Recurrent Revascularization at 10 Years After Percutaneous Treatment of Drug-Eluting Stent Restenosis

Age-related ten-year outcomes after percutaneous coronary intervention of in-stent restenosis

BACKGROUND

Older patients are often underrepresented in clinical trials investigating the treatment of coronary drug-eluting stent (DES) restenosis, but outcome data is urgently needed in an ageing society. Thus, the aim of this observational, retrospective study was to close this lack of evidence.

METHODS

Between January 2007 and February 2021, 3511 patients with 5497 in-stent restenosis (ISR) lesions were treated at two large-volume centers in Munich, Germany. We compared the rates of cardiac death, myocardial infarction (MI) and repeat revascularization in 1105 patients (31.5 %) older than 75 years with 2406 patients (68.5 %) younger than 75 years. Survival was analyzed using the Kaplan-Meier method. Differences between the groups were tested with the log-rank test. Conventional multivariable analysis with adjustment for relevant variables was performed.

RESULTS

Older patients were more frequently female (30.1 % vs. 17.9 %, p < 0.001) and presented less frequently with stable angina (67.8 % vs. 72.0 %, p < 0.001). After 10 years, the rates of cardiac death were 56.8 % in older patients and 27.4 % in younger patients (HRadj, 2.45 [95 % CI, 2.09-2.88], p < 0.001). Accounting for the risk of death, no difference was found regarding the rates of MI while target lesion revascularization (TLR) occurred less frequently in older patients (24.2 % vs. 33.7 %; HRadj, 0.77 [95 % CI, 0.66-0.89], p < 0.001).

CONCLUSIONS

In the long-term, rates of cardiac death after percutaneous coronary intervention of DES-ISR were higher and TLR rates were lower in patients older than 75 years. There was no difference in the rates of MI.

Optical coherence tomography versus angiography to guide percutaneous coronary intervention in patients with in-stent restenosis: an observational study

BACKGROUND

Although optical coherence tomography (OCT) guidance with the 'MLDMAX' criteria is very useful for de-novo lesions during percutaneous coronary intervention (PCI), there are limited studies on its benefits in patients with in-stent restenosis (ISR). This study aimed to compare the clinical outcomes of patients with ISR who underwent repeat PCI (re-PCI) with OCT or angiographic guidance.

METHODS

This retrospective study enrolled 2142 patients with ISR who underwent re-PCI at Nanjing First Hospital from January 2016 to January 2023. The primary endpoint was the incidence of target vessel failure (TVF) post-re-PCI within 3 years. The secondary endpoints included each component of TVF.

RESULTS

After propensity score matching, 161 matched pairs were enrolled. OCT guidance of re-PCI was associated with a significantly lower risk of TVF compared with angiographic guidance alone [hazard ratio (HR), 0.51; 95% confidence interval (CI), 0.31-0.83; P  = 0.007] in patients with ISR. However, only 68.9% of patients with ISR met the final criteria of 'MLDMAX' post-re-PCI, which was associated with a lower risk of TVF compared with patients without meeting the OCT criteria (HR, 0.24; 95% CI, 0.11-0.54; P  < 0.001), and satisfied the angiographic criteria (HR, 0.40; 95% CI, 0.19-0.85; P  = 0.017).

CONCLUSION

Compared with angiographic guidance, OCT guidance significantly reduced TVF risk following re-PCI for ISR lesions, especially for patients who met the final criteria of 'MLDMAX'.

Ten-year clinical outcomes after left main coronary artery stenting with new-generation or early-generation DES

INTRODUCTION AND OBJECTIVES

Long-term data after stenting of the left main coronary artery (LMCA) are scarce, especially regarding new-generation drug-eluting stents (DES). This analysis aimed to describe the 10-year clinical outcomes of patients who underwent percutaneous coronary intervention with different DES generations for LMCA disease.

METHODS

Individual patient data from the randomized controlled ISAR-LEFT MAIN and ISAR-LEFT MAIN 2 trials were pooled and 10-year clinical follow-up was obtained. The Kaplan-Meier method was used to calculate event rates. The main endpoints of interest for this analysis were all-cause mortality, myocardial infarction, target lesion revascularization and definite stent thrombosis.

RESULTS

A total of 1257 patients were included in this analysis, of which 650 patients were treated with new-generation DES and 607 with early-generation DES. At 10 years, the mortality rate was more than 40% in both groups. After statistical adjustment, 10-year mortality was significantly reduced in patients treated with new-generation DES compared with those treated with early-generation DES (HRadj, 0.78; 95%CI, 0.62-0.97). After 10 years, the risk of myocardial infarction (HRadj, 0.43; 95%CI, 0.23-0.80), target lesion revascularization (HRadj, 0.66; 95%CI, 0.49-0.89), and definite stent thrombosis (HRadj, 0.13, 95%CI, 0.04-0.49) was significantly reduced by new-generation DES compared with early-generation DES.

CONCLUSIONS

Patients undergoing percutaneous coronary intervention for LMCA disease have high 10-year mortality regardless of DES generation. The use of new-generation DES in patients with LMCA disease is associated with improved long-term clinical outcomes compared with early-generation DES.

Solanum lycopersicum derived exosome-like nanovesicles alleviate restenosis after vascular injury through the Keap1/Nrf2 pathway

Despite the significant alleviation of clinical cardiovascular diseases through appropriate interventional treatments, the recurrence of vascular restenosis necessitating reoperation remains a substantial challenge impacting patient prognosis. Plant-derived exosome-like nanovesicles (PELNs) are integral to interspecies cellular communication, with their functions and potential applications garnering significant attention from the research community. This study extracted Solanum lycopersicum-derived exosome-like nanovesicles (SL-ELNs) and demonstrated their inhibition of PDGF-BB-induced proliferation, migration, and phenotypic transformation of vascular smooth muscle cells (VSMCs). Mechanistically, miRNA164a/b-5p within the SL-ELNs reduced the expression of Keap1 mRNA, thereby increasing nuclear translocation of Nrf2 and enhancing the expression of antioxidant genes to alleviate oxidative stress. In a mouse carotid artery injury model, it was further confirmed that miRNA164a/b-5p within the SL-ELNs could inhibit neointimal hyperplasia. These results suggest that SL-ELNs inhibit VSMCs proliferation, migration, and phenotypic transformation, and they might be potential therapeutic agents for the prevention or treatment of restenosis.

Paclitaxel-Coated Balloon Versus Uncoated Balloon Angioplasty for Coronary In-Stent Restenosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

In-stent restenosis (ISR) accounts for 10% of percutaneous coronary intervention (PCI) in the United States. Paclitaxel-coated balloons (PCBs) have been evaluated as a therapy for coronary ISR in multiple randomized controlled trials (RCTs). We searched PubMed/MEDLINE, Cochrane Library, and ClinicalTrials.gov (from inception to April 1, 2024) for RCTs evaluating PCBs versus uncoated balloon angioplasty (BA) in patients with coronary ISR. The outcomes of interest were target lesion revascularization (TLR), major adverse cardiovascular events (MACEs), all-cause mortality, cardiovascular mortality, myocardial infarction (MI), and stent thrombosis. We pooled the estimates using an inverse variance random-effects model. The effect sizes were reported as risk ratio (RR) with 95% confidence interval (CI). A total of 6 RCTs with 1,343 patients were included. At a follow-up ranging from 6 to 12 months from randomization, the use of PCBs was associated with a statistically significant decrease in TLR (RR 0.28, 95% CI 0.11 to 0.68) and MACE (RR 0.35, 95% CI 0.20 to 0.64) compared with BA for coronary ISR. However, there was no significant difference in risk between PCBs and BA in terms of all-cause mortality (RR 0.56, 95% CI 0.14 to 2.31), cardiovascular mortality (RR 0.61, 95% CI 0.02 to 16.85), MI (RR 0.60, 95% CI 0.27 to 1.31), and stent thrombosis (RR 0.13, 95% CI 0.00 to 5.06). In conclusion, this meta-analysis suggests that PCBs compared with uncoated BA for the treatment of coronary ISR at intermediate-term follow-up of 1 year were associated with a significant decrease in TLR and MACE without any difference in mortality, MI, or stent thrombosis.

Comparative long-term efficacy and safety of two paclitaxel-coated balloons with different coating strategies for the treatment of drug-eluting coronary stent restenosis

BACKGROUND

We previously showed non-inferiority of a low-dose paclitaxel-coated balloon (PCB) with citrate excipient (Agent PCB) as compared to normal-dose iopromide excipient (SeQuent Please PCB) in terms of angiographic and clinical endpoints at 12 months. The long-term clinical efficacy and safety of Agent PCB is not defined.

METHODS

262 patients (323 DES-ISR lesions) were enrolled in this study and treated with either Agent PCB (125 patients, 151 lesions) in the ISAR-DESIRE 3a trial or with SeQuent Please PCB (137 patients, 172 lesions) in the setting of the randomized ISAR-DESIRE 3 trial with similar in- and exclusion criteria serving as historical control arm. The follow-up period was extended to 7 years. The efficacy and safety endpoints of this analysis were target-lesion revascularization (TLR), death, myocardial infarction (MI) and target lesion thrombosis (TLT) at 7 years.

RESULTS

At 7 years, 206 patients (78.6%) were alive. The risks of TLR (hazard ratio [HR]: 1.29, 95% confidence interval [CI]: 0.87-1.90; p = 0.205), death (HR: 1.38, 95% CI: 0.82-2.35; p = 0.227), MI (HR: 1.10, 95% CI: 0.39-3.15; p = 0.852) and TLT (HR: 2.18, 95% CI: 0.20-24.10; p = 0.523) were comparable between Agent PCB and SeQuent PCB. Multivariate analysis showed comparable risks of TLR, death and MI between both PCB devices.

CONCLUSIONS

In patients treated for DES-ISR by angioplasty with Agent PCB and SeQuent Please PCB, there was no statistically significant difference in TLR at 7 years. Randomized trials with standardized lesion preparation and long-term follow-up are warranted to further evaluate comparative efficacy of both devices. (ClinicalTrials. gov Identifier: NCT02367495).