for Isolated Left Anterior Descending Artery Disease

The optimal revascularization strategy for isolated left anterior descending (LAD) artery disease, minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI), remains a subject of debate. This updated meta-analysis aimed to compare the long-term outcomes of MIDCAB versus PCI for patients with isolated LAD artery disease. Three databases were systematically searched to identify randomized controlled trials (RCTs) and adjusted studies. Primary outcomes included long-term survival and repeat target vessel revascularization (TVR). The secondary endpoint was long-term major adverse cardiovascular events (MACEs). Hazards ratios (HR) and Confidence Intervals (CI) were calculated for long-term outcomes and a random effects model was used. Sensitivity analyses included subgroups analysis of stent-type. Nine articles, comprising 4 RCTs, totaling 2,168 patients (MIDCAB = 1,086 and PCI = 1,080) were included. The weighted mean follow-up was 4.35 ± 4.9 years. Long-term survival was comparable between MIDCAB and PCI (HR = 0.76; 95% CI, 0.58 to 1.00; p = 0.05). MIDCAB was associated with a significantly lower rate of repeat TVR (HR = 0.35; 95% CI, 0.25 to 0.49; p <0.0001) and a reduced risk of MACEs (HR = 0.59; 95% CI, 0.43 to 0.81; p <0.0001), although the difference was not evident in subgroup analysis comparing MIDCAB and PCI with drug-eluting stent (HR = 0.66; 95% CI, 0.46 to 1.06; p = 0.09). In conclusion, this meta-analysis of RCTs and adjusted studies shows that in patients with isolated LAD lesion, MIDCAB and PCI exhibit comparable long-term survival. However, MIDCAB is associated with a significantly reduced risk of long-term repeat TVR and MACEs compared to PCI.

Long-term outcomes of minimally invasive direct coronary artery bypass vs second generation drug eluting stent for management of isolated left anterior descending artery disease

INTRODUCTION

This study aimed to compare the long-term outcomes in a propensity matched population receiving either minimally invasive direct coronary artery bypass (MIDCAB) using left internal thoracic artery (LITA) to the left anterior descending artery (LAD) or percutaneous coronary intervention using second generation everolismus-eluting stents (DES-PCI) in patients treated for isolated proximal LAD stenosis.

METHODS

Between January 2012 and December 2017, 421 patients with a nonemergency status undergoing primary isolated proximal LAD revascularization were retrospectively analyzed and were divided into two groups: 111 patients receiving MIDCAB LITA to LAD and 310 patients receiving DES-PCI. Propensity score matching selected 111 pairs and both groups were comparable for all baseline characteristics and well balanced.

RESULTS

In the matched cohort, median follow-up time was 5.19 years (interquartile range, 3.50-6.96). MIDCAB and DES-PCI had comparable long-term outcomes in terms of mortality (Hazard ratio (HR) stratified on matched pairs: 1.60; 95 %CI; 0.58-4.37; P = 0.29), stroke (HR stratified on matched pairs: 0.44; 95 %CI; 0.04-5.13; P = 0.56) and major adverse cardiac and cerebral events (MACCE) (HR stratified on matched pairs:0.57; 95 %CI; 0.26-1.22; P = 0.21). However, MIDCAB was associated with reduced incidence of myocardial infarction (MI) (HR stratified on matched pairs:0.46; 95 %CI; 0.15-0.56; P = 0.001) as well as reduced incidence of target vessel repeat revascularization (TVR) (HR stratified on matched pairs: 0.12; 95 %CI; 0.001; P = 0.01).

CONCLUSION

MIDCAB LITA-LAD offers superior freedom from MI rate and TVR with similar mortality, stroke and MACCE compared with second generation DES-PCI in the treatment of isolated proximal LAD disease.

Minimally Invasive Coronary Artery Bypass Grafting is the Future: Pro

Coronary artery bypass grafting (CABG) remains one of the most commonly performed operations worldwide. However, most CABG operations performed today are as invasive -apart from saphenous vein harvesting- as they were 50 years ago. While heart valve operations have become less invasive, CABG faces formidable challenges in doing so. Valve surgery requires a single surgical exposure to the valve intervened on, but less invasive CABG necessitates multiple surgical exposures to harvest internal thoracic artery conduits, source their inflow plus that of other grafts, and expose each coronary target to be grafted -including anterior, lateral, posterior, and inferior vessels. In this article, we rationalize why we believe that conventional CABG remains unduly invasive, associated with morbidity and prolonged recovery, and why less invasive CABG in its many forms, which we describe, represents a safe, practical, diffusible, and less invasive alternative to sternotomy CABG. Centers of excellence in coronary artery surgery should dedicate resources and expertise to developing high-quality, safe, durable, and advanced forms of lesser invasive CABG.

Alternative Approaches to Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention, How Do They Compare?: A Systematic Review and Meta-Analysis

Coronary artery disease (CAD) is a leading cause of mortality worldwide. Severe symptomatic CAD is treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Alternative CABG (ACABG) approaches including thoracotomy, off-pump, total endoscopic, and robotic-assisted CABG are increasing in prevalence to address the increased early risk of CABG. This systematic review and meta-analysis aims to review the contemporary literature comparing outcomes after ACABG and PCI. Pubmed, Medline, and Embase were systematically searched by 2 authors for articles comparing the outcomes after ACABG and PCI. A total of 1154 articles were screened, and 11 were included in this review. The RevMan 5.4 software was used to perform a meta-analysis of the pooled data. Individual studies found rates of long-term survival, major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), and repeat revascularization either favored ACABG or did not differ significantly. Pooled estimates of the compiled data identified rates of MACCE, MI, and repeat revascularization favored ACABG. The results of this review demonstrated the favorable rates of long-term mortality, MACCE, MI, and repeat revascularization for ACABG in addition to similar short-term mortality and stroke when compared with PCI. Advancement of both CABG and PCI continues to improve patient outcomes. With the increasing prevalence of ACABG, similar studies will need to be undertaken with further direct comparisons between ACABG and PCI. Finally, hybrid revascularization should continue to be explored for its combined benefits of long-term outcomes, short-term safety, and ability to achieve complete revascularization.

Minimally Invasive Direct Coronary Artery Bypass Grafting: Sixteen Years of Single-Center Experience

Background: Coronary artery disease is a major cause of death globally. Minimally invasive direct coronary artery bypass (MIDCAB), using a small left anterior thoracotomy, aims to provide a less invasive alternative to traditional procedures, potentially improving patient outcomes with reduced recovery times. Methods: This retrospective, non-randomized study analyzed 310 patients who underwent MIDCAB between July 1999 and April 2022. Data were collected on demographics, clinical characteristics, operative and postoperative outcomes, and follow-up mortality and morbidity. Statistical analysis was conducted using IBM SPSS, with survival curves generated via the Kaplan-Meier method. Results: The cohort had a mean age of 63.3 ± 10.9 years, with 30.6% females. The majority of surgeries were elective (76.1%), with an average operating time of 129.7 ± 35.3 min. The median rate of intraoperative blood transfusions was 0.0 (CI 0.0-2.0) Units. The mean in-hospital stay was 8.7 ± 5.5 days, and the median ICU stay was just one day. Early postoperative complications were minimal, with a 0.64% in-hospital mortality rate. The 6-month and 1-year mortalities were 0.97%, with a 10-year survival rate of 94.3%. There were two cases of perioperative myocardial infarction and no instances of stroke or new onset dialysis. Conclusions: The MIDCAB approach demonstrates significant benefits in terms of patient recovery and long-term outcomes, offering a viable and effective alternative for patients suitable for less invasive procedures. Our results suggest that MIDCAB is a safe option with favorable survival rates, justifying its consideration in high-volume centers focused on minimally invasive techniques.

Long-term Incidence of Myocardial Infarction and Death After CABG and PCI for Isolated Left Anterior Descending Artery Disease: A Meta-analysis of Randomized Controlled Trials

Background

To compare the long-term incidence of myocardial infarction (MI) and death in patients randomized to coronary artery bypass grafting (CABG) vs percutaneous coronary intervention (PCI) for treatment of isolated left anterior descending (LAD) coronary artery disease.

Methods

We systematically identified all randomized controlled trials comparing PCI with stenting to CABG with a left internal mammary artery (LIMA) graft in patients with isolated LAD disease who had at least 4 years of follow-up. The primary outcome of interest was MI. Secondary outcomes were all-cause mortality and target vessel revascularization (TVR).

Results

Four trials were included in the current analysis, with a total of 573 patients randomized to CABG with a LIMA (n = 285) vs PCI (n = 288) and followed for 4 to 10 years. At latest follow-up (weighted mean 8.3 years), there was no statistically significant difference in the risk of MI between CABG and PCI (relative risk [RR], 1.33; 95% CI, 0.62-2.83; P = .46), nor was there a statistically significant difference in mortality between the groups (RR, 1.04; 95% CI, 0.70-1.65; P = .84). There was a significantly lower risk of TVR after CABG compared with PCI (RR, 0.27; 95% CI, 0.15-0.46; P < .001).

Conclusions

The current meta-analysis suggests that there is insufficient evidence that CABG with a LIMA confers protection against MI or death compared to PCI with a stent for isolated LAD disease. CABG was, however, associated with reduced rates of TVR.

Correlation Between Periprocedural Myocardial Infarction, Mortality, and Quality of Life in Coronary Revascularization Trials: A Meta-analysis

BACKGROUND

The prognostic importance of periprocedural myocardial infarction (pMI) and its inclusion in the composite outcomes of coronary revascularization trials are controversial. We assessed whether pMI is a surrogate for all-cause or cardiac mortality and quality of life (QoL) outcomes in coronary revascularization trials.

METHODS

All randomized trials comparing percutaneous coronary intervention vs coronary artery bypass grafting (MEDLINE, EMBASE, Cochrane Library) were identified. Trials were included if they reported data for pMI and mortality. Trial-level associations between pMI and all-cause or cardiac mortality and QoL were assessed using the coefficient of determination (R 2 ). The criterion for surrogacy was set at 0.7. Subgroup analyses based on pMI definition and on key clinical/procedural variables were performed.

RESULTS

Twelve trials were included (11,549 patients; weighted mean follow-up: 5.6 years). There was a positive correlation between pMI and all-cause mortality (slope, 1.81; 95% CI, 1.00-2.63; R 2 = 0.72). In the trials that defined pMI as a rise in cardiac biomarkers >5 times the upper reference limit, pMI positively correlated with both all-cause (slope, 2.07; 95% CI, 1.00-3.14; R 2 = 0.93) and cardiac mortality (slope, 0.70; 95% CI, 0.20-1.19; R 2 = 0.87); no such relationships were present in trials that used a lower biomarker threshold. An inverse correlation was found between pMI and long-term changes in the Short Form Health Survey Physical Component score (slope, -4.66; 95% CI, -5.75 to -3.57; R 2 =0.99).

CONCLUSIONS

In the published coronary revascularization trials, pMI defined by larger biomarker elevations was associated with subsequent mortality and reduced QoL. These findings suggest that large pMI should be included as an outcome measure in coronary revascularization trials.

Twenty-year outcomes of minimally invasive direct coronary artery bypass surgery: The Leipzig experience

OBJECTIVE

Minimally invasive direct coronary artery bypass (MIDCAB) surgery involving left anterior descending coronary artery grafting with the left internal thoracic artery through a left anterior small thoracotomy is being routinely performed in some specified centers for patients with isolated complex left anterior descending coronary artery disease, but very few reports regarding long-term outcomes exist in literature. Our study was aimed at assessing and analyzing the early and long-term outcomes of a large cohort of patients who underwent MIDCAB procedures and identifying the effects of changing trends in patient characteristics on early mortality.

METHODS

A total of 2667 patients, who underwent MIDCAB procedures between 1996 and 2018, were divided into 3 groups on the basis of the year of surgery: group A, 1996-2003 (n = 1333); group B, 2004-2010 (n = 627) and group C, 2011-2018 (n = 707). Groupwise characteristics and early postoperative outcomes were compared. Long-term survival for all patients was analyzed and predictors for late mortality were identified using Cox proportional hazards methods.

RESULTS

The mean age was 64.5 ± 10.9 years and 691 (25.9%) patients were female. Group C patients (log EuroSCORE I = 4.9 ± 6.9) were older with more cardiac risk factors and comorbidities than groups A (log EuroSCORE I = 3.1 ± 4.5) and B (log EuroSCORE I = 3.5 ± 4.7). Overall and groupwise in-hospital mortality was 0.9%, 1.0%, 0.6%, and 1.0% (P = .7), respectively. Overall 10-, 15-, and 20-year survival estimates for all patients were 77.7 ± 0.9%, 66.1 ± 1.2%, and 55.6 ± 1.6%, respectively.

CONCLUSIONS

MIDCAB can be safely performed with very good early and long-term outcomes. In-hospital mortality remained constant over the 22-year period of the study despite worsening demographic profile of patients.

Unilateral left-sided thoracoscopic ablation of atrial fibrillation concomitant to minimally invasive bypass grafting of the left anterior descending artery

OBJECTIVES

Thoracoscopic ablation for atrial fibrillation (AF) and minimally invasive direct coronary artery bypass (MIDCAB) with robot-assisted left internal mammary artery (LIMA) harvesting may represent a safe and effective alternative to more invasive surgical approaches via sternotomy. The aim of our study was to describe the feasibility, safety and efficacy of a unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB surgery.

METHODS

Retrospective analysis of a prospectively gathered cohort was performed of all consecutive patients with AF and at least a critical left anterior descending artery (LAD) stenosis that underwent unilateral left-sided thoracoscopic AF ablation and concomitant off-pump MIDCAB surgery in the Maastricht University Medical Centre between 2017 and 2021.

RESULTS

Twenty-three patients were included [age 69 years (standard deviation = 8), paroxysmal AF 61%, left atrial volume index 42 ml/m2 (standard deviation = 11)]. Unilateral left-sided thoracoscopic isolation of the left (n = 23) and right (n = 22) pulmonary veins and box (n = 21) by radiofrequency ablation was succeeded by epicardial validation of exit- and entrance block (n = 22). All patients received robot-assisted LIMA harvesting and off-pump LIMA-LAD anastomosis through a left mini-thoracotomy. The perioperative complications consisted of one bleeding of the thoracotomy wound and one aborted myocardial infarction not requiring intervention. The mean duration of hospital stay was 6 days (standard deviation = 2). After discharge, cardiac hospital readmission occurred in 4 patients (AF n = 1; pleural- and pericardial effusion n = 2, myocardial infarction requiring the percutaneous intervention of the LIMA-LAD n = 1) within 1 year. After 12 months, 17/21 (81%) patients were in sinus rhythm when allowing anti-arrhythmic drugs. Finally, the left atrial ejection fraction improved postoperatively [26% (standard deviation = 11) to 38% (standard deviation = 7), P = 0.01].

CONCLUSIONS

In this initial feasibility and early safety study, unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB for LIMA-LAD grafting is a feasible, safe and efficacious for patients with AF and a critical LAD stenosis.

Minimally invasive surgery or stenting for left anterior descending artery disease - meta-analysis

Minimally invasive direct coronary artery bypass (MIDCAB) surgery and percutaneous coronary intervention (PCI) are both well-established minimally invasive revascularization strategies in patients with proximal left anterior descending (LAD) lesions. We aimed to evaluate the 20-years' experience by performing a systematic review and meta-analysis comparing MIDCAB versus PCI in adults with proximal LAD disease. We searched MEDLINE, EMBASE and Cochrane on October 1st, 2021 for articles published in the year 2000 or later. The primary outcome was all-cause mortality. Secondary outcomes included cardiac mortality, repeat target vessel revascularization (rTVR), myocardial infarction (MI), and cerebrovascular accident (CVA). Outcomes were analysed at short-term, mid-term, and long-term follow-up. Random effects meta-analyses were performed. Events were compared using risk ratios (RR) with 95% confidence intervals (CI). Our search yielded 17 studies pooling 3847 patients. At short-term follow-up, cardiac mortality was higher with MIDCAB than with PCI (RR 7.30, 95% CI: 1.38 to 38.61). At long-term follow-up, MIDCAB showed a decrease in all-cause mortality (RR 0.66, 95% CI: 0.46 to 0.93). MIDCAB showed a decrease in rTVR at mid-term follow-up (RR 0.16, 95% CI: 0.11 to 0.23) and at long-term follow-up (RR 0.25, 95% CI: 0.17 to 0.38). MI and CVA comparisons were not significant. In conclusion, in patients with proximal LAD lesions, MIDCAB showed a higher short-term mortality in the RCTs, but the cohort studies suggested a lower all-cause mortality at long-term follow-up. We confirm a decreased rTVR at mid-term follow-up in the RCTs and long-term follow-up in the cohort studies.

Minimally invasive direct coronary artery bypass after percutaneous coronary intervention

OBJECTIVES

Minimally invasive direct coronary artery bypass (MIDCAB) with the left internal thoracic artery (LITA) provides excellent long-term results for isolated left anterior descending coronary artery (LAD) disease. We tried to evaluate the impact of the previous percutaneous coronary intervention (p-PCI) for LAD on the clinical outcomes of MIDCAB in this study.

METHODS

A total of 197 patients with isolated LAD disease underwent MIDCAB in our center from February 2009 to May 2020. 51 patients had the p-PCI for LAD and 146 patients did not. The primary outcome was the major adverse cardiovascular event (MACE).

RESULTS

The incidences of the perioperative outcomes were comparable between the two groups (p > .05). The median follow-up time was 48.0 months (interquartile range, 25.9-85.5 months). The incidences of MACE (p < .001) and myocardial infarction or recurrent angina (p < .001) were significantly higher in the p-PCI group than those in the non-PCI group. The estimated 5-year freedom from MACE in the p-PCI group was significantly lower (56.1%, 95% confidence interval [CI]: 41.2%-71.0% vs. 83.4%, 95% CI: 76.7%-90.1%, p < .001). The previous LAD-PCI (hazard ratio [HR]: 2.664, 95% CI: 1.471-4.822, p = .001) and the history of peripheral arterial disease (HR: 3.145, 95% CI: 1.085-9.113, p = .035) were the independent predictors of MACE. The p-PCI group had a higher diseased graft rate than the non-PCI group (10.9% vs. 2.3%, p = .046).

CONCLUSIONS

The previous LAD-PCI may deteriorate the outcomes of MIDCAB in patients with isolated LAD disease.

In-hospital outcomes of treatment of patients with acute coronary syndrome using distal radial access

Endovascular methods are leading in the treatment of patients with acute coronary syndrome (ACS). Transradial access (TRA) is traditionally used, but there are some disadvantages. Distal transradial access (dTRA) is an alternative to conventional TRA, but its outcomes in patients with ACS are controversial.

Aim. To evaluate the safety and efficacy of vascular accesses, as well as in-hospital outcomes of treatment of patients with ACS using conventional TRA versus dTRA.

Material and methods. This single-center, prospective, randomized study included 264 patients with ACS, which were divided into 2 groups: group 1 (n=132) — dTRA, group 2 (n=132) — TRA. The groups were comparable in the initial clinical, laboratory and angiographic characteristics.

Results. During percutaneous coronary intervention, 240 drug-eluting stents were implanted in 184 patients. In 10 patients, access was converted: from dTRA to TRA in 2,3% (n=3), from dTRA to femoral  — 3,0% (n=4), from dTRA to femoral in 2,3% (n=3). The mean puncture time was 125,1±11,9 s in group 1 and 58,8±8,2 s in group 2 (p<0,00005). There was no difference in the total intervention duration as follows: 30,5±7,1 min and 29,4±4,6 min (p=0,1428), respectively. The time to hemostasis was significantly higher in the TRA group: 354,2±28,1 vs 125,4±15,3 min in group 1 (p<0,00005). When using dTRA, a lower incidence of hematomas (0,8 (n=1) vs 7,0% (n=9) (p=0,019)), spasm (5,6 (n=7) vs 13,2% (n=17) (p=0,039)) and radial artery occlusion (0,8 (n=1) vs 6,2% (n=8) (p=0,036)). The number of major adverse cardiac events (MACE) in both groups was comparable: 10,4% (n=13) and 10,1% (n=13) in group 1 and 2, respectively (p=0,932).

Conclusion. The use of dTRA does not increase the total procedure duration compared to conventional TRA. The complication rate was comparable in both study groups. When dTRA was used, the incidence of local complications was significantly lower compared to conventional TRA. Thus, dTRA can be an alternative to conventional TRA, but large randomized trials are required for final conclusions.

The Current State of Coronary Revascularization: Percutaneous Coronary Intervention versus Coronary Artery Bypass Graft Surgery

The question of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery remains among the most important questions in the treatment of coronary artery disease. The leading North American and European societies largely agree on the current guidelines for the revascularization of unprotected left-main disease (ULMD) and multivessel disease (MVD) which are largely supported by the outcomes of several large randomized trials including SYNTAX, PRECOMBAT, NOBLE, and EXCEL. While these trials are of the highest quality, currently available, they suffer several limitations, including the use of bare metal and/or first-generation drug-eluting stents in early trials and lack of updated surgical outcomes data. The objective of this review is to briefly discuss these key early trials, as well as explore contemporary studies, to provide insight on the current state of coronary revascularization. Evidence suggests that in ULMD and MVD, there are similar mortality rates for CABG and PCI but PCI is associated with fewer "early" strokes, whereas CABG is associated with fewer "late" strokes, myocardial infarctions, and lower need for repeat revascularization. Additionally, studies suggest that CABG remains superior to PCI in patients with intermediate/high SYNTAX scores and in MVD with concomitant proximal left anterior descending (pLAD) artery stenosis. Despite the preceding research and its basis for our current guidelines, there remains significant variation in care that has yet to be quantified. Emerging studies evaluating second-generation drug-eluting stents, specific lesion anatomy, and minimally invasive and hybrid approaches to CABG may lend itself to more individualized patient care.

Long-term clinical outcomes of coronary artery bypass graft surgery compared to those of percutaneous coronary intervention with second generation drug eluting stents in patients with stable angina and an isolated lesion in the proximal left anterior descending artery

OBJECTIVES

We compared the long-term outcomes of percutaneous coronary intervention with second-generation drug-eluting stents (PCI-DES) and coronary artery bypass graft surgery (CABG) with the left internal mammary artery in stable angina patients with isolated single-vessel proximal left anterior descending artery (pLAD) disease.

BACKGROUND

Long-term outcomes of second-generation PCI-DES and CABG in isolated pLAD lesions have not been extensively studied.

METHODS

We included 631 PCI-DES patients and 379 CABG patients. Unadjusted and adjusted hazard ratios (HRs) were derived for major adverse cardiac events (MACEs), their components (cardiac death, nonfatal myocardial infarction [MI] not attributed to a non-target vessel, target-lesion revascularization), and patient-related outcome (PRO, composed of all-cause mortality, any MI, any revascularization).

RESULTS

In the unadjusted and adjusted analyses, no significant difference was observed between the two groups at follow-up (mean:4.6 ± 2.5 years) for MACEs (HR: 1.45, 95% CI: 0.92-2.28, p = .11; HR:1.43, 95% CI: 0.91-2.26, p = .13), PRO (HR: 1.18, 95%CI: 0.86-1.61, p = .30; HR: 1.18, 95% CI: 0.86-1.62, p = .31), cardiac death (HR: 0.97, 95% CI: 0.46-2.05, p = .93; HR: 0.79, 95% CI: 0.36-1.72, p = .56) and MI (HR: 1.43, 95% CI: 0.49-4.13, p = .51; HR: 1.57, 95% CI: 0.53-4.64, p = .42). Compared with CABG, PCI-DES had a borderline significantly greater risk of repeat revascularization (HR: 1.99, 95% CI: 1.00-3.94, p = .05; HR: 1.95, 95% CI: 0.98-3.9, p = .06). Angina recurred more often after PCI (p < .001), whereas more arrhythmias developed after CABG (p = .02). PCI-DES resulted in fewer in-hospital complications (p < .001) and shorter hospitalizations (p < .001).

CONCLUSIONS

The long-term clinical outcomes of second-generation PCI-DES and CABG in patients with stable angina and isolated pLAD disease were comparable.

Advances in revascularization of the left coronary artery

Ischaemic heart disease is the most common cardiovascular disease worldwide, and it contributes to a significant source of morbidity and mortality internationally. It can be asymptomatic for many years and present suddenly with acute coronary syndrome or can be progressive with angina and eventual acute myocardial infarction. Diseases of the left coronary system can be drastic and fatal if not managed correctly. With ongoing increase in the practice of percutaneous intervention; patient demographics for conventional coronary artery bypass grafting surgery have more risk factors than before. Conventional bypass surgery has also evolved to include minimally invasive and hybrid techniques. Although some evidence supports each approach, controversies remain.

Robotically assisted coronary artery bypass graft surgery versus drug-eluting stents for patients with stable isolated proximal left anterior descending disease

OBJECTIVE

To compare the midterm outcomes of patients with isolated left anterior descending disease (iLAD) who underwent robotically assisted coronary artery bypass graft (R-CABG) and percutaneous coronary intervention (PCI) with drug eluting stents (DES).

METHOD

Clinic data was collected in 223 patients who underwent R-CABG in our hospital between July, 2007 to November, 2014. Cardiology Database System of our hospital was used to identify 4047 patients who underwent PCI with DES for LAD lesion between April, 2011 to November, 2014. Total 496 patients received DES and 108 patients underwent R-CABG after screening. Patients were propensity matched into 108 R-CABG and DES pairs according to vital statistic. Mortality, myocardial infarction (MI), stroke, repeat target lesion revascularization (r-TLR), main adverse cardiac and cerebral events (MACCE), and angina relief were compared across pairs.

RESULT

Kaplan-Meier estimates for R-CABG and DES had no significant difference in mortality (p = 1.00), MI (p = .32), Stroke (p = .80), and MACCE (p = .47), but the rate of r-TLR (p = .03) were lower in R-CABG group. Patients who underwent R-CABG had better angina relief (p = .02), lower rate of arrhythmia (p < .001), and recurrent angina (p = .02) after operation compared patients received DES.

CONCLUSION

R-CABG offers lower r-TLR rate and better angina relief compared with DES for revascularization in patients with isolated proximal LAD stenosis and there was no difference in mortality, MI, stroke, and MACCE between them.

Techniques and approaches for revascularisation of left heart coronary diseases

Coronary artery disease and its associated clinical sequelae are a significant medical burden to clinicians and patients. Severe coronary artery disease presenting in the context of acute myocardial ischaemia, or stable plaques causing chronic symptoms despite best conservative and pharmacological intervention, are often amenable to further intervention such as coronary artery bypass grafting. This procedure has been extensively compared to newer and less invasive techniques, such as percutaneous coronary intervention, and other minimally invasive procedures such as robotic or endoscopic techniques. This review summarises the current evidence on revascularisation of the left coronary artery system, with particular emphasis on key clinical endpoints of mortality, myocardial infarction, stroke and repeat revascularisation.

Reasons for Conversion and Adverse Intraoperative Events in Robotically Enhanced Minimally Invasive Coronary Artery Revascularization

OBJECTIVE

The transition from sternotomy access to minimally invasive coronary artery bypass grafting is associated with steep learning curves. This study reports the reasons for sternotomy conversions from robotically enhanced minimally invasive direct coronary artery bypass grafting (RE-MIDCAB) and describes potential risk reduction strategies.

METHODS

The perioperative data of 759 RE-MIDCAB patients (mean age 65.9 ± 10 years, 25.5% female, 30.2% multivessel disease) operated between July 1, 2002 and November 30, 2018 were reviewed for the reasons of conversion and adverse intraoperative events. Hybrid revascularization was planned in 204 (26.9%) patients.

RESULTS

Sternotomy conversion occurred in 30 (4.0%) patients. Lung adhesions and unsuccessful single-lung ventilation prohibited safe RE-MIDCAB internal thoracic artery (ITA) harvesting in 11 (36.7%) and 1 (3.3%) patients, respectively. ITA dysfunction (n = 11, 36.7%) and inadequate target vessel visualization (n = 3, 10.0%) were among the anatomical reasons for conversions. Adverse intraoperative events included ventricle perforation (n = 1, 3.3%) and sustained ventricular arrhythmia (n = 1, 3.3%). The in-hospital mortality and mean length of hospitalization for sternotomy conversion were 3.3% (n = 1 of 30) and 13.4 ± 14.5 days, respectively. Perioperative morbidities included pneumonia (n = 4, 13.3%). Premorbid renal dysfunction predicted sternotomy conversion at the 5% level of significance.

CONCLUSIONS

RE-MIDCAB provides an attractive surgical platform for primary- or hybrid coronary artery procedures. The progressive increase in patient risk profiles, strict quality control, and focus on clinical governance require awareness of reasons that potentially contribute RE-MIDCAB to sternotomy conversion to ensure safe and sustainable programs.

Sex-specific outcome after minimally invasive direct coronary artery bypass for single-vessel disease

OBJECTIVES

Female gender is reported as an independent risk factor for a poor outcome after coronary artery bypass grafting. We analysed the influence of gender on surgical outcome in patients with single-vessel disease undergoing minimally invasive direct coronary artery bypass (MIDCAB).

METHODS

From January 1998 to December 2016, a total of 607 consecutive patients with single-vessel disease (31.9% women) underwent MIDCAB at our institution. Major adverse cardiac and cerebrovascular events (MACCE) were recorded during a median follow-up period of 8.0 years. Survival time was estimated for all patients and after applying propensity score matching (138 women vs 138 men). Multivariable Cox regression analysis identified risk factors predicting a long-term mortality rate.

RESULTS

In women, a longer surgical time (125 vs 113 min; P &lt; 0.001) and a higher transfusion rate were recorded (13.0% vs 5.1%; P = 0.001) with similar rates of in-hospital deaths (1.0% vs 0.5%; P = 0.60) and MACCE (1.5% vs 0.7%; P = 0.39). Survival and MACCE-free survival during the follow-up period did not differ significantly between genders (P = 1.0, P = 0.36). Survival and MACCE-free survival rates after 5 years were 94% and 90% in women compared to 91% and 86% in men. Propensity score matching demonstrated improved long-term survival rates in women (P = 0.029). Insulin-dependent diabetes mellitus, postoperative atrial fibrillation and prolonged intensive care unit stay were associated with long-term deaths for both genders, whereas obesity, former myocardial infarction and preoperative atrial fibrillation were significant risk factors in men.

CONCLUSIONS

Female patients showed no adverse outcomes after MIDCAB, although risk factors were gender-specific. Overall, MIDCAB demonstrated excellent short- and long-term results as a treatment for single-vessel disease in both genders.

Comparison of Minimally Invasive Direct Coronary Artery Bypass and Percutaneous Coronary Intervention Using Second-Generation Drug-Eluting Stents for Coronary Artery Disease - Propensity Score-Matched Analysis

BACKGROUND

Some studies comparing minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI) have reported MIDCAB's superiority, but they did not investigate contemporary PCI with newer generation drug-eluting stents (DES). We compared clinical outcomes after MIDCAB with previously reported outcomes after PCI with second-generation DES.

METHODS AND RESULTS

We retrospectively reviewed the records of patients treated with MIDCAB. Baseline characteristics and clinical outcomes after MIDCAB were compared with those for left anterior descending artery disease treated via PCI. The primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), a composite of cardiovascular death, non-fatal myocardial infarction, ischemic stroke, and target vessel revascularization (TVR). A propensity score-matching (PSM) analysis was conducted to adjust for between-group differences in baseline characteristics. We analyzed 77 patients treated with MIDCAB and 2,206 treated with PCI. The MIDCAB group was older and had more severe coronary disease and a higher incidence of left ventricular dysfunction. Over a 3-year follow-up, the PCI group had favorable MACCE outcomes. After PSM, there were no between-group differences in MACCE (MIDCAB, 15.6% vs. PCI, 23.4%; hazard ratio [HR], 0.80; 95% CI: 0.38-1.68, P=0.548) or TVR (MIDCAB, 2.6% vs. PCI, 5.2%; HR, 0.51; 95% CI: 0.10-3.09, P=0.509).

CONCLUSIONS

Clinical outcomes were similar between MIDCAB and PCI using second-generation DES over 3 years of follow-up.

State-of-the-Art Coronary Artery Bypass Grafting: Patient Selection, Graft Selection, and Optimizing Outcomes

Despite the progressive expansion of clinical indications for percutaneous coronary intervention and the increasingly high risk profile of referred patients, coronary artery bypass grafting (CABG) remains the mainstay in multivessel disease, providing good long-term outcomes with low complication rates. Multiple arterial grafting, especially if associated with anaortic techniques, might provide the best longer-term outcomes. A surgical approach individualized to the patients' clinical and anatomic characteristics, and surgeon and team experience, are key to excellent outcomes. Current evidence regarding patient selection, indications, graft selection, and potential strategies to optimize outcomes in patients treated with CABG is summarized.

Short and long-term results of endoscopic atraumatic coronary artery off-pump bypass grafting in patients with left anterior descending artery stenosis

BACKGROUND

To perform a retrospective analysis of patients who underwent endoscopic atraumatic coronary artery off-pump bypass grafting (EACAB) in a single center over a period of 11 years.

METHODS

Data was acquired from the hospital registry and patient medical records. In order to determine changes in clinical profile, patients were subdivided into three groups regarding year of surgery: 1998-2002 (group 1), 2003-2005 (group 2), 2006-2009 (group 3). In-hospital analysis up to 30 days and long-term observation were conducted.

RESULTS

The study cohort consisted of 714 patients (581 male). Procedural success accounted for 99% of all patients. No mortality was observed up to 30 days. Complications in the early period included pleural effusion (7.6%), cardiac arrhythmias (3.6%), bleeding related revision (2.7%) and wound infection (1.6%). Mean follow-up was 6 years (2132 ± 1313 days; median: 1918.5). Nineteen (2.7%) patients died, of which 52.6% (10 patients) were due to heart related conditions. Overall frequency of major adverse cerebral and cardiovascular events (MACCE) was 10.8% (77 patients). The Kaplan-Meyer analysis defined survival rate and event-free survival in long-term observation of 96.1% and 85.3%, respectively. Ejection fraction (EF) < 50% was the only independent factor of mortality (OR: 3.35). Regarding cumulative MACCE, older age (OR: 1.72), lower EF (OR: 3.03), the history of percutaneous coronary intervention (OR: 2.13) and higher New York Heart Association class (OR: 2.63) influenced the incidence rate.

CONCLUSIONS

The presented short and very long-term results confirm that EACAB is an efficient alternative for patients requiring revascularization of the left anterior descending artery. The elimination of cardiopulmonary bypass significantly reduces the number of complications.

Minimally invasive coronary artery bypass grafting

Minimally invasive cardiac surgery (MICS)-CABG is a technique that at its core has patient comfort, early return to routine activities, meeting patient expectations for less invasive options, and maintaining the highest possible standards of care and outcomes. The technique requires not only surgical dexterity but also integration of significant technological advancements in patient care. At a time when percutaneous interventions are often prescribed on the pretext of increased patient comfort and demand, minimally invasive myocardial revascularization becomes even more relevant. Minimally invasive myocardial revascularization is ever evolving and encompasses both small-incision open techniques as well as endoscopic-assisted procedures. The success of the procedure depends not only on the learning curve and familiarity with the technology but also on appropriate patient selection. Mere feasibility of the technique is not sufficient, and the results have to be comparable with the long-established techniques of conventional coronary artery bypass grafting both in terms of early morbidity and mortality as well as long-term outcomes. In this review, we discuss patient selection and technical aspects of minimally invasive coronary artery bypass grafting. We also provide an evidence-based comparison to early and long-term outcomes with conventional coronary artery bypass grafting. Finally, we review the uptake and outcomes of minimally invasive revascularization in the Indian subcontinent.

Comparison of minimally invasive direct coronary artery bypass and drug-eluting stents for management of isolated left anterior descending artery disease: a systematic review and meta-analysis of 7,710 patients

BACKGROUND

In the contemporary era of drug-eluting stents (DES) the issue of optimal revascularization strategy for patients with isolated disease of the left anterior descending (LAD) artery has gained more significance. We aimed to evaluate the current best evidence on the subject by performing a systematic review and meta-analysis of the studies comparing minimally invasive direct coronary artery bypass (MIDCAB) grafting with DES in patients with isolated LAD disease.

METHODS

A literature search was conducted from 1966 through March 2018 using MEDLINE, EMBASE, and other scientific databases to identify relevant articles. Analyzed outcomes included all-cause mortality, myocardial infarction (MI), major adverse cardiac and cerebrovascular events (MACCE) and target vessel revascularization (TVR). The random effects model was used to calculate the outcomes of both binary and continuous data to control any heterogeneity between the studies. Heterogeneity amongst the trials was determined by means of the Cochran Q value and quantified using the I2 inconsistency test. All P values were 2-sided and a 5% level was considered significant.

RESULTS

A total of 7,710 patients from 12 studies were identified. There was no significant difference in mortality rate [pooled odds ratio (OR) =0.92; 95% confidence interval (CI), 0.65 to 1.32; P=0.66], MI rate (pooled OR =1.13, 95% CI, 0.62 to 2.06; P=0.69) or MACCE (pooled OR =1.31; 95% CI, 0.58 to 2.95; P=0.52). However, TVR rate was significantly more for patients having percutaneous intervention with DES (pooled OR =0.27; 95% CI, 0.16 to 0.45; P<0.0001) compared to MIDCAB.

CONCLUSIONS

MIDCAB offers superior freedom from TVR with similar mortality, MI rate, and MACCE compared to percutaneous intervention with DES for revascularization in patient with isolated proximal LAD stenosis.

Bilirubin coating attenuates the inflammatory response to everolimus-coated stents

The aim of this study was to evaluate the effects of bilirubin- and/or everolimus (EVL)-coated stents to prevent arterial neointimal hyperplasia and inflammation in vitro and in vivo. The stents were prepared by spray coating bare metal stents (BMS) with bilirubin and/or EVL. Study groups were divided into (1) BMS, (2) bilirubin-coated stents (BES), (3) commercialized stents (Synergy™; EES), and (4) bilirubin/EVL-coated stents (B-EES). The coating thickness and drug release rates were comparable to previous reports (i.e., <4 µm thickness and 50% drug release in 7 days). Smooth muscle cell migration was inhibited in both EVL-containing groups (20.5 ± 3.80% in EES and 18.4 ± 2.55% in B-EES) compared to the non-EVL-containing groups (78.0 ± 6.41% in BMS and 76.1 ± 4.88% in BES) (n = 10, p < 0.05). Stents were randomly implanted to 40 coronary arteries in 20 pigs and subjected to various analyses after 4 weeks of implantation. As results, the inflammation score was dramatically increased in the EES group (2.1 ± 0.42) compared to that of the other groups (1.5 ± 0.55, 1.3 ± 0.23, and 1.5 ± 0.27 for BMS, BES, and B-EES, respectively, n = 10, p < 0.05). Immunofluorescence analysis revealed that inflammation was prevented in the bilirubin-containing groups (BES and B-EES). However, the percent area of restenosis was decreased in the EVL-containing groups (20.5 ± 4.11% for EES and 18.4 ± 3.61% for B-EES) compared to the non-EVL-containing groups (32.3 ± 6.41% for BMS and 29.6 ± 5.95% for BES, n = 10, p < 0.05). The percent areas of restenosis determined by histopathology, optical coherence tomography, and micro-computed tomography were consistent. In addition, the stent was barely covered in the EES and B-EES groups at 4 weeks postimplantation. These dual drug-coated stents may be especially beneficial to patients who have an increased risk of inflammation. These stents have great potential for use in cardiovascular applications. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1486-1495, 2018.

Clinical Effect and Prognosis of Off-Pump Minimally Invasive Direct Coronary Artery Bypass

Background

Coronary artery bypass grafting (CABG) is a common procedure to circumvent the obstruction of coronary arteries when stents are unsuitable. CABG is a very traumatic surgery that requires redirecting blood flow to an external pump. Thus, this procedure has many risks during and after surgery, and minimizing these risks would greatly benefit the patients.

Material/Methods

We selected 126 patients with coronary artery syndrome and who were unsuitable for stent percutaneous coronary intervention. The observation group received minimally invasive direct coronary artery bypass (MIDCAB), while the control group was treated with off-pump CABG.

Results

Blood markers and echocardiography before and after treatment improved equally in both groups. Neither group exhibited obvious adverse reactions, or liver and kidney function damage. However, surgical bleeding and postoperative observation days were significantly reduced in the MIDCAB group. Death and cardiac shock at the end of follow-up were significantly lower in the MIDCAB group.

Conclusions

Overall, the clinical benefits of MIDCAB and OP-CABG were similar, but MIDCAB significantly reduced postoperative hospital stay and intraoperative blood transfusion, and improved clinical prognosis.

The future of off-pump coronary artery bypass grafting: a North American perspective

Off-pump coronary artery bypass graft (OPCAB) is currently performed routinely in a minority of specialized centers and in many more centers, utilized only when a porcelain aorta mandates a no-touch aortic technique. The OPCAB literature can be summarized as follows: (I) large-scale randomized trials in relatively low risk patients that include surgeons with a range of experience demonstrating no consistent beneficial differences in major cardiovascular and cerebrovascular outcomes but lower transfusion rates and shorter length of stay, tempered by some reports of higher rates of incomplete revascularization and lower rates of long term graft patency; (II) smaller randomized controlled trials (RCTs) from highly specialized programs demonstrating equivalent or superior outcomes with OPCAB and similar completeness of revascularization and graft patency; and (III) observational data from large databases demonstrating a consistent benefit of OPCAB, especially in higher-risk patient subsets. Our rationale for OPCAB remains that if complete and precise revascularization can be safely and routinely accomplished, then the patient should benefit by avoiding the morbidities that can be attributed to aortic cannulation/clamping, cardiopulmonary bypass (CPB), hemodilution, hypothermia and global myocardial ischemia/cardioplegia. We further believe that OPCAB procedures should emphasize the use of arterial grafts to optimize long term patency and minimize aortic manipulation to limit the risk of stroke. Moving forward, the off-pump surgical community and specialty societies must address the challenge of training surgeons and their teams to master this technically demanding procedure. Furthermore, OPCAB opens the door to minimally-invasive surgical revascularization via hybrid coronary revascularization (HCR). A large NIH-funded RCT is currently underway to determine whether hybrid revascularization can offer a superior alternative to multi-vessel percutaneous coronary intervention for patients with low SYNTAX score and proximal LAD disease.

Meta-Analysis of Percutaneous Coronary Intervention With Drug-Eluting Stent Versus Coronary Artery Bypass Grafting for Isolated Proximal Left Anterior Descending Coronary Disease

We performed a meta-analysis of the studies comparing the efficacy and safety of coronary artery bypass surgery against percutaneous coronary intervention with drug-eluting stents (PCI-DES) in patients with isolated LAD disease. Because of the limited randomized trial data, the optimal revascularization strategy for patients with isolated LAD disease remains uncertain. Using MEDLINE and EMBASE to source data, 11 studies (3 randomized trials and 8 cohort studies) including 5,044 participants were identified. No significant difference in mortality between PCI-DES and coronary artery bypass surgery (CABG; 111 of 2,122 [5.2%] and 120 of 2,574 [4.7%]; relative risk [RR] 1.23; 95% confidence interval [CI] 0.90 to 1.69) was detected. For MACE, PCI-DES was associated with significant increase in adverse events (RR 1.41; 95% CI 1.03 to 1.93, 8 studies, 4,230 participants). There were no significant differences in the risk of myocardial infarction (RR 0.86; 95% CI 0.58 to 1.26) or stroke (RR 2.36; 95% CI 0.54 to 10.43) between the 2 groups. There were 239 target vessel revascularization (TVR) events among 2,237 participants in the PCI-DES group (10.7%) and 145 TVR events among 2,793 participants in the CABG group (5.2%) with a significant increased risk of TVR in the PCI group (RR 2.52; 95% CI 1.69 to 3.77, 5,030 participants) compared with CABG. In conclusion, for patients with isolated disease of the LAD, meta-analysis of the available data suggests revascularization with a PCI-DES strategy offers similar mortality, MI, and stroke rates to CABG at the expense of increased TVR. Much of the data are derived from registries using first-generation DES, and further randomized trials with more contemporary platforms are needed.

Current state and future direction of hybrid coronary revascularization

PURPOSE OF REVIEW

The most optimal revascularization strategy in patients with multivessel coronary artery disease is a subject of ongoing debate. Hybrid coronary revascularization (HCR) aims to combine the advantages of both percutaneous and surgical revascularization in a single strategy. This review provides a timely overview of the use, practice patterns, clinical outcomes and future perspectives of HCR.

RECENT FINDINGS

A number of technological advances in stent technology and minimal invasive surgical techniques have enabled the use of HCR, in which the left internal mammary artery is grafted to the left anterior descending artery followed or preceded by percutaneous coronary intervention of non-left anterior descending artery lesions. Currently, HCR is reserved for a highly selected patient population, representing less than 1% of the total coronary artery bypass grafting volume in the United States. Clinical outcomes from observational studies as well as a randomized feasibility trial show encouraging results.

SUMMARY

HCR shows promising clinical results in patients with multivessel disease and/or left main involvement. Engagement from interventional and surgical communities, and adequate patient selection based on local expertise, and data from randomized controlled trials are needed to establish a permanent role in the armamentarium for coronary revascularization.

Cardiac surgery 2015 reviewed

For the year 2015, almost 19,000 published references can be found in PubMed when entering the search term "cardiac surgery". The last year has been again characterized by lively discussions in the fields where classic cardiac surgery and modern interventional techniques overlap. Lacking evidence in the field of coronary revascularization with either percutaneous coronary intervention or bypass surgery has been added. As in the years before, CABG remains the gold standard for the revascularization of complex stable triple-vessel disease. Plenty of new information has been presented comparing the conventional to transcatheter aortic valve implantation (TAVI) demonstrating similar short- and mid-term outcomes at high and low risk, but even a survival advantage with transfemoral TAVI at intermediate risk. In addition, there were many relevant and interesting other contributions from the purely operative arena. This review article will summarize the most pertinent publications in the fields of coronary revascularization, surgical treatment of valve disease, heart failure (i.e., transplantation and ventricular assist devices), and aortic surgery. While the article does not have the expectation of being complete and cannot be free of individual interpretation, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.

Repeat revascularization: Percutaneous coronary intervention after coronary artery bypass graft surgery

Repeat myocardial revascularization procedures are markedly different from de novo interventions, with increased procedural risk and technical-demanding complexity. However the number of patients previously treated with coronary artery bypass graft (CABG) that need a repeat revascularization due to graft failure is increasing consistently. Late graft failure, usually caused by saphenous vein grafts (SVG) attrition, is certainly not uncommon. However PCI on degenerated SVG presents higher complication rate and worse clinical outcome compared with native arteries interventions. In acute graft failure setting, PCI represents a valuable option to treat postoperative myocardial infarction.

Prednisolone- and sirolimus-eluting stent: Anti-inflammatory approach for inhibiting in-stent restenosis

Glucocorticoids are powerful anti-inflammatory, immunosuppressive, and anti-proliferative agents. The aim of this study was to evaluate the effectiveness of a prednisolone- (PDScs) and sirolimus-coated stent (SRLcs) in preventing artery vessel neointimal hyperplasia and inflammatory reactions in vitro and in vivo. PDS, a synthetic glucocorticoid, is a derivative of cortisol, which is used to treat a variety of inflammatory and autoimmune conditions. The stents were fabricated with PDS, SRL, or both agents using a layer-by-layer coating system (designated as PDScs, SRLcs, and PDSRLcs, respectively). The surface morphology of the PDScs showed an evenly dispersed and roughened shape, which was smoothened by the SRL coating. Half of the total drug amounts were released within seven days, followed by an additional release, which continued for up to 28 days. The proliferation of smooth muscle cells was inhibited in the SRLcs group (31.5 ± 4.08%), and this effect was enhanced by PDS addition (PDSRLcs, 46.8 ± 8.11%). Consistently, in the animal study, the restenosis rate was inhibited by the SRLcs and PDSRLcs (18.5 ± 6.23% and 14.5 ± 3.55%, respectively). Especially, fibrin expression and inflammation were suppressed in the PDS-containing group (PDScs, 0.6 ± 0.12 and 1.4 ± 0.33; PDSRLcs, 0.7 ± 0.48 and 1.7 ± 0.12, respectively) compared to PDS non-containing groups (BMS, 1.1 ± 0.12, and 1.8 ± 0.55; SRLcs, 1.6 ± 0.32 and 2.0 ± 0.62, respectively). Moreover, re-endothelialization was enhanced in the PDScs group as determined using immunohistochemistry with a cluster of differentiation (CD)-31 antibodies. These results suggest that the inhibitory effect of SRLcs on anti-restenosis can be accelerated by additional coating with PDS, which has promising properties as a bioactive compound with useful anti-inflammatory effects.