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Sahyouni M, Stouffer GA. Instent CTO-What Is the Best Treatment Strategy? Cardiovasc Drugs Ther 2024; 38:393-394. [PMID: 38270692 DOI: 10.1007/s10557-024-07556-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 01/26/2024]
Affiliation(s)
- Mark Sahyouni
- Campbell University School of Osteopathic Medicine, Lillington, NC, 27546, USA
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, 27599-7075, USA.
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2
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Yeh RW, Shlofmitz R, Moses J, Bachinsky W, Dohad S, Rudick S, Stoler R, Jefferson BK, Nicholson W, Altman J, Bateman C, Krishnaswamy A, Grantham JA, Zidar FJ, Marso SP, Tremmel JA, Grines C, Ahmed MI, Latib A, Tehrani B, Abbott JD, Batchelor W, Underwood P, Allocco DJ, Kirtane AJ. Paclitaxel-Coated Balloon vs Uncoated Balloon for Coronary In-Stent Restenosis: The AGENT IDE Randomized Clinical Trial. JAMA 2024; 331:1015-1024. [PMID: 38460161 PMCID: PMC10924708 DOI: 10.1001/jama.2024.1361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/30/2024] [Indexed: 03/11/2024]
Abstract
Importance Drug-coated balloons offer a potentially beneficial treatment strategy for the management of coronary in-stent restenosis. However, none have been previously evaluated or approved for use in coronary circulation in the United States. Objective To evaluate whether a paclitaxel-coated balloon is superior to an uncoated balloon in patients with in-stent restenosis undergoing percutaneous coronary intervention. Design, Setting, and Participants AGENT IDE, a multicenter randomized clinical trial, enrolled 600 patients with in-stent restenosis (lesion length <26 mm and reference vessel diameter >2.0 mm to ≤4.0 mm) at 40 centers across the United States between May 2021 and August 2022. One-year clinical follow-up was completed on October 2, 2023. Interventions Participants were randomized in a 2:1 allocation to undergo treatment with a paclitaxel-coated (n = 406) or an uncoated (n = 194) balloon. Main Outcomes and Measures The primary end point of 1-year target lesion failure-defined as the composite of ischemia-driven target lesion revascularization, target vessel-related myocardial infarction, or cardiac death-was tested for superiority. Results Among 600 randomized patients (mean age, 68 years; 157 females [26.2%]; 42 Black [7%], 35 Hispanic [6%] individuals), 574 (95.7%) completed 1-year follow-up. The primary end point at 1 year occurred in 17.9% in the paclitaxel-coated balloon group vs 28.6% in the uncoated balloon group, meeting the criteria for superiority (hazard ratio [HR], 0.59 [95% CI, 0.42-0.84]; 2-sided P = .003). Target lesion revascularization (13.0% vs 24.7%; HR, 0.50 [95% CI, 0.34-0.74]; P = .001) and target vessel-related myocardial infarction (5.8% vs 11.1%; HR, 0.51 [95% CI, 0.28-0.92]; P = .02) occurred less frequently among patients treated with paclitaxel-coated balloon. The rate of cardiac death was 2.9% vs 1.6% (HR, 1.75 [95% CI, 0.49-6.28]; P = .38) in the coated vs uncoated balloon groups, respectively. Conclusions and Relevance Among patients undergoing coronary angioplasty for in-stent restenosis, a paclitaxel-coated balloon was superior to an uncoated balloon with respect to the composite end point of target lesion failure. Paclitaxel-coated balloons are an effective treatment option for patients with coronary in-stent restenosis. Trial Registration ClinicalTrials.gov Identifier: NCT04647253.
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Affiliation(s)
- Robert W. Yeh
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Jeffrey Moses
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York
| | | | - Suhail Dohad
- Cedars Sinai Medical Center, Los Angeles, California
| | - Steven Rudick
- Lindner Center for Research and Education at Christ Hospital, Cincinnati, Ohio
| | - Robert Stoler
- Baylor Scott & White Heart and Vascular Hospital, Dallas, Texas
| | | | | | | | | | | | | | | | - Steven P. Marso
- Overland Park Regional Medical Center, Overland Park, Kansas
| | | | - Cindy Grines
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia
| | | | - Azeem Latib
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Behnam Tehrani
- The Inova Schar Heart and Vascular Institute, Falls Church, Virginia
| | - J. Dawn Abbott
- Lifespan Cardiovascular Institute, Rhode Island Hospital, Providence
| | - Wayne Batchelor
- The Inova Schar Heart and Vascular Institute, Falls Church, Virginia
| | | | | | - Ajay J. Kirtane
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York
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3
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Rivard A. Real-World Treatment of In-Stent Restenosis: The Return of the Balloon. Can J Cardiol 2024:S0828-282X(24)00180-6. [PMID: 38402952 DOI: 10.1016/j.cjca.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/15/2024] [Accepted: 02/13/2024] [Indexed: 02/27/2024] Open
Affiliation(s)
- Alain Rivard
- Department of Medicine, Centre Hospitalier de l'Université de Montréal Research Centre, Montréal, Québec, Canada.
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Zhang Y, Wu Z, Wang S, Liu T, Liu J. Clinical Outcome of Paclitaxel-Coated Balloon Angioplasty Versus Drug-Eluting Stent Implantation for the Treatment of Coronary Drug-Eluting Stent In-Stent Chronic Total Occlusion. Cardiovasc Drugs Ther 2023; 37:1155-1166. [PMID: 35930211 PMCID: PMC10721670 DOI: 10.1007/s10557-022-07363-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2022] [Indexed: 11/25/2022]
Abstract
AIMS In-stent chronic total occlusion (IS-CTO) represents a unique challenge for percutaneous coronary intervention. Whether the optimal treatment for IS-CTO is angioplasty with paclitaxel-coated balloons (PCBs) or repeat stenting with drug-eluting stents (DESs) is unclear. We aimed to evaluate the long-term clinical outcome of PCB angioplasty and DES repeat stenting for DES IS-CTO. METHODS We retrospectively included patients with DES IS-CTO who underwent successful PCB angioplasty or DES repeat stenting from January 2016 to December 2019. The primary endpoints were major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, and target lesion revascularization (TLR). Cox proportional hazards model was performed to compare the risk of MACEs between PCB angioplasty and DES repeat stenting, and to further explore the prognostic factors of patients with DES IS-CTO. RESULTS A total of 214 patients with DES IS-CTO were enrolled: 78 patients (36.4%) treated with PCB and 136 patients (63.6%) treated with DES respectively. The median follow-up was 1160 days, and MACEs were observed in 28.2% of patients with PCB angioplasty versus 26.5% of patients with DES repeat stenting (P = 0.784), mainly driven by TLR (21.8% vs. 19.9%, P = 0.735). There was no significant difference in the risk of MACEs between the PCB group and the DES group (hazard ratio [HR] 1.25, 95% confidence interval [CI] 0.64-2.46, P = 0.512). Multivariate Cox analysis revealed that chronic kidney disease and ≥ 3 stent layers in the lesion were independent predictors of MACEs, while switching to another antiproliferative drug was an independent protective factor (all P < 0.05). CONCLUSIONS PCB angioplasty was an effective alternative treatment strategy for DES IS-CTO, which had similar long-term outcomes to DES repeat stenting in contemporary practice, but both were accompanied by a high rate of long-term MACEs. Improving the poor prognosis of patients with DES IS-CTO remains a challenge.
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Affiliation(s)
- Yuchao Zhang
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Zheng Wu
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Shaoping Wang
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Tong Liu
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Jinghua Liu
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China.
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Zhang H, Zhang Y, Tian T, Wang T, Chen J, Yuan J, Qian J, Hu F, Dou K, Qiao S, Wu Y, Guan C, Yang W, Song L. Comparison of Recurrent With First-Time In-Stent Restenosis. Am J Cardiol 2023; 206:168-174. [PMID: 37708747 DOI: 10.1016/j.amjcard.2023.08.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/15/2023] [Accepted: 08/20/2023] [Indexed: 09/16/2023]
Abstract
Recurrent in-stent restenosis (Re-ISR) remains a therapeutic challenge. We aimed to investigate the clinical characteristics, treatment, and long-term outcomes in patients with Re-ISR compared with those with first-time ISR (First-ISR). This retrospective study consecutively enrolled patients who underwent percutaneous coronary intervention (PCI) for ISR in Fuwai Hospital between January 2017 and December 2018. Re-ISR was defined as a second event of ISR after a previous successful treatment of the ISR lesion. The primary outcome was defined as a composite of all-cause death, spontaneous myocardial infarction, and repeat revascularization. A total of 2,006 patients (2,154 lesions) with ISR underwent successful PCI were enrolled and categorized into 2 groups: the Re-ISR group (246 patients/259 lesions) and the First-ISR group (1,760 patients/1,895 lesions). During a mean follow-up of 36 months, the primary outcomes occurred in 80 patients (32.5%) in the Re-ISR group and 349 patients (19.3%) in the First-ISR group (p <0.001 by log-rank test), major driven by spontaneous myocardial infarction (4.9% vs 2.7%, p = 0.049) and repeat revascularization (30.1% vs 16.5%, p <0.001). The multivariable Cox regression analysis revealed that Re-ISR was independently associated with a higher rate of major adverse cardiovascular events (adjusted hazard ratio 1.88, 95% confidence interval 1.39 to 2.53, p <0.001) and repeated revascularization (adjusted hazard ratio 2.09, 95% confidence interval 1.53 to 2.84, p <0.001). The relation remained consistent after the propensity score analysis. In conclusion, in the present cohort of patients who underwent PCI for ISR, Re-ISR was significantly associated with a higher risk of long-term outcomes than First-ISR.
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Affiliation(s)
- Han Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yin Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Tian
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tianjie Wang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jue Chen
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinqing Yuan
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Qian
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fenghuan Hu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kefei Dou
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shubin Qiao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongjian Wu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Changdong Guan
- Catheterization Laboratories, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weixian Yang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Song
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Sedhom R, Cortese B, Khedr M, Bharadwaj A, Brilakis ES, Pershad A, Basir MB, Alaswad K, Yeh RW, Megaly M. Utilization of Non-Drug-Eluting Devices for Inpatient Percutaneous Coronary Intervention in the United States. Am J Cardiol 2023; 186:209-215. [PMID: 36328830 DOI: 10.1016/j.amjcard.2022.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/11/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
Abstract
There is a paucity of data on the contemporary use of non-drug-eluting devices (balloon angioplasty or bare-metal stents) in contemporary percutaneous coronary intervention (PCI) in the United States. We utilized the Nationwide Readmissions Database to identify patients hospitalized to undergo PCI with non-drug-eluting devices from 2016 to 2019. The main outcome of interest was the trends in utilization over the study years. Among 1,870,262 PCI procedures, 127,810 (6.8%) were performed with non-drug-eluting devices; 72% of these were in the setting of acute myocardial infarction (MI). The use of non-drug-eluting devices decreased throughout the study period from 12.9% of all PCI in the first quarter of 2016 to 3.4% in the last quarter of 2019 (p <0.001). Factors associated with their use included advanced age and high bleeding risk. Only a small percentage were used as a bridge to coronary artery bypass graft surgery (2%) and for treatment of in-stent restenosis (3%). The in-hospital mortality was 5.8% for the entire cohort and 6.6% when the indication for use was an acute MI. In patients presenting with an acute MI, reinfarction within 30 days was common and occurred in 18% of the patients. In conclusion, the use of non-drug-eluting devices in PCI in the United States decreased from 2016 to 2019. Factors associated with their use included old age and high bleeding risk. Due to suboptimal outcomes in patients currently being treated with non-drug-eluting devices, there remains an unmet clinical need for alternative treatment options.
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Affiliation(s)
- Ramy Sedhom
- Division of Cardiology, Loma Linda University Health, Loma Linda, California
| | - Bernardo Cortese
- Foundation for Cardiovascular Research and Innovation, Milan, Italy
| | - Mohamed Khedr
- Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Aditya Bharadwaj
- Division of Cardiology, Loma Linda University Health, Loma Linda, California
| | | | - Ashish Pershad
- Division of Cardiology, Chandler Regional Medical Center, Chandler, Arizona
| | - Mir B Basir
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Khaldoon Alaswad
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Robert W Yeh
- Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael Megaly
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan.
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Erdogan E, Bajaj R, Lansky A, Mathur A, Baumbach A, Bourantas CV. Intravascular Imaging for Guiding In-Stent Restenosis and Stent Thrombosis Therapy. J Am Heart Assoc 2022; 11:e026492. [PMID: 36326067 PMCID: PMC9750080 DOI: 10.1161/jaha.122.026492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Advances in stent technology and the design of endovascular devices with thinner struts, anti-inflammatory and antithrombotic polymers, and better drug kinetics have enhanced the safety and efficacy of the second-generation drug-eluting stents and broadened their use in the therapy of high-risk patients and complex anatomies. However, despite these developments, in-stent restenosis and stent thrombosis remain the Achilles' heel of percutaneous coronary intervention, with their cumulative incidence reaching up to 10% at 5 years following percutaneous coronary intervention. The treatment of stent failure poses challenges and is associated with a worse prognosis than conventional percutaneous coronary intervention. Several studies have recently highlighted the value of intravascular imaging in identifying causes of stent failure, underscored its role in treatment planning, and registries have shown that its use may be associated with better clinical outcomes. The present review aims to summarize the evidence in the field; it discusses the value of intravascular imaging in identifying the mechanisms of in-stent restenosis and stent thrombosis in assessing the morphological characteristics of neointima tissue that appears to determine long-term outcomes in evaluating procedural results, and presents the findings of studies supporting its value in guiding therapy in stent failure.
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Affiliation(s)
- Emrah Erdogan
- Department of Cardiology, Barts Heart CentreBarts Health NHS TrustLondonUnited Kingdom
- Centre for Cardiovascular Medicine and DevicesWilliam Harvey Research Institute, Queen Mary University of LondonUnited Kingdom
- Department of Cardiology, Faculty of MedicineYuzuncu Yil UniversityVanTurkey
| | - Retesh Bajaj
- Department of Cardiology, Barts Heart CentreBarts Health NHS TrustLondonUnited Kingdom
- Centre for Cardiovascular Medicine and DevicesWilliam Harvey Research Institute, Queen Mary University of LondonUnited Kingdom
| | - Alexandra Lansky
- Centre for Cardiovascular Medicine and DevicesWilliam Harvey Research Institute, Queen Mary University of LondonUnited Kingdom
- Yale University School of MedicineNew HavenCT
| | - Anthony Mathur
- Department of Cardiology, Barts Heart CentreBarts Health NHS TrustLondonUnited Kingdom
- Centre for Cardiovascular Medicine and DevicesWilliam Harvey Research Institute, Queen Mary University of LondonUnited Kingdom
| | - Andreas Baumbach
- Department of Cardiology, Barts Heart CentreBarts Health NHS TrustLondonUnited Kingdom
- Centre for Cardiovascular Medicine and DevicesWilliam Harvey Research Institute, Queen Mary University of LondonUnited Kingdom
- Yale University School of MedicineNew HavenCT
| | - Christos V. Bourantas
- Department of Cardiology, Barts Heart CentreBarts Health NHS TrustLondonUnited Kingdom
- Centre for Cardiovascular Medicine and DevicesWilliam Harvey Research Institute, Queen Mary University of LondonUnited Kingdom
- Institute of Cardiovascular SciencesUniversity College LondonLondonUnited Kingdom
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Kawai K, Virmani R, Finn AV. In-Stent Restenosis. Interv Cardiol Clin 2022; 11:429-443. [PMID: 36243488 DOI: 10.1016/j.iccl.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
In-stent restenosis (ISR) remains a potential complication after percutaneous coronary intervention, even in the era of drug-eluting stents, and its treatment remains suboptimal. Neoatherosclerosis is an important component of the pathology of ISR and is accelerated in drug-eluting stents compared with bare-metal stents. Coronary angiography is the gold standard for evaluating the morphology of ISR, although computed tomography angiography is emerging as an alternative noninvasive modality to evaluate the presence of ISR. Drug-coated balloons and stent reimplantation are the current mainstays of treatment for ISR, and the choice of treatment should be based on clinical background and lesion morphology.
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Affiliation(s)
- Kenji Kawai
- CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Renu Virmani
- CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Aloke V Finn
- CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA; University of Maryland, School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
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Li H, Dai Q, Shu L, Wu T, Yang D, Liu Y. Stent retriever thrombectomy in the treatment of basal artery stent thrombosis: Two case reports. Medicine (Baltimore) 2022; 101:e30541. [PMID: 36086693 PMCID: PMC10980432 DOI: 10.1097/md.0000000000030541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/10/2022] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Stent thrombosis is a rare but serious complication that requires timely treatment. Catheter thrombectomy is the first-line therapy for this condition; however, it may be challenging for patients with in-stent emboli located in the basilar artery. PATIENT CONCERNS Herein, we reported 2 cases with stent thrombosis in the vertebrobasilar artery, including their imaging and clinical findings. Both patients were successfully treated with stent retriever thrombectomy. DIAGNOSIS The presence of cerebral infarction was diagnosed by magnetic resonance. Cranial computed tomography excluded cerebral hemorrhage, and basilar artery occlusion was considered in combination with the medical history. INTERVENTIONS After cerebral angiography confirmed basilar artery occlusion, the stent thrombectomy was used to remove the thrombus. OUTCOMES The emboli were removed from the stent, and the angiography confirmed that the blood flow in the posterior cerebral circulation was recovered to TICI level 3. Moreover, all symptoms disappeared. LESSONS Cerebral vascular stent thrombectomy is a feasible approach for treating cerebral vascular stent thrombosis.
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Affiliation(s)
- Hang Li
- The First Clinical Medical College, Henan University of Traditional Chinese Medicine, Zhengzhou, Henan, China
| | - Qinghai Dai
- The First Clinical Medical College, Henan University of Traditional Chinese Medicine, Zhengzhou, Henan, China
| | - Lingfeng Shu
- The First Clinical Medical College, Henan University of Traditional Chinese Medicine, Zhengzhou, Henan, China
| | - Tao Wu
- Department of Intervention, the First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, Henan, China
| | - Dongyi Yang
- Department of Intervention, the First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, Henan, China
| | - Yangyang Liu
- Department of Intervention, the First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, Henan, China
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Abouelnour A, Gori T. Intravascular imaging in coronary stent restenosis: Prevention, characterization, and management. Front Cardiovasc Med 2022; 9:843734. [PMID: 36017094 PMCID: PMC9395642 DOI: 10.3389/fcvm.2022.843734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Despite the introduction of drug-eluting stents to combat the neointimal hyperplasia that occurred after BMS implantation, in-stent restenosis is still encountered in a significant number of patients, particularly as increasingly complex lesions are tackled by percutaneous coronary intervention. Many biological and mechanical factors interplay to produce restenosis, some of which are avoidable. Intravascular imaging provided unique insights into various forms of stent-related mechanical issues that contribute to this phenomenon. From a practical perspective, intravascular imaging can therefore help to optimize the stenting procedure to avert these issues. Moreover, once the problem of restenosis eventuates, imaging can guide the management by tackling the underlying identified mechanism. Finally, it can be used to evaluate the re-intervention results. Nevertheless, with the emergence of different treatment options, more evidence is needed to define patient/lesion-specific characteristics that may help to tailor treatment selection in a way that improves clinical outcomes.
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Affiliation(s)
- Amr Abouelnour
- Zentrum für Kardiologie, Kardiologie I, Deutsches Zentrum für Herz und Kreislauf Forschung, University Medical Center Mainz, Mainz, Germany
- Department of Cardiovascular Medicine, Cardiovascular Institute, Assiut University, Assiut, Egypt
| | - Tommaso Gori
- Zentrum für Kardiologie, Kardiologie I, Deutsches Zentrum für Herz und Kreislauf Forschung, University Medical Center Mainz, Mainz, Germany
- *Correspondence: Tommaso Gori,
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Yi M, Wu L, Ke X. Prognostic Value of High-Sensitivity C-Reactive Protein in In-Stent Restenosis: A Meta-Analysis of Clinical Trials. J Cardiovasc Dev Dis 2022; 9:jcdd9080247. [PMID: 36005411 PMCID: PMC9409410 DOI: 10.3390/jcdd9080247] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/29/2022] [Accepted: 07/31/2022] [Indexed: 12/10/2022] Open
Abstract
Background: A risk assessment of in-stent restenosis (ISR) patients is critical for providing adequate treatment. Nevertheless, the prognostic value of high-sensitivity CRP (hs-CRP) levels on ISR has not been consistently demonstrated in clinical studies. In the current meta-analysis, we aim to assess the predictive role of hs-CRP in patients treated with stenting. Methods: We searched PubMed, Web of Science, Embase, and the Cochrane Registry through May 2022. We selected random control trials that compared the effects of different interventions, and that revealed the effects of hs-CRP. Two reviewers independently screened the articles, extracted the data, and assessed the quality of the studies according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The data were pooled using a random-effects meta-analysis. Results: Nine articles were included in the meta-analysis. A total of 1.049 patients received stent implantation, and 185 ISR events were recorded during the 1–12-month follow-up period. Baseline hs-CRP levels were not associated with the prediction of ISR among patients receiving stent implantation. The OR of hs-CRP for ISR was 1.81 (0.92–2.69). In the subgroup analysis, 6–12-month hs-CRP levels, diabetes mellitus (DM), and age ≥60(years)were associated with a higher risk of ISR. Conclusions: This meta-analysis shows that higher levels of baseline hs-CRP are not associated with an increased risk of ISR in stented patients. However, an increased risk of ISR was associated with hs-CRP levels at 6 to 12 months of follow-up, which is higher in studies with diabetes mellitus patients and the elderly.
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Affiliation(s)
- Ming Yi
- Department of Cardiology, Liuyang Hospital of Traditional Chinese Medicine, Liuyang 410300, China
- Department of Clinical Medicine, University of South China, Hengyang 421001, China
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen, (Shenzhen Sun Yat-sen Cardiovascular Hospital), Shenzhen 518057, China
| | - Lu Wu
- Department of Cardiology, Liuyang Hospital of Traditional Chinese Medicine, Liuyang 410300, China
- Correspondence: (L.W.); (X.K.)
| | - Xiao Ke
- Department of Clinical Medicine, University of South China, Hengyang 421001, China
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen, (Shenzhen Sun Yat-sen Cardiovascular Hospital), Shenzhen 518057, China
- Correspondence: (L.W.); (X.K.)
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Giustino G, Colombo A, Camaj A, Yasumura K, Mehran R, Stone GW, Kini A, Sharma SK. Coronary In-Stent Restenosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 80:348-372. [PMID: 35863852 DOI: 10.1016/j.jacc.2022.05.017] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/16/2022] [Accepted: 05/23/2022] [Indexed: 12/15/2022]
Abstract
The introduction and subsequent iterations of drug-eluting stent technologies have substantially improved the efficacy and safety of percutaneous coronary interventions. However, the incidence of in-stent restenosis (ISR) and the resultant need for repeated revascularization still occur at a rate of 1%-2% per year. Given that millions of drug-eluting stents are implanted each year around the globe, ISR can be considered as a pathologic entity of public health significance. The mechanisms of ISR are multifactorial. Since the first description of the angiographic patterns of ISR, the advent of intracoronary imaging has further elucidated the mechanisms and patterns of ISR. The armamentarium and treatment strategies of ISR have also evolved over time. Currently, an individualized approach using intracoronary imaging to characterize the underlying substrate of ISR is recommended. In this paper, we comprehensively reviewed the incidence, mechanisms, and imaging characterization of ISR and propose a contemporary treatment algorithm.
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Affiliation(s)
- Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Anton Camaj
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Keisuke Yasumura
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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13
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Abstract
In-stent restenosis (ISR) remains the most common cause of stent failure after percutaneous coronary intervention (PCI). Recent data suggest that ISR-PCI accounts for 5-10% of all PCI procedures performed in current clinical practice. This State-of-the-Art review will primarily focus on the management of ISR but will begin by briefly discussing diagnosis and classification. We then move on to detail the evidence base underpinning the various therapeutic strategies for ISR before finishing with a proposed ISR management algorithm based on current scientific data.
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Affiliation(s)
- Fernando Alfonso
- Department of Cardiology, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, IIS-IP, CIBER-CV, Calle de Diego de León 62, 28006 Madrid, Spain
| | - J. J. Coughlan
- Deutsches Herzzentrum München und Technische Universität München, Munich, Germany,Department of Cardiology, ISAResearch, German Heart Center, Munich, Germany,Cardiovascular Research Institute, Mater Private Network, Dublin, Ireland,School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Daniele Giacoppo
- Department of Cardiology, ISAResearch, German Heart Center, Munich, Germany,Cardiovascular Research Institute, Mater Private Network, Dublin, Ireland,School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland,Department of Cardiology, Alto Vicentino Hospital, Santorso, Italy
| | - Adnan Kastrati
- Deutsches Herzzentrum München und Technische Universität München, Munich, Germany,Department of Cardiology, ISAResearch, German Heart Center, Munich, Germany,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Robert A. Byrne
- Cardiovascular Research Institute, Mater Private Network, Dublin, Ireland,School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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14
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Madanchi M, Cioffi GM, Attinger-Toller A, Wolfrum M, Moccetti F, Seiler T, Vercelli L, Burkart P, Toggweiler S, Kobza R, Bossard M, Cuculi F. Long-term outcomes after treatment of in-stent restenosis using the Absorb everolimus-eluting bioresorbable scaffold. Open Heart 2021; 8:openhrt-2021-001776. [PMID: 34518287 PMCID: PMC8438862 DOI: 10.1136/openhrt-2021-001776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/27/2021] [Indexed: 01/28/2023] Open
Abstract
Background Early studies evaluating the performance of bioresorbable scaffold (BRS) Absorb in in-stent restenosis (ISR) lesions indicated promising short-term to mid-term outcomes. Aims To evaluate long-term outcomes (up to 5 years) of patients with ISR treated with the Absorb BRS. Methods We did an observational analysis of long-term outcomes of patients treated for ISR using the Absorb BRS (Abbott Vascular, Santa Clara, California, USA) between 2013 and 2016 at the Heart Centre Luzern. The main outcomes included a device-oriented composite endpoint (DOCE), defined as composite of cardiac death, target vessel (TV) myocardial infarction and TV revascularisation, target lesion revascularisation and scaffold thrombosis (ScT). Results Overall, 118 ISR lesions were treated using totally 131 BRS among 89 patients and 31 (35%) presented with an acute coronary syndrome. The median follow-up time was 66.3 (IQR 52.3–77) months. A DOCE had occurred in 17% at 1 year, 27% at 2 years and 40% at 5 years of all patients treated for ISR using Absorb. ScTs were observed in six (8.4%) of the cohort at 5 years. Conclusions Treatment of ISR using the everolimus-eluting BRS Absorb resulted in high rates of DOCE at 5 years. Interestingly, while event rates were low in the first year, there was a massive increase of DOCE between 1 and 5 years after scaffold implantation. With respect to its complexity, involving also a more unpredictable vascular healing process, current and future BRS should be used very restrictively for the treatment of ISR.
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Affiliation(s)
- Mehdi Madanchi
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | | | | | - Mathias Wolfrum
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Federico Moccetti
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Thomas Seiler
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Luca Vercelli
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Philipp Burkart
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Stefan Toggweiler
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Richard Kobza
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Matthias Bossard
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Florim Cuculi
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
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15
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Yasumura K, Ueyama H, Jeffrey S, Vengrenyuk Y, Barman N, Suleman J, Kini AS, Sharma SK. Rotational atherectomy for the management of undilatable in-stent restenosis with single or multiple stent layers. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 34:32-37. [PMID: 33514489 DOI: 10.1016/j.carrev.2021.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND There is no consensus on the best treatment of undilatable coronary in-stent restenosis (ISR) regardless of the number of stent layers. We aimed to evaluate the procedural and clinical outcomes of rotational atherectomy (RA) to treat undilatable coronary ISR with single or multiple stent layers. METHODS We retrospectively evaluated consecutive patients treated with RA for undilatable ISR with single or multiple stent layers in the Mount Sinai catheterization laboratory between January 2016 and September 2018. Procedural success was defined as angiographic success without in-hospital major adverse cardiac events (MACE): a composite of death, myocardial infarction (MI), and target lesion revascularization (TLR). Clinical outcomes were assessed at one-year post-procedure. RESULTS A total of 26 patients were included in the study, in which 18 (69.2%) patients were with multiple stent layers. After RA, 9 (34.6%) were received a new drug-eluting stent, and 6 (23.1%) were treated with intravascular brachytherapy. Angiographic success was achieved in 24 (92.3%) patients, and procedural success was achieved in 22 (84.6%) patients. In-hospital MACE occurred in 4 (15.4%) patients, all due to periprocedural non-Q wave MI. Within one year, MACE occurred in 9 (34.6%) patients with 5 (19.2%) TLR. CONCLUSIONS RA for undilatable ISR with single or multiple stent layers was performed with favorable procedural outcomes and a relatively high MACE rate driven by TLR within one year.
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Affiliation(s)
- Keisuke Yasumura
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Hiroki Ueyama
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Selan Jeffrey
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Yuliya Vengrenyuk
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Nitin Barman
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Javed Suleman
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Annapoorna S Kini
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Samin K Sharma
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, NY, New York, USA.
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16
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Outcomes With Combined Laser Atherectomy and Intravascular Brachytherapy in Recurrent Drug-Eluting Stent In-Stent Restenosis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 22:29-33. [DOI: 10.1016/j.carrev.2020.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/10/2020] [Accepted: 06/10/2020] [Indexed: 11/24/2022]
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17
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Intracoronary Vascular Brachytherapy in the Contemporary Drug-Eluting Stent Era: Peeling Back the Stent Layers of the Proverbial "In-Stent Restenosis Onion". CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 23:36-37. [PMID: 33272882 DOI: 10.1016/j.carrev.2020.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 11/20/2022]
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18
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Laksono S, Setianto B, Surya SP. Drug-eluting balloon: is it useful? Egypt Heart J 2020; 72:80. [PMID: 33175218 PMCID: PMC7658274 DOI: 10.1186/s43044-020-00116-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/30/2020] [Indexed: 01/09/2023] Open
Abstract
Background Coronary artery disease is one of the major issues in the medical world around the globe. The prevalence tends to increase. The use of coronary intervention is one of the ways often used in the management of coronary artery disease due to its satisfying result from earlier studies. Nowadays, there are several different techniques in coronary intervention: balloon vs stent. Main body The stent-based vascular interventions are increasingly being used over balloon-based coronary intervention. However, revascularization intervention using stent often have undesirable long-term effects compared to balloon. Besides, stent-based interventions are also considered more expensive, use more complicated techniques, and use more drug regimens. On the other hand, percutaneous coronary intervention techniques using balloons coated by anti-proliferation drugs have begun to be glimpsed by many interventionists. Studies have found many benefits that cannot be given by stent-based intervention therapy. Conclusions Angioplasty using percutaneous coronary intervention techniques reveals satisfying result compared to conservative medical treatment. The indication and technique of percutaneous coronary intervention is still evolving until now. Currently, percutaneous coronary intervention using stent, either bare-metal stent or drug-eluting stent, is preferred by interventionist. Nevertheless, recent clinical trial favors the using of drug-eluting balloon for percutaneous coronary intervention in terms of both clinical outcome and complication in several scenarios.
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Affiliation(s)
- Sidhi Laksono
- Cardiac Catheterization Laboratory, Department of Cardiology and Vascular Medicine, RSUD Pasar Rebo, Jakarta, Indonesia. .,Faculty of Medicine, Universitas Muhammadiyah Prof. DR. Hamka, Tangerang, Indonesia.
| | - Budhi Setianto
- Department of Cardiology and Vascular Medicine of National Cardiovascular Center of Harapan Kita, Faculty of Medicine of Universitas Indonesia, Jakarta, Indonesia
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19
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Impact of hemodialysis on clinical and angiographic outcomes in in-stent restenotic lesions following optical coherence tomography-guided drug-coated balloon treatment. Cardiovasc Interv Ther 2020; 36:429-435. [PMID: 33048289 DOI: 10.1007/s12928-020-00718-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
Hemodialysis (HD) is associated with a high in-stent restenosis (ISR) rate even in the second-generation era. Drug-coated balloons (DCB) generally provide excellent clinical outcomes in patients with ISR lesions. Nonetheless, safety and efficacy of DCB for ISR lesions in HD patients are largely unknown. A total of 17 centers across Japan participated in this study. Patients were eligible for the study if ISR lesions were treated with DCB. Enrolled patients were divided into 2 groups (HD and non-HD groups). Angiographic, OCT, and clinical outcomes were compared between the HD and the non-HD groups. A total of 210 patients were enrolled (36 patients in the HD group, and 174 patients in the non-HD group). At 8 months, the binary restenosis rate was significantly higher (26.3% versus 11.3%, p = 0.02) and in-segment late loss was significantly higher (0.49 ± 0.61 mm versus 0.23 ± 0.33 mm, p = 0.02) in the HD group than the non-HD group. In the OCT analyses, change of minimum stent area between post- and pre-procedure was significantly smaller in the HD group compared to the non-HD group (0.08 ± 0.95 mm2 versus 0.68 ± 1.07 mm2, p = 0.004). Target vessel failure (TVF) rate at 2 years was significantly different between the 2 groups (25.0% in the HD group and 12.1% in the non-HD group, p = 0.04). In the multivariate analysis, HD was a significant predictor for TVF (Hazard ratio 5.81, 95% CI 1.28-26.4, p = 0.02). Clinical and angiographic outcomes following OCT-guided DCB treatment in ISR lesions were significantly worse in HD patients compared to non-HD patients.Clinical Trial Registration Information: https://clinicaltrials.gov/ct2/show/NCT02300454.
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20
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Megaly M, Glogoza M, Xenogiannis I, Vemmou E, Nikolakopoulos I, Omer M, Saad M, Willson L, Monyak DJ, Sullivan P, Pershad A, Chavez I, Mooney M, Traverse J, Wang Y, Garcia S, Poulose A, Burke MN, Brilakis ES. Coronary Intravascular Brachytherapy for Recurrent Coronary Drug-Eluting Stent In-Stent Restenosis: A Systematic Review and Meta-Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 23:28-35. [PMID: 32883584 DOI: 10.1016/j.carrev.2020.08.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To examine the outcomes with intravascular brachytherapy (IVBT) in recurrent in-stent restenosis (ISR). BACKGROUND Recurrent ISR can be challenging to treat and IVBT can be used for recurrent ISR but has received limited study. METHODS We performed a systematic review and meta-analysis of five observational studies, including 917 patients (1014 lesions) with recurrent ISR, defined as having at least two prior ISR episodes with previous treatment with a stent, who underwent treatment with IVBT. Outcomes of interest included target vessel revascularization (TVR), myocardial infarction (MI), and all-cause mortality. RESULTS During a mean follow-up of 24 ± 7 months, the incidence of TVR was 29.2% (95% CI 18.0-40.4%). The incidence of MI and all-cause mortality were 4.3% (95% CI 1.7%-6.9%) and 7.3% (95% CI 3.2-11.5%), respectively. At one- and two-years after PCI the incidence of TVR was 17.5% (95% CI 13.6%-21.4%) and 26.7% (95% CI 16.6%-36.9%), respectively and the incidence of MI was 3.1% (95% CI 2-4.2%) and 3.9% (95% CI 1-6.8%), respectively. CONCLUSION Intravascular brachytherapy can be used to treat recurrent ISR, although TVR is needed in approximately one of four patients at two years.
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Affiliation(s)
- Michael Megaly
- Banner University Medical Center, UA College of Medicine-Phoenix, AZ, USA
| | | | | | - Evangelia Vemmou
- Minneapolis Heart Institute at Abbott Northwestern Hospital, USA
| | | | | | - Marwan Saad
- Division of Cardiovascular Medicine, The Warren Alpert School of Medicine at Brown University, Providence, RI, USA
| | | | - David J Monyak
- Minneapolis Heart Institute at Abbott Northwestern Hospital, USA
| | - Patsa Sullivan
- Minneapolis Heart Institute at Abbott Northwestern Hospital, USA
| | - Ashish Pershad
- Banner University Medical Center, UA College of Medicine-Phoenix, AZ, USA
| | - Ivan Chavez
- Minneapolis Heart Institute at Abbott Northwestern Hospital, USA
| | - Michael Mooney
- Minneapolis Heart Institute at Abbott Northwestern Hospital, USA
| | - Jay Traverse
- Minneapolis Heart Institute at Abbott Northwestern Hospital, USA
| | - Yale Wang
- Minneapolis Heart Institute at Abbott Northwestern Hospital, USA
| | - Santiago Garcia
- Minneapolis Heart Institute at Abbott Northwestern Hospital, USA
| | - Anil Poulose
- Minneapolis Heart Institute at Abbott Northwestern Hospital, USA
| | - M Nicholas Burke
- Minneapolis Heart Institute at Abbott Northwestern Hospital, USA
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21
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Yin D, Mintz GS, Song L, Chen Z, Lee T, Kirtane AJ, Parikh MA, Moses JW, Fall KN, Jeremias A, Ali ZA, Shlofmitz RA, Maehara A. In-stent restenosis characteristics and repeat stenting underexpansion: insights from optical coherence tomography. EUROINTERVENTION 2020; 16:e335-e343. [DOI: 10.4244/eij-d-18-01191] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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22
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Megaly M, Glogoza M, Xenogiannis I, Vemmou E, Nikolakopoulos I, Willson L, Monyak DJ, Sullivan P, Stanberry L, Sorajja P, Chavez I, Mooney M, Traverse J, Wang Y, Garcia S, Poulose A, Burke MN, Brilakis ES. Outcomes of intravascular brachytherapy for recurrent drug-eluting in-stent restenosis. Catheter Cardiovasc Interv 2020; 97:32-38. [PMID: 31943747 DOI: 10.1002/ccd.28716] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/25/2019] [Accepted: 12/29/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To examine the outcomes of vascular brachytherapy (VBT) for recurrent drug-eluting stents (DES) in-stent restenosis (ISR). BACKGROUND Recurrent DES-ISR can be challenging to treat. VBT has been used with encouraging results. METHODS We report the long-term outcomes of patients with recurrent DES-ISR treated with VBT between January 2014 and September 2018 at a tertiary care institution. The main outcome was target lesion failure (TLF), defined as the composite of clinically driven target lesion revascularization (TLR), target lesion myocardial infarction (MI), and target lesion-related cardiac death. Cox proportional hazards analysis was performed to identify variables associated with recurrent TLF. RESULTS During the study period, 116 patients (143 lesions) underwent VBT. Median follow-up was 24.7 (14.5-35.4) months. The incidence of TLR, target-lesion MI, and TLF was 18.9%, 5.6%,and 20.1% at 1 year, and 29.4%, 10.5%, and 32.9% at 2 years.Initial presentation with acute coronary syndrome (ACS) was independently associated with TLF (hazard ratio = 1.975, 95% CI [1.120, 3.485], p = .019). Lesions treated with intravascular ultrasound (IVUS) guidance had a lower incidence of TLR (14.3% vs. 39.6%, log-rank p = .038), and a trend toward lower incidence of TLF (19% vs. 42.6%, log-rank p = .086). CONCLUSIONS VBT can improve the treatment of recurrent DES-ISR, but TLF occurs in approximately one in three patients at 2 years. Initial presentation with ACS was associated with higher TLF and the use of IVUS with a trend for lower incidence of TLF.
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Affiliation(s)
- Michael Megaly
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota.,Department of Cardiovascular Medicine, Hennepin Healthcare, Minneapolis, Minnesota
| | - Matthew Glogoza
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Iosif Xenogiannis
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Evangelia Vemmou
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Ilias Nikolakopoulos
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Laura Willson
- Department of Radiation Oncology, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - David J Monyak
- Department of Radiation Oncology, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Patsa Sullivan
- Department of Radiation Oncology, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Larissa Stanberry
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Paul Sorajja
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Ivan Chavez
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Michael Mooney
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Jay Traverse
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Yale Wang
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Santiago Garcia
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Anil Poulose
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | - Emmanouil S Brilakis
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
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23
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Abstract
Despite on-going evolution and iteration of drug-eluting stent (DES) technology, the prevalence of in-stent restenosis (ISR) remains relatively unchanged, encompassing ≈10% of percutaneous coronary interventions. The mechanism of ISR is multifactorial, including biological, mechanical, patient, and operator-related factors. The main mechanical contributors are stent underexpansion or fracture, while biological factors include local inflammation leading to aggressive neointimal proliferation and late neoatherosclerosis. Intracoronary imaging is critical to identify the mechanism of ISR and tailor therapy accordingly. The presentation of DES-ISR is not benign and is challenging for optimal treatment. Among the proposed treatment modalities are scoring and high-pressure balloons, percutaneous coronary intervention with additional DES, atheroablative therapies by laser or mechanical atherectomy, drug-coated balloons, vascular brachytherapy, and surgical revascularization. We propose a new classification for ISR that differentiates among mechanical, biological, and mixed etiologies. Stratifying ISR by mechanism guides individualized treatment of DES-ISR to improve clinical outcomes. An algorithmic approach, guided by intracoronary imaging, for the treatment of DES-ISR, is recommended based on the specific cause of restenosis.
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Affiliation(s)
- Evan Shlofmitz
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Micaela Iantorno
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
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24
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Affiliation(s)
- Fernando Alfonso
- Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Javier Cuesta
- Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain
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