Clinical outcome of patients undergoing multivessel coronary stent implantation

Trials comparing coronary artery bypass grafting with percutaneous transluminal coronary angioplasty and primary stent implantation in patients with multivessel coronary artery disease

With marked improvements in stent technology as adjunct to balloon angioplasty for multivessel coronary disease, several newer trials are currently in progress reviewing the optimal revascularization strategy. This review provides background from older studies and addresses the current progress and design of these newer trials.

Multivessel coronary stenting versus bypass surgery in patients with multivessel coronary artery disease and normal left ventricular function: immediate and 2-year long-term follow-up

BACKGROUND

Compared with coronary artery bypass surgery (CABG), the clinical benefits of intracoronary stenting have not been established in patients with multivessel coronary lesions.

METHODS AND RESULTS

To compare the clinical outcomes of intracoronary stenting with that of CABG, we reviewed the outcomes of patients with multivessel coronary artery disease from an observational database. Two hundred consecutive patients with multivessel coronary artery disease and normal left ventricular function were evaluated. In 200 patients, multivessel stenting was performed in 100 and CABG was performed in 100. Complete revascularization was achieved in 95% in the CABG group and in 69% in the stent group (P <.05). The duration of total hospital stay and coronary care unit admission was significantly shorter in the stent group (P <.05). The long-term survival was similar between the 2 groups. There were no significant differences of cardiac events between the 2 groups except for the recurrence of angina (19% in stenting vs 8% in CABG, P =.03) and target lesion revascularization (19% vs 2%, P <.01) in the patients with stents.

CONCLUSIONS

In selected patients with multivessel coronary artery disease and normal left ventricular function, intracoronary stenting may offer an effective alternative to coronary bypass surgery.

Clinical outcome after multivessel coronary stent implantation

BACKGROUND

Percutaneous transluminal coronary angioplasty (PTCA) has been shown to be an effective therapy for multivessel coronary artery disease, although more frequent acute complications and an increased need to repeat revascularization than with single-vessel PTCA continue to be limitations. Intracoronary stent placement has been shown to reduce the rate of acute complications and the need for subsequent revascularization. We sought to evaluate the outcome among patients undergoing successful multivessel coronary intervention with stents.

METHODS

The participants were 175 patients without coronary artery bypass grafts who underwent multivessel coronary revascularization in which stent placement was attempted in all treated segments from January 1992 through March 1998 at our institution. Clinical and angiographic characteristics and outcomes were analyzed.

RESULTS

Stent placement was attempted for 428 coronary lesions. The angiographic success rate was 100%. Modified American College of Cardiology-American Heart Association type B2 and C lesions accounted for 74.5% of the lesions. Three patients (1.7%) died in the hospital. No patient had Q-wave myocardial infarction or needed coronary artery bypass grafting. Procedural success was achieved for 172 patients (98.3%). The Kaplan-Meier probability of freedom from death or myocardial infarction at 12 months was 96.6%, of any revascularization was 81. 7%, and of death, myocardial infarction, and any revascularization combined was 79.8%. The use of long-acting nitrates at 12 months was reduced (34.3% versus 19.1%, P =.01).

CONCLUSIONS

Multivessel coronary stent placement is associated with an excellent procedural success rate despite a high rate of adverse lesion characteristics and a high event-free survival rate during the follow-up period. The likelihood that revascularization will not have to be repeated during the first follow-up year is significantly better than that for historic controls of multivessel PTCA.

Baseline clinical and angiographic variables associated with long-term outcome after successful intracoronary stent implantation

Although randomized studies have demonstrated improved outcomes with stents over balloon angioplasty in straightforward coronary narrowings in low-risk patients, this advantage is less clear for complex lesions and high-risk patients. This study was designed to identify clinical and angiographic variables that are associated with long-term outcome after stent implantation. We identified 1,709 patients undergoing successful stent placement without in-hospital major adverse events. We analyzed clinical, lesional, and procedural variables to determine their correlation with outcome. Mean duration of follow-up was 1.6 +/- 1.4 years. Cox proportional-hazards models and stepwise methods were used to assess which covariates were potentially related to each end point. The occurrence of death/myocardial infarction (MI) was associated with any history of congestive heart failure (relative risk [RR] 3.3, 95% confidence interval [CI] 2.3 to 4.7, p <0.0001), procedure within 24 hours of MI (RR 2.3, CI 1.3 to 4.1, p = 0.0048), vein graft intervention (RR 1.8, CI 1.3 to 2.6, p = 0.0007), and prior MI (RR 1.8, CI 1.2 to 2.6, p = 0.004). Repeat revascularization was associated with multivessel stent placement (RR 1.8, CI 1.2 to 2.8, p = 0.006) and stent for abrupt closure (RR 1.7, CF 1.1 to 2.7, p = 0.03), but was less frequent with de novo lesions and right coronary artery lesions (RR 0.6, CI 0.5 to 0.8, p = 0.0007, and RR 0.8, CI 0.6 to 1.0, p = 0.05, respectively). The cumulative end point of death/MI/repeat revascularization was associated with congestive heart failure (RR 1.7, CI 1.3 to 2.2, p <0.0001), multivessel stent placement (RR 1.6, Cl 1.1 to 2.3, p = 0.03), warfarin therapy (RR 1.4, CI 1.2 to 1.8, p = 0.001), and procedure within 24 hours of MI (RR 1.5, CI 1.1 to 2.1, p = 0.02), but was less frequent with complete revascularization and right coronary artery intervention (RR 0.8, CI 0.7 to 0.99, p = 0.04, and RR 0.7, CI 0.6 to 0.9, p = 0.009, respectively). Thus, this study demonstrates that there are readily identifiable characteristics in patients treated successfully with stents that are associated with long-term outcome.