Long term outcome after coronary stent implantation: a 10 year single centre experience of 1000 patients

Clair JR, Knowlton KU, Khan ND, Bhalla N, Anderson JL. Contemporary Predictors of Major Adverse Cardiovascular Events Following Percutaneous Coronary Intervention: A Nationally Representative US Sample

Background: Patient outcomes after percutaneous coronary intervention (PCI) have improved over the last 30 years due to better techniques, therapies, and care processes. This study evaluated contemporary predictors of post-PCI major adverse cardiovascular events (MACE) and summarized risk in a parsimonious risk prediction model. Methods: The Cardiovascular Patient-Level Analytical Platform (CLiPPeR) is an observational dataset of baseline variables and longitudinal outcomes from the American College of Cardiology's CathPCI Registry® and national claims data. Cox regression was used to evaluate 2-6 years of patient follow-up (mean: 2.56 years), ending in December 2017, after index PCI between 2012 and 2015 (N = 1,450,787), to examine clinical and procedural predictors of MACE (first myocardial infarction, stroke, repeat PCI, coronary artery bypass grafting, and mortality). Cox analyses of post-PCI MACE were landmarked 28 days after index PCI. Results: Overall, 12.4% (n = 179,849) experienced MACE. All variables predicted MACE, with cardiogenic shock, cardiac arrest, four diseased coronary vessels, and chronic kidney disease having hazard ratios (HRs) ≥ 1.50. Other major predictors of MACE were in-hospital stroke, three-vessel disease, anemia, heart failure, and STEMI presentation. The index revascularization and discharge prescription of aspirin, P2Y12 inhibitor, and lipid-lowering medication had HR ≤ 0.67. The primary Cox model had c-statistic c = 0.761 for MACE versus c = 0.701 for the parsimonious model and c = 0.752 for the parsimonious model plus treatment variables. Conclusions: In a nationally representative US sample of post-PCI patients, predictors of longitudinal MACE risk were identified, and a parsimonious model efficiently encapsulated them. These findings may aid in assessing care processes to further improve care post-PCI outcomes.

Prospective Cohort Study of Soluble Urokinase Plasminogen Activation Receptor and Cardiovascular Events in Patients With CKD

Introduction

Soluble urokinase plasminogen activation receptor (suPAR) is an immune-derived pathogenic factor for kidney and atherosclerotic disease. Whether the association between suPAR and cardiovascular (CV) outcomes is dependent on the severity of underlying kidney disease is unclear.

Methods

We measured serum suPAR levels in 4994 participants (mean age 60 years; 60% men; 36% with diabetes mellitus; mean estimated glomerular filtration rate (eGFR) 49 ml/min per 1.73 m2, SD 18) of the German Chronic Kidney Disease (GCKD) cohort and examined its association with all-cause death, CV death, and major CV events (MACE) across the range of eGFR and urine albumin-to-creatinine ratio (UACR).

Results

The median suPAR level was 1771 pg/ml (interquartile range [IQR] 1447-2254 pg/ml). SuPAR levels were positively and independently correlated with age, eGFR, UACR, and parathyroid hormone levels. There were 573 deaths, including 190 CV deaths and 683 MACE events at a follow-up time of 6.5 years. In multivariable analyses, suPAR levels (log2) were associated with all-cause death (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.21-1.53), CV death (HR 1.27, 95% CI 1.03-1.57), and MACE (HR 1.13, 95% CI 1.00-1.28), and were not found to differ according to diabetes mellitus status, baseline eGFR, UACR, or parathyroid hormone levels. In mediation analysis, suPAR's direct effect on all-cause death, CV death, and MACE accounted for 77%, 67%, and 60% of the total effect, respectively; whereas the effect mediated through eGFR accounted for 23%, 34%, and 40%, respectively.

Conclusion

In a large cohort of individuals with chronic kidney disease (CKD), suPAR levels were associated with mortality and CV outcomes independently of indices of kidney function, consistent with its independent role in the pathogenesis of atherosclerosis.

Life-long clinical outcome after the first myocardial revascularization procedures: 40-year follow-up after coronary artery bypass grafting and percutaneous coronary intervention in Rotterdam

OBJECTIVES

Our goal was to evaluate the outcomes of the first patients treated by venous coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCIs) with balloon angioplasty at a single centre who have reached up to 40 years of life-long follow-up.

METHODS

We analysed the outcomes of the first consecutive patients who underwent (venous) CABG (n = 1041) from 1971 to 1980 and PCI (n = 856) with balloon angioplasty between 1980 and 1985. Follow-up was successfully achieved in 98% of patients (median 39 years, range 36-46) who underwent CABG and in 97% (median 33 years, range 32-36) of patients who had PCI.

RESULTS

The median age was 53 years in the CABG cohort and 57 years in the PCI cohort. A total of 82% of patients in the CABG group and 37% of those in the PCI group had multivessel coronary artery disease. The cumulative survival rates at 10, 20, 30 and 40 years were 77%, 39%, 14% and 4% after CABG, respectively, and at 10, 20, 30 and 35 years after PCI were 78%, 47%, 21% and 12%, respectively. The estimated life expectancy after CABG was 18 and 17 years after the PCI procedures. Repeat revascularization was performed in 36% and 57% of the patients in the CABG and PCI cohorts, respectively.

CONCLUSIONS

This unique life-long follow-up analysis demonstrates that both CABG and PCI were excellent treatment options immediately after their introduction as the standard of care. These procedures were lifesaving, thereby indirectly enabling patients to be treated with newly developed methods and medical therapies during the follow-up years.

Factors Affecting In-stent Restenosis in Patients Undergoing Percutaneous Coronary Angioplasty

Percutaneous coronary angioplasty (PCI) and stent implantation are the most common therapeutic strategies for coronary artery stenosis; however, in-stent restenosis (ISR) is one of its important challenges. Although in some studies, coronary artery disease (CAD) factors are deemed to be the causes of ISR, in some others, the relationship between CAD factors and ISR are not observed. Over the past ten years, there has been no review article on factors affecting the ISR. This article aimed to review the possible factors affecting ISR in patients undergoing PCI. This narrative review study was conducted on PubMed, Web of Science, Scopus, and Google Scholar databases between 1 January 1990 and 30 July 2017. After initial screening of 1728 retrieved articles, 1401 articles were excluded to due irrelevancy to the review; and finally, 39 papers were selected for data collection. Our study results showed that the site and length of implanted stent, hypertension and diabetes are the most probable factors affecting ISR. Further studies are required for evaluation of the effect of other possible risk factors such as genetic sequencing, obesity, chronic infections and hemoglobin A1C levels.

Comparison of very long-term clinical and angiographic outcomes of bare metal stent implants between patients with and without type 2 diabetes

BACKGROUND

Data on a large patient population regarding very long-term outcomes after bare metal stent (BMS) implantation in diabetic patients are lacking. The aim of this study was to evaluate the very long-term (8-17 years) clinical and 6-month angiographic outcomes of BMS implantations in patients with and without type 2 diabetes.

METHODS AND RESULTS

A total of 2391 patients (579 with and 1812 without diabetes) who received BMS implantations between November 1995 and May 2004 were enrolled from the Cardiovascular Atherosclerosis and Percutaneous TrAnsluminal INterventions (CAPTAIN) registry into this study. During a mean follow-up period of 152±53months, the diabetic patients had higher rates of all-cause mortality (28% vs. 15%, p<0.001), re-infarction (6% vs. 5%, p=0.284), target lesion revascularization (13% vs. 10%, p=0.049), and a lower cardiovascular event-free survival rate (42% vs. 56%, p<0.001) compared to the patients without diabetes. The diabetic patients also had a higher restenosis rate (26% vs. 18%, p<0.001) at 6-month angiographic follow-up. The multivariate analysis of risk factors for cardiac event-free survival included age (hazard ratio [HR]: 1.011; p=0.001), hypertension (HR: 1.168; p=0.011), diabetes mellitus (HR: 1.353; p<0.001), pre-existing coronary artery disease (HR: 1.341; p<0.001), and left ventricular ejection fraction (LVEF) (HR: 0.992; p=0.002) (Table 7). The Kaplan-Meier analysis showed a significant difference in cardiovascular event-free survival rate between the two groups (p<0.001).

CONCLUSION

The clinical and angiographic outcomes of diabetic patients with BMS implantations were worse than those of patients without diabetes after a very long-term follow-up period.

Association between RDW and stent thrombosis in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Stent thrombosis is a rare but potentially fatal complication of percutaneous coronary interventions (PCIs). In recent years, the predictive and prognostic value of the red cell distribution width (RDW) as an indicator of inflammation has been shown in many cardiovascular diseases. Aim of this study was to examine the predictive value of RDW for stent thrombosis in patients who underwent successful stent implantation for ST-elevation myocardial infarction (STEMI).In this retrospective study, 146 patients who underwent successful PCI to native coronary artery due to STEMI previously and presented with acute coronary syndrome with stent thrombosis were included (stent thrombosis group). A total of 175 patients who had similar procedural characteristics (type, diameter, and length of stent) and not had stent thrombosis were consisted control group.Patients were divided into tertiles according to the admission RDW values (12.9 ± 0.4, 14.2 ± 0.4, and 16.3 ± 1.5, respectively). Stent thrombosis developed in 47 (40.9%) patients in the lowest tertile, 39 (37.9%) patients in mid tertile, and 60 (58.3%) patients in the highest tertile (P = 0.006). Female gender ratio was statistically significantly higher in the 3rd tertile (13 [11.3%], 8 [7.8%], 24 [23.3%], P = 0.003, respectively). RDW (OR: 1.397 [95% CI 1.177-1.657], P < 0.001) and platelet count (OR: 1.008 [95% CI 1.004-1.012], P < 0.001) remained independent predictors of stent thrombosis after multivariate logistic regression analysis. ROC curve analysis demonstrated that, admission RDW values higher than 13.9 can predict the development of stent thrombosis with a sensitivity of 57% and a specificity of 52% (The area under the ROC curve: 0.59 [95% CI 0.53-0.65] P = 0.007).High RDW values found to be independently associated with the development of stent thrombosis in patients with STEMI.

Long-term (>3 Years) Clinical and Angiographic Outcomes of Coronary Multilink Stent Implantations: A Single Center Experience

The ACS Multilink (ML) stent is a novel second-generation stent. The largest amount of information available on the long-term outcome of coronary stenting is based on the use of Palmaz-Schatz stents. Fewer data exist on long-term follow-up results of ML coronary stents implantations. The authors present the long-term (>3 years) clinical and angiographic follow-up results of the ACS Multilink coronary stents implanted in their institution. From May 1996 to December 1997, 125 patients underwent 133 coronary ML stent implantations. Stented vessels were as follows: 49% left anterior descending artery, 31% right coronary artery, and 20% left circumflex coronary artery. Indications for stent implantations were elective in 64%, because of suboptimal result from percutaneous transluminal coronary angioplasty (PTCA) in 26%, and bailout from PTCA in 10% of patients. The mean reference diameter of stented vessels was 3.2 ±0.2 mm. The mean percentage stenosis was 80 ±11% and 3 ±5% before and after stent implantation, respectively. Long-term clinical follow-up was completed in 75% (80 men, mean age 53 ±10 years) of the patients (either by interview or phone), and angiographic follow-up (37 ±12 months) was completed in 58% of the patients. There were no baseline clinical or angiographic differences between those angiographically followed up and the remaining patients. Angiographic restenosis (>50% diameter stenosis) was detected in 22% of stents. Target lesion revascularization was 12%, nontarget lesion revascularization was 14% in angiographically followed up patients. During the follow-up period death and new myocardial infarction occurred in 12% and 6% of patients, respectively, and survival rate was 88%. This study provides long-term follow-up results of intracoronary Multilink stent implantations for native coronary artery lesions. These data show that clinical and angiographic benefits of ML stents are comparable to those of the first-generation stents, especially to the Palmaz-Schatz stents, of which results have been reported previously. A considerable rate of nontarget lesion revascularization occurs during the follow-up period.

Clinical and angiographic outcomes after intracoronary bare-metal stenting

Background

Data from a large patient population regarding very long-term outcomes after BMS implantation are inadequate. This study aimed to evaluate the very long-term (8–17 years) clinical and long-term (3–5 years) angiographic outcomes after intracoronary bare-metal stenting (BMS).

Methods and Results

From the Cardiovascular Atherosclerosis and Percutaneous TrAnsluminal INterventions (CAPTAIN) registry, a total of 2391 patients with 2966 lesions treated with 3190 BMSs between November 1995 and May 2004 were evaluated. In total, 1898 patients with 2364 lesions, and 699 patients with 861 lesions underwent 6-month and 3- to 5- year angiographic follow-up, respectively. During a mean follow-up period of 149±51 months, 18.6% of the patients died (including 10.8% due to cardiac death), 6.1% developed reinfarction, 16.2% had target lesion revascularization (including 81% of the patients within the first year), 14.5% underwent new lesion stenting (including 72% of the patients after 3 years), 2.4% underwent coronary bypass surgery, and 1.6% had definite stent thrombosis. The overall cardiovascular event-free survival rate was 58.5%. The 6-month angiographic study indicated a 20% restenosis rate. The minimal luminal diameter increased from 0.65±0.44 mm to 3.02±0.46 mm immediately after stenting, decreased to 2.06±0.77 mm at the 6-month follow-up, and increased to 2.27±0.68 mm at the 3- to 5-year follow-up.

Conclusions

This study provides clinical and angiographic results from a large population of patients who underwent BMS implantations after a long-term follow-up period (149±51 months). The progression of coronary atherosclerosis developed over time, and presented with new lesion required stent implantation. The follow-up angiographic findings reconfirmed the late and sustained improvement in luminal diameter between 6 months and 3–5 years.

Mid-term outcomes after off-pump coronary surgery in patients with prior intracoronary stent

OBJECTIVE

An increasing number of patients undergoing heart surgery have had a prior coronary stent placement. This study was designed to examine the effect of this situation on the mid-term outcomes of off-pump coronary artery bypass graft (OP-CABG) surgery.

METHODS

A comparative retrospective non-randomized comparison was performed as follows: all patients undergoing OP-CABG from January 2005 to December 2009 at our centre were divided into two groups: those who did or did not have stents at the time of surgery. We compared the incidences of the following events: (i) death and (ii) combined major adverse cardiac events (MACEs): death, myocardial infarction (MI) and repeat revascularization. Cox's proportional hazards analysis adjusted by a propensity score (n:m) were performed to determine the effects of prior stent placement on the risks of such events.

RESULTS

A total of 1020 patients were included, of which 156 (15.6%) had at least one stent. The median follow-up was 32.32 months (interquartile rank 18.08-48). The overall 1, 3 and 5-year survival rates were 95, 92 and 91% for the without-stent group vs. 82, 77 and 74% for the with-stent group, respectively. The 1, 3 and 5-year survival rates free from MACEs were: 92, 87 and 76% for patients without stent vs. 77, 66 and 56% for those with stents. Patients with stent showed an increased risk of death [hazard ratio (HR) 3.631, 95% confidence interval (CI) 2.29-5.756] and MACEs (HR 2.784, 95% CI 1.962-3.951). When adjusted by the propensity score, prior stent placement continued to increase the risks of death (HR 3.795, 95% CI 2.319-6.21) and MACEs (HR 2.89, 95% CI 2.008-4.158).

CONCLUSIONS

Patients with intracoronary stents have a lower survival rate and a greater risk of death, MI or need for repeat revascularization during the mid-term follow-up after OP-CABG.

Acute myocardial infarction late following stent implantation: Incidence, mechanisms and clinical presentation

Acute myocardial infarction (AMI) can occur late following stent implantation with an incidence up to >6% at 3-4 years, with no difference between DES and BMS. AMI can originate either from the stented site or from disease progression at nonstented sites. Restenosis, against previous thoughts, can lead to AMI. Stent thrombosis occurs with similar overall frequency following DES and BMS implantations, although a higher very late stent thrombosis with DES has been observed. Dissimilar mechanisms between BMS and DES thrombosis are very likely, with impaired neointimal healing being the rule for DES but the exemption for BMS. The use of invasive imaging techniques is useful in elucidating the involved mechanism. Disease progression is a particularly important cause of AMI late post stenting. The angiographic study depicted stent failure and disease progression equally implicated in the AMI late post stenting. When the AMI underlying mechanism is stent thrombosis, it usually occurs earlier and more frequently presented as STEMI compared to the other causes of AMI. The AMI caused by restenosis is more often presented as nonSTEMI, while disease progression leads to AMI later than the other causes. Further research should address equally not only the stent related inadequacies but also disease progression as causes of the future AMI. Angiographic follow-up and intracoronary imaging seem the most appropriate methods to define the exact pathophysiologic mechanism responsible for the AMI post stenting.

Selective adhesion and growth of vascular endothelial cells on bioactive peptide nanofiber functionalized stainless steel surface

Metal-based scaffolds such as stents are the most preferred treatment methods for coronary artery disease. However, impaired endothelialization on the luminal surface of the stents is a major limitation occasionally leading to catastrophic consequences in the long term. Coating the stent surface with relevant bioactive molecules is considered to aid in recovery of endothelium around the wound site. However, this strategy remains challenging due to restrictions in availability of proper bioactive signals that will selectively promote growth of endothelium and the lack of convenience for immobilization of such signaling molecules on the metal surface. In this study, we developed self-assembled peptide nanofibers that mimic the native endothelium extracellular matrix and that are securely immobilized on stainless steel surface through mussel-inspired adhesion mechanism. We synthesized Dopa-conjugated peptide amphiphile and REDV-conjugated peptide amphiphile that are self-assembled at physiological pH. We report that Dopa conjugation enabled nanofiber coating on stainless steel surface, which is the most widely used backbone of the current stents. REDV functionalization provided selective growth of endothelial cells on the stainless steel surface. Our results revealed that adhesion, spreading, viability and proliferation rate of vascular endothelial cells are remarkably enhanced on peptide nanofiber coated stainless steel surface compared to uncoated surface. On the other hand, although vascular smooth muscle cells exhibited comparable adhesion and spreading profile on peptide nanofibers, their viability and proliferation significantly decreased. Our design strategy for surface bio-functionalization created a favorable microenvironment to promote endothelial cell growth on stainless steel surface, thereby providing an efficient platform for bioactive stent development for long term treatment of cardiovascular diseases.

Very Long-Term (15 to 20 Years) Clinical and Angiographic Outcome After Coronary Bare Metal Stent Implantation

Background—

We previously reported that the long-term luminal response after coronary bare metal stenting is triphasic, with an early restenosis phase spanning the 6 months after the index procedure, an intermediate-term regression phase from 6 months to 3 years, and a late renarrowing phase beyond 4 years. However, the clinical significance of late luminal renarrowing remains unknown.

Methods and Results—

Angiographic and clinical follow-up of the same cohort of 405 patients with successful Palmaz-Schatz stent placement was extended beyond 15 years. Clinical follow-up was completed in 98% of patients at 5 years and in 81% at 15 years. The incidence of death and cardiac death at 15 years was 45.4% and 20.6%, respectively. Paired long-term (4 to 10 years) and very long-term (>10 years) angiographic studies without intercurrent target lesion revascularization were performed in 55 lesions, and minimal luminal diameter further decreased from 1.88±0.50 mm to 1.60±0.73 mm ( P =0.002). Late target lesion revascularization after initial stabilization of the stented segments occurred rarely within 4 years. Beyond 4 years, however, the incidence of late target lesion revascularization increased steadily from 3.3% at 4 years to 24.7% at 15 years. The incidence of definite very late stent thrombosis was low (1.5% at 15 years).

Conclusions—

Luminal renarrowing of the stented segment beyond 4 years was a progressive process extending beyond 10 years. The angiographic observation of late in-stent restenosis was clinically relevant because a corresponding progressive increase in the incidence of late target lesion revascularization was observed beyond 4 years and up to 15 to 20 years after bare metal stent implantation.

Mechanisms of nonfatal acute myocardial infarction late after stent implantation: the relative impact of disease progression, stent restenosis, and stent thrombosis

BACKGROUND

The impact of stent restenosis, stent thrombosis, or progression of disease at another site as responsible mechanisms of acute myocardial infarction (AMI) after stent implantation is not clear.

METHODS

By searching our catheterization laboratory database for a 4-year period, 91 cases of nonfatal AMI at least 1 month after stent implantation (32.6% drug-eluting stents) were identified. By detailed comparison of post-AMI with the initial percutaneous coronary intervention angiogram, the mechanism of AMI was analyzed.

RESULTS

Acute myocardial infarction was attributed to disease progression at another site in 42 (46.2%), stent restenosis in 35 (38.4%), and stent thrombosis in 10 (11%) cases. The AMI mechanism could be either stent related or disease progression (nonidentifiable culprit lesion) in 4 cases (4.4%). The median time from percutaneous coronary intervention to AMI was 27, 19, and 9 months for disease progression at another site, restenosis, and stent thrombosis group, respectively (P = .03). ST-elevation myocardial infarction occurred in 38.1% of the disease progression, in 20% of the restenosis, and in 60% of the stent thrombosis cases (P = .046).

CONCLUSIONS

In a "real world" population, late after stent implantation, a patient has an almost equal probability to have suffered a nonfatal AMI from either stent restenosis/thrombosis or disease progression at another site. Continuous research efforts are necessary to equally address both stent therapy and disease progression.

Use of Proxis for percutaneous coronary intervention in patients with totally occluded saphenous vein grafts: an alternative approach

Surgery is a common approach for diffuse coronary artery disease. Saphenous vein grafts are frequently used but are characterized by degeneration and high incidence of failure at 10 years. Percutaneous coronary intervention is preferred over re-operation because of age, comorbidity and the diffusion of coronary artery disease. With the saphenous vein graft occluded, percutaneous coronary intervention of native vessels and medical therapy alone are commonly suggested. We report three cases of patients with totally occluded saphenous vein grafts with suitable characteristics for treatment with Proxis, a device able to induce a proximal protection of the target vessel, minimizing the risk of distal embolization as well as the quantity of contrast required. In all patients there were no complications or cardiac enzyme elevations, and each case resulted in complete revascularization immediately postprocedure. Patients were asymptomatic at 6-month follow-up and procedural success was shown in two patients that consented to follow-up angiography. We conclude that Proxis could be a valuable tool for percutaneous coronary intervention of totally occluded saphenous vein grafts in patients who are poor candidates for percutaneous coronary intervention of native vessel; nevertheless these observations should be confirmed by a long-term follow-up controlled study.

Clinical outcomes with off-pump coronary surgery after angioplasty with stent

INTRODUCTION AND OBJECTIVES

The aim was to determine whether prior coronary stent implantation affects postoperative outcomes in patients undergoing coronary artery bypass grafting.

METHODS

Between January 2005 and April 2008, a retrospective analysis was carried out to evaluate the effect of prior coronary stent implantation in patients undergoing off-pump coronary surgery on the incidence of major cardiovascular events in the postoperative period (i.e. at 30 days or during postoperative hospitalization).

RESULTS

In total, 796 consecutive patients underwent coronary artery bypass grafting. Of these, 116 (14.6%) had a coronary stent at the time of surgery. Patients with and without stents had similar levels of risk (i.e. EuroSCORE). Multivariate analysis, adjusted for the presence of confounding variables (i.e. preoperative left ventricular ejection fraction <40%, critical preoperative state, age, history of cerebrovascular accident, recent acute myocardial infarction, number of diseased coronary vessels, incomplete revascularization and on-pump conversion), showed that the presence of a stent was significantly associated with increased risks of postoperative myocardial infarction (relative risk [RR]=3.13; 95% confidence interval [CI], 1.75-5.96), in-hospital cardiac mortality (RR=4.62; 95% CI, 1.76-12.11) and in-hospital all-cause mortality (RR=3.65; 95% CI, 1.60-8.34).

CONCLUSIONS

In our experience, coronary artery stent implantation prior to coronary surgery was associated with increased risks of postoperative myocardial infarction, cardiac mortality and all-cause mortality in the postoperative period.

Predictors of Long-Term Major Adverse Cardiac Events and Clinical Restenosis following Elective Percutaneous Coronary Stenting

Limited data exist regarding the predictors of long-term clinical outcomes following elective percutaneous coronary intervention (PCI) in the current era of stenting. The authors investigated the predictors of major adverse cardiac events (MACE) and clinical restenosis in 740 consecutive patients who underwent successful elective PCI with bare metal stents (BMSs) or drug-eluting stents (DESs). At 30-month follow -up, compared with BMS recipients, DES recipients had a significantly lower rate of MACE, which was mainly driven by a decreased repeat target vessel PCI. The rate of 30-month clinical restenosis was significantly lower in DES recipients. The authors conclude that baseline clinical, angiographic, and procedural characteristics determine long-term MACE and clinical restenosis after elective PCI, with DES being the independent predictor for both.

Primary stent therapy for symptomatic intracranial atherosclerotic stenosis: 1-year follow-up angiographic and midterm clinical outcomes

OBJECT

The aim of this study was to report 1-year angiographic follow-up results and midterm clinical outcomes in patients with symptomatic intracranial atherosclerotic lesions treated with stent placement.

METHODS

Ten patients with ischemic symptoms referable to stenotic intracranial atherosclerotic arteries, with greater than 60% stenosis, underwent elective surgery in which a primary stent was placed. All patients underwent pretreatment (> or =1 week) combination oral antiplatelet (clopidogrel and aspirin) therapy and long-term (6-month) combination oral antiplatelet (clopidogrel and aspirin) therapy after stents were placed. The procedure involved selecting stents of the same size as the diameter of the target vessel and slowly inflating the balloon to its nominal pressure. One-year angiography and midterm clinical follow-up data were obtained. The stents were successfully placed in all patients without any perioperative complication. The mean preoperative stenosis rate of 81% decreased to 4% after the stent was placed. Nine patients who underwent follow-up angiography (one patient refused) at a mean of 12.3 months (range 10-19 months) had no changes in luminal diameter compared with the immediate postoperative luminal diameter. Luminal narrowing increased, from 15 to 38%, in one case in which there was comparatively greater residual stenosis (15%). No patient suffered new ischemic symptoms during a mean clinical follow-up period of 21 months (range 12-36 months).

CONCLUSIONS

Elective stent surgery can provide good angiographic and clinical midterm outcomes in patients with symptomatic intracranial atherosclerotic stenosis, and the procedure is associated with a high degree of technical success. Reassessment of these promising results is needed in a larger population and in a randomized prospective comparison study.

Long-Term Outcome of First-Generation Metallic Coronary Stent Implantation in Patients With Coronary Artery Disease Observational Study Over a Decade

BACKGROUND

In the era of drug-eluting stents, percutaneous coronary intervention (PCI) has been considered an established therapeutic modality for patients with coronary artery disease (CAD). However, little is known about the long-term prognosis.

METHODS AND RESULTS

Using data obtained from a single-center registry for cases of first-generation bare metallic stent (BMS) implantation, a 10-year follow-up study in patients with CAD was performed. Data for 125 serial patients (aged 62+/-9 years, 104 males) in whom a BMS was successfully implanted was analyzed. Cardiac death (n=16 [12.8%]), including sudden cardiac death (n=9 [7.2%]), non-cardiac death (n=17 [13.6%]) and non-fatal acute myocardial infarction (n=16 [12.8%]) were documented. At 10 years, cumulative probabilities of target and non-target lesion revascularization were 20.5% and 41.5%, respectively, and only 39.2% of the patients were free from cardiac events (cardiac death/myocardial infarction/unplanned revascularization). Age and left ventricular ejection fraction (LVEF) were significant predictors of total death, and LVEF and the use of diuretics were predictors of cardiac events.

CONCLUSIONS

Stabilization of the initial stented site was relatively good and the majority of cardiac events might have originated in non-target lesions. Prevention of systemic arteriosclerosis progression is important for patients with CAD, even after successful PCI.

Outcome after coronary artery bypass graft surgery, coronary angioplasty and stenting

AIMS

We undertook this prospective observational study to investigate the long-term prognosis after balloon angioplasty (PTCA), coronary stenting (CS) and coronary artery bypass grafting (CABG).

METHODS AND RESULTS

A total number of 1038 patients with PTCA (n=499), CS (n=294) or CABG (n=245) were followed-up over a mean time of 6.4+/-1.8 years. Forty-two patients (4.0%) were lost to follow-up, leaving a study population of 996 subjects who were available for analyses. The primary and secondary endpoints were mortality and major adverse cardiac events (MACE), respectively. Overall death rate was 19.3%. Age, pulse pressure, smoking, diabetes, serum LDL cholesterol levels and left ventricular ejection fraction rather than the intervention type independently predicted mortality. The incidence rate of MACE was 53.7%. Compared to PTCA patients, CS patients had lower (hazard ratio 0.693; 95% confidence interval 0.514-0.793) and CABG patients the lowest risk of MACE (hazard ratio 0.343; 95% confidence interval 0.261-0.450). Further risk factors for MACE were serum LDL cholesterol levels, three-vessel coronary artery disease and left ventricular ejection fraction of <30%.

CONCLUSION

Long-term mortality does not differ among patients who received percutaneous interventions or CABG. Major adverse cardiac events occur more often in patients with previous percutaneous interventions, whereby CS has advantage over PTCA.

Histopathological findings of new in-stent lesions developed beyond five years

We analyzed 14 cases of new lesions inside implanted bare-metal stents. In every case, there was no angiographic restenosis within 3 years, but a new lesion was observed inside a stented segment at long-term follow-up (>5 years). Fourteen cases were evaluated: 9 with Wiktor stents, 2 with Palmaz-Schatz stents, and 3 with ACS Multilink stents. The interval from stent implantation to follow-up angiography was 63-147 months (89 +/- 23). Thirteen lesions were treated by percutaneous coronary intervention (PCI) and stenotic tissue was obtained by directional coronary atherectomy (DCA) in 10 cases. All retrieved samples were composed of newly developed atherosclerosis facing the healed neointimal layer, and four samples showed histopathological findings of acute coronary syndrome. Stent struts were retrieved in four cases and no inflammation was observed surrounding them. Qualitative and quantitative analysis of stent struts was performed in two cases that showed no metal corrosion. These findings suggest that new atherosclerotic progression occurred inside the implanted stent without peristrut inflammation.

A Cost-Effectiveness Analysis of a Hypothetical Catheter-Based Strategy for the Detection and Treatment of Vulnerable Coronary Plaques with Drug-Eluting Stents

AIM

Extensive efforts are underway to develop methods for the detection and treatment of vulnerable/high-risk coronary artery plaques. We utilized decision analysis to evaluate the hypothetical clinical benefits and cost-effectiveness of a catheter-based strategy.

METHODS AND RESULTS

Currently, stenotic coronary plaques are treated without regard to vulnerability. In a new strategy, vulnerable coronary plaques are detected with a catheter-based test and treated with a drug-eluting stent, regardless of degree of stenosis. A Markov-decision model was developed to compare the new strategy with current practice. Monte Carlo simulations were performed from a societal perspective, costs were converted to year 2003 U.S. dollars, and future costs and outcomes were discounted at 3%. Sensitivity analyses were performed to evaluate the effect of assumptions on variables such as the prevalence of vulnerable plaques and treatment effect. In 60-year-old male patients with coronary stenoses the new strategy would be less expensive and more effective than current practice (37,045 dollars vs 38,257 dollars and 10.23 vs 9.86 quality-adjusted life years (QALYs), respectively). The benefits of the new strategy were robust in sensitivity analyses (e.g., if the prevalence of vulnerable plaques in this patient group was 50% or more and the sensitivity and specificity of the new test were at least 0.80).

CONCLUSION

In selected patients with coronary artery stenosis, the detection of vulnerable plaques with a catheter-based test followed by their treatment with a drug-eluting stent could be a less expensive and more effective strategy than current practice. If applied to 1 million such patients in the United States undergoing catheterization, the new strategy would add 370,000 QALYs and save 1.2 billion dollars per year.

Two-year follow-up intravascular ultrasound analysis after bare metal stent implantation in 120 lesions

The objective of this study was to examine long-term changes after bare metal stent implantation in a relatively large number of patients. There are few reports of intravascular ultrasound (IVUS) studies performed on stented and nonstented (reference) segments beyond 6 months after bare metal stenting. Using IVUS, we evaluated serial changes in stented and reference segments between 6 and 24 months after stent implantation in 110 patients with 120 lesions. Serial IVUS images were acquired at five equidistant intrastent sites and at two different reference segment sites. Measurements were made of the external elastic membrane (EEM), stent, lumen, and intimal hyperplasia (IH = stent - lumen) area. For the whole patient group, between 6 and 24 months, the mean IH area in stented segments decreased from 2.6 +/- 1.0 to 2.3 36+/- 0.9 mm2 (P < 0.001), and the mean lumen area increased from 6.2 +/- 2.0 to 6.5 +/- 1.9 mm2 (P < 0.001). The mean IH area decreased in 91 lesions (76%) and increased in 29 lesions (24%) between 6 and 24 months. There were no significant changes in EEM or lumen area in the reference segments. Late angiographic restenosis (diameter stenosis > or = 50%) occurred in three lesions between 6 and 24 months. A late target lesion revascularization was performed for one lesion. In the period of time between 6 and 24 months after stenting, IH regression occurred in most (76%) stent lesions, resulting in late lumen increase. However, IH progression was observed in 24% of in-stent lesions. No significant changes of EEM or lumen area occurred in the reference segments.

Incidence of thrombotic stent occlusion during the first three months after sirolimus-eluting stent implantation in 500 consecutive patients

Sirolimus-eluting stents have been used in our institution for all percutaneous interventions, without clinical or anatomic exclusion criteria, as part of the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital registry. We analyzed the incidence of (sub)acute stent thrombosis after sirolimus-eluting stent implantation in an unselected population of 510 consecutive patients. At 3-month follow-up, (sub)acute stent thrombosis was diagnosed in 2 patients (0.4%) 6 hours and 11 days after the procedure, respectively. These cases occurred in diabetic women with complex coronary lesions. Intravascular ultrasound examination showed inadequate stent expansion and uncovered distal dissection as possible mechanical explanations for the thrombosis.

Myocardial perfusion imaging following percutaneous coronary intervention: the importance of restenosis, disease progression, and directed reintervention

Percutaneous coronary intervention (PCI) has become a mainstay in the treatment of patients with coronary artery disease. Currently, more than one million coronary angioplasty and stent implantation procedures are performed annually. Although increasingly complex lesions and higher risk patients are being successfully treated percutaneously, restenosis and disease progression continue to cause significant morbidity. Restenosis occurs in approximately one-third of patients, one-half of who remain asymptomatic, while disease progression occurs at rates approaching 7% per year. Despite technological advances, unadjusted mortality rates have actually increased since the mid-1980s, and the current annual risk of a major adverse cardiac event following PCI is 5% to 7%. Although randomized clinical trials are needed to more definitively show a benefit, when performed six or more months following PCI, myocardial perfusion imaging reliably identifies patients most at risk of a poor long-term outcome. Directed reintervention can have a salutary impact on the prognosis of these patients. In view of recent data showing a positive impact of imaging and reintervention in patients after PCI, current guidelines should be reassessed.

Significant gender-related differences in radiofrequency catheter ablation therapy

OBJECTIVES

We investigated possible differences between male and female patients regarding ablation therapy.

BACKGROUND

Gender-related differences might have a major impact on different aspects of radiofrequency ablation therapy. Data on this topic are very limited, focusing almost exclusively on success and recurrence rates.

METHODS

The study population consisted of 894 consecutive patients who underwent catheter ablation of accessory pathways (n = 519) and/or atrioventricular nodal re-entrant tachycardia (AVNRT) (n = 379). There were 418 (46.8%) male and 476 (53.2%) female patients.

RESULTS

Female patients were referred for ablation later than male patients (185 +/- 143 vs. 157 +/- 144 months after onset of symptoms, p < 0.001) and after having been given more antiarrhythmic drugs (1.6 +/- 1.2 vs. 1.3 +/- 1.1, p < 0.001). Women were more symptomatic, with a higher number of patients having >1 tachycardia episode per month (80.3% vs. 70.3% in men, p < 0.001). Fluoroscopy time, radiofrequency applications, and procedure duration were similar in male and female patients undergoing accessory pathway ablation as well as in male and female patients undergoing AVNRT ablation. No difference was seen in success, complication, and recurrence rates between men and women.

CONCLUSIONS

Physicians and/or patients tend toward a more conservative approach in female patients. Women are referred for ablation later than are men, after a longer duration of symptoms, and after having been given more antiarrhythmic drugs. However, potential concerns on behalf of physicians or female patients do not seem to be justified: ablation procedures in women had equally high success, low complication, and low recurrence rates as those procedures in male patients.

Predictive value of myocardial tomoscintigraphy in asymptomatic diabetic patients after percutaneous coronary intervention

OBJECTIVE

This study was designed to assess the prognostic value of myocardial tomoscintigraphy perfusion imaging after percutaneous coronary intervention (PCI) in asymptomatic diabetic patients.

METHODS

One hundred and fourteen diabetic patients were followed up during 27+/-16 (mean+/-SD) months after the myocardial tomoscintigraphy. PCI-related events were studied after myocardial tomoscintigraphy stress testing and included major cardiac events (MACE) (cardiovascular death, myocardial infarction) and revascularization (bypass surgery or new PCI). Stress myocardial tomoscintigraphy imaging was performed 5+/-5 months after PCI and ischemia was considered as present if at least 2 contiguous segments were showing reversible defects.

RESULTS

Persistent silent ischemia was found in 49/114 (43%) patients. No difference was observed between the two groups for MACE: four among the 65 (6%) non ischemic patients versus 2 among the 49 (4%) ischemic patients (NS). In contrast, 15 (31%) among the ischemic patients and 4 (6%) among the non ischemic patients underwent iterative revascularization (p<0.01). The relative risk of revascularization for patients with significant ischemia was 5.5 versus non ischemic patients (p<0.001).

CONCLUSION

After PCI, in asymptomatic diabetic patients followed by myocardial tomoscintigraphy a high frequency of persistent silent ischemia was found and associated with a high risk for repeat interventional procedure, although no increase in major cardiac events was observed.

Stent-induced restenosis in the swine coronary artery is inhibited by a platelet-derived growth factor receptor tyrosine kinase inhibitor, TKI963

Activities of vascular smooth muscle cells (SMCs) such as proliferation, migration, and matrix production contribute to restenosis following clinical interventions of angioplasty and stent placement. Because activation of platelet-derived growth factor (PDGF)-receptor tyrosine kinase (PDGFr-TK) influences these processes and promotes restenosis, TKI963, an inhibitor of the PDGFr-TK was discovered, and its efficacy was evaluated in blocking stent-induced restenosis as analyzed by intravascular ultrasound (IVUS). TKI963, a low-molecular-weight compound, inhibited the cell-free PDGFbetar-TK with a K(i) value of 56 +/- 14 nM. TKI963 also inhibited PDGF-dependent events in human aortic SMCs (e.g., in situ PDGFr autophosphorylation, mitogenesis, chemotaxis, and collagen production with median inhibitory concentration values of approximately 300 nM) without affecting the activity of a series of membrane receptor tyrosine kinases and intracellular serine/threonine kinases. In vivo, stent-induced restenosis in the swine coronary artery was reduced by oral administration of TKI963 (1.25, 2.5, and 5 mg/kg BID, for 28 days). Late lumen cross-sectional area (CSA) loss, plaque CSA growth, and plaque volume in the stent determined by IVUS were dose-relatedly decreased (33-62% at 1.25 mg/kg BID to 66-92% at 5 mg/kg BID, depending on the parameter) compared with controls. TKI963 treatment of </=1 week following stent placement had no effect on the prevention of restenosis. TKI963, a selective, orally bioavailable inhibitor of the PDGFr-TK, dose-relatedly reduced stent-induced restenosis and did so by inhibiting PDGF-dependent activities that occur as late events following stent placement.

What is the role for improved long-term antiplatelet therapy after percutaneous coronary intervention?

BACKGROUND

Coronary stent placement has replaced balloon angioplasty as the percutaneous coronary intervention (PCI) method of choice, primarily because of its lower restenosis rate. Compared with aspirin (ASA) monotherapy or ASA plus warfarin, the ticlopidine and ASA combination is superior in reducing thrombotic events after stenting. Clopidogrel plus ASA appears to be at least as effective as ticlopidine and ASA. Intravenous glycoprotein IIb/IIIa inhibitors effectively prevent periprocedural thrombotic complications, but their short duration of action and parenteral dosing don't allow for long-term protection. This review aimed to answer how long after PCI with a stent patients are at risk for recurrent thrombotic events and what the optimal way to prevent them is.

RESULTS

Classically, ASA has been prescribed indefinitely, whereas adenosine diphosphate receptor antagonists have been discontinued after 2 to 4 weeks. However, the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial found that long-term dual antiplatelet therapy with clopidogrel and ASA was more effective than ASA alone in preventing major cardiovascular events in patients with acute coronary syndrome, including those treated with PCI.

CONCLUSION

Results from additional ongoing studies are needed to clarify the role of long-term dual oral antiplatelet therapy in preventing ischemic events in patients who have undergone PCI.

Long-term (three-year) outcomes after stenting of unprotected left main coronary artery stenosis in patients with normal left ventricular function

The purpose of this study was to analyze long-term follow-up information from patients treated with stenting for unprotected left main coronary artery (LMCA) stenosis. Stenting of unprotected LMCA stenosis is often performed in selected patients, but the long-term safety of this therapy is not yet established. Between January 1995 and September 2000, 270 consecutive patients with unprotected LMCA stenosis and normal left ventricular function who underwent treatment at 4 clinical centers were included in this study. Data were forwarded to the coordinating center using a standard case report form. The procedural success rate was 98.9%. There were no deaths, 3 stent thromboses, and 3 Q-wave myocardial infarctions during the hospitalization. Angiographic follow-up was performed in 237 patients (follow-up rate 87.8%), and the restenosis rate was 21.1%. The reference size was an independent predictor of binary restenosis (odds ratio 0.543, 95% confidence interval 0.308 to 0.957, p = 0.03). During the follow-up period (32.3 +/- 18.5 months), there were 20 deaths (8 cardiac, 12 noncardiac) and 5 nonfatal myocardial infarctions. Target and new lesion revascularizations were required in 45 (16.7%) and 31 (11.5%) patients, respectively. The cumulative probabilities free from major adverse cardiac events were 81.9 +/- 2.4%, 78.4 +/- 2.6%, and 77.7 +/- 2.7%, respectively, at 1, 2, and 3 years. Combined coronary artery disease and postprocedural minimal luminal diameter were the significant predictors of major adverse cardiac events. Thus, the long-term prognosis of patients after stenting of unprotected LMCA stenosis was favorable in selected patients with normal left ventricular function.

Effects of coronary stenting on vessel patency and long-term clinical outcome after percutaneous coronary revascularization in diabetic patients

OBJECTIVES

We sought to compare coronary stent implantation with balloon angioplasty (BA), in a diabetic population, in terms of the six-month angiographic outcome and four-year clinical events.

BACKGROUND

Diabetic patients have a poor angiographic and clinical outcome after standard coronary BA. To date, it is still unclear whether stent implantation may improve this outcome.

METHODS

We investigated this issue by individual matching of 314 diabetic patients treated with either coronary stenting or standard BA. These two groups were derived from a population of consecutive diabetic patients (1993 to 1996). Matching criteria were gender, anti-diabetic regimen, stenosis location, reference diameter, and minimal luminal diameter (+/-0.4 mm). One lesion per patient was considered for matching.

RESULTS

Baseline characteristics were similar between the two groups of 157 patients. At six months, the rates of restenosis (27% vs. 62%; p < 0.0001) and occlusion (4% vs. 13%; p < 0.005) were lower in the stent group than in the BA group. This was associated with a significant decrease in ejection fraction at six months in the BA group (p = 0.02) while, during the same period, no change was observed in the stent group (p = NS). Subgroup analysis demonstrated that angiographic benefit was consistent among the subgroups. At four years, the combined clinical end point of cardiac death and non-fatal myocardial infarction was lower in the stent group (14.8% vs. 26.0%; p = 0.02), as was the need for repeat revascularization (35.4% vs. 52.1%; p = 0.001).

CONCLUSIONS

In a population of diabetic patients, coronary stent implantation was associated with a highly beneficial effect on the six-month angiographic outcome and four-year clinical events compared with standard BA.

Randomized comparison of cilostazol versus ticlopidine hydrochloride for antiplatelet therapy after coronary stent implantation for prevention of late restenosis

BACKGROUND

Cilostazol is a newly developed antiplatelet drug that has been widely applied for clinical use. Its antiplatelet action appears to be mainly related to inhibition of intracellular phosphodiesterase activity. Recently, cilostazol has been used for antiplatelet therapy after coronary stent implantation. However, its evaluation has not been established yet.

METHODS

This prospective randomized trial was designed to investigate the efficacy of cilostazol for the prevention of late restenosis and acute or subacute stent thrombosis in comparison with ticlopidine hydrochloride. One hundred thirty consecutive patients, scheduled for elective coronary stenting, were randomly assigned to receive oral aspirin (81 mg/day) plus ticlopidine hydrochloride therapy (200 mg/day; group I) or aspirin plus cilostazol therapy (200 mg/day; group II). These medications were started at least 2 days before coronary intervention and continued until follow-up coronary angiography was performed 6 months later.

RESULTS

Subacute stent thrombosis was observed in 2 patients of group I but in no patients of group II. Major cardiac events were similarly present in both groups. Elevated transaminase levels were observed more frequently in group I than in group II (P <.05). Each of the quantitative coronary angiography variables before and immediately after coronary stenting were similar in both groups. At follow-up angiography, however, late lumen loss (0.69 +/- 0.79 mm vs 0.28 +/- 0.40 mm; P <.01) and loss index (0.42 +/- 0.56 vs 0.16 +/- 0.27; P <.01) were smaller in group II than in group I. Restenosis rate (13% vs 31%; P <.05) and target lesion revascularization rate (7% vs 21%; P <.05) were both lower in group II than in group I.

CONCLUSION

Aspirin plus cilostazol therapy may be an effective regimen for prevention of not only stent thrombosis but also restenosis.

Long-term clinical and angiographic follow-up after coronary stent placement in native coronary arteries

BACKGROUND

Although coronary stents have been proved effective in reducing clinical cardiac events for up to 3 to 5 years, longer term clinical and angiographic outcomes have not yet been fully clarified.

METHODS AND RESULTS

To evaluate longer term (7 to 11 years) outcome, clinical and angiographic follow-up information was analyzed in 405 patients with successful stenting in native coronary arteries. Primary or secondary stabilization, which was defined as freedom from death, coronary artery bypass grafting, and target lesion-percutaneous coronary intervention (TL-PCI) during the 14 months after the initial procedure or after the last TL-PCI, was achieved in 373 patients (92%) overall. Only 7 patients (1.7%) underwent TL-PCI more than twice. After the initial 14-month period, freedom from TL-PCI reached a plateau at 84.9% to 80.7% over 1 to 8 years. However, quantitative angiographic analysis in 179 lesions revealed a triphasic luminal response characterized by an early restenosis phase until 6 months, an intermediate-term regression phase from 6 months to 3 years, and a late renarrowing phase beyond 4 years. Minimal luminal diameter in 131 patients with complete serial data were 2.62+/-0.4 mm immediately after stenting, 2.0+/-0.49 mm at 6 months, 2.19+/-0.49 mm at 3 years, and 1.85+/-0.56 mm beyond 4 years (P<0.0001).

CONCLUSIONS

The efficacy and safety of coronary stenting seemed to be clinically sustained at 7 to 11 years of follow-up. However, late luminal renarrowing beyond 4 years was common, which demonstrates the need for further follow-up.

Long-term prognostic value of 201Tl single-photon emission computed tomographic myocardial perfusion imaging after coronary stenting

BACKGROUND

The prognostic value of (201)Tl myocardial imaging has been demonstrated in several studies concerning patients with a known significant coronary artery disease. However, the evolution of a coronary stenosis after stenting is difficult to predict. This study was designed to assess the prognostic value of (201)Tl single-photon emission computed tomography (thallium SPECT) perfusion imaging in patients after intracoronary stenting.

METHODS

One hundred fifty-two patients were studied. They were followed up during 40 +/- 13 (mean +/- SD) months after thallium SPECT. Stent-related events were studied after thallium stress testing and included cardiovascular death, myocardial infarction, and revascularization. Stress thallium imaging was performed 5 +/- 2 months after stenting, and ischemia was considered to be present if at least 2 contiguous segments were showing reversible defects.

RESULTS

Only 3 (3%) among the 105 nonischemic patients had major cardiac events during the follow-up versus 13 (28%) of the 47 ischemic patients (P < .001) after thallium SPECT. The relative risk of major cardiac events for patients with significant ischemia was 10.5 compared with nonischemic patients (P < .001). Fourteen (30%) of the ischemic patients and 8 (8%) among the nonischemic patients underwent iterative revascularization (P < .001). Therefore, only 11 (10%) of the nonischemic patients had major cardiac events or revascularization compared with 24 (51%) of the ischemic patients (P < .001).

CONCLUSIONS

Absence of ischemia on thallium SPECT imaging at 5 months after coronary stenting indicates a low risk for cardiovascular events or interventional procedure. These results may have important clinical implications in patient treatment.

Long-term outcome after coronary stenting

The present review assesses the data on long-term outcome after coronary stenting. Histological, angiographical and intravascular imaging data have shown that the insertion of stents constitutes only a transient stimulus to lumen renarrowing, that this process is almost complete at 6 months and that a certain degree of neointima regression is also possible after this time. Clinical data have confirmed the sustained benefit of stenting in the long term. Careful selection of optimal stent designs and application of the recent advances in adjunctive pharmacological therapy are currently effective strategies to improve both short-and long-term results with coronary stenting. However, further efforts are needed and are ongoing to combat restenosis, a process that counters the excellent short-term results of stenting in the long term.