Ten-Year Clinical Outcomes From a Trial of Three Limus-Eluting Stents With Different Polymer Coatings in Patients With Coronary Artery Disease

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prospective randomized single-blind multicenter study to assess the safety and effectiveness of the SELUTION SLR 014 drug eluting balloon in the treatment of subjects with in-stent restenosis: Rationale and design

BACKGROUND

Repeat drug-eluting stenting is superior to balloon angioplasty for prevention of recurrent in-stent restenosis (ISR), but carries a potential disadvantage of multiple layers of stent. The safety and effectiveness of a sirolimus drug-eluting balloon as an alternative has not been assessed.

STUDY DESIGN AND METHODS

The SELUTION4ISR trial is a prospective, multicenter, single-blinded, randomized, controlled trial. A total of 418 subjects with bare metal or drug-eluting stent (DES) ISR with up to 2 previous stent procedures at the target lesion, lesion length <26 mm and reference diameter ≥2.0 mm - ≤4.5 mm will be randomized 1:1 to treatment with either the SELUTION SLR™ DEB (SLR DEB) or standard of care (SOC), which includes either repeat DES or balloon angioplasty without drug coating. A subset of subjects will undergo planned angiographic and optical coherence tomography follow-up. The primary endpoint will be target lesion failure, defined as cardiac death, target vessel myocardial infarction, or clinically-driven target lesion revascularization at 12 months follow-up. The study will sequentially assess noninferiority of the SLR DEB to SOC in the overall cohort, followed by noninferiority then superiority of the SLR DEB to DES in the cohort with only 1 previous stent at the target lesion.

TRIAL REGISTRATION

The trial is registered at Clinicaltrials.gov (NCT04280029).

CURRENT STATUS

The trial completed enrollment in July 2024.

CONCLUSION

The SELUTION4ISR study will evaluate the safety and effectiveness of SLR DEB in a prospective, randomized, international, multicenter trial for treatment of coronary ISR.

Smoking Status at Baseline and 10-Year Outcomes After Drug-Eluting Stent Implantation: Insights From the DECADE Cooperation

BACKGROUND

Studies investigating 10-year outcomes according to smoking status at baseline in a largescale population undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation are scarce.

OBJECTIVES

The authors sought to assess the association between smoking status at baseline and 10-year outcomes after PCI with DES implantation.

METHODS

We pooled individual participant data from 5 randomized trials including patients with 10-year follow-up after DES implantation. We divided participants into 2 groups as per smoking status at baseline. The main outcome was all-cause death. Secondary outcomes included cardiovascular death, myocardial infarction (MI), definite stent thrombosis (ST), and repeat revascularization (of target lesion, target vessel [TVR], or non-target vessel).

RESULTS

A total of 9,527 patients undergoing PCI with DES implantation were included in this analysis, (smoking n = 2,365; nonsmoking, n = 7,162). After multivariable adjustment, smoking was associated with a higher risk of all-cause death (HRadj: 1.45; 95% CI: 1.33-1.59), cardiovascular death (HRadj: 1.59; 95% CI: 1.41-1.80), and definite ST (HRadj: 2.09; 95% CI: 1.34-3.26) over 10 years after PCI. The risk of MI was comparable in the first 30 days after PCI, but increased significantly from 1 to 10 years in the smoking group (HRadj: 1.60; 95% CI: 1.36-1.90). Smoking was associated with a lower risk of target lesion revascularization and target vessel revascularization, but a comparable risk of non-target vessel revascularization.

CONCLUSIONS

In patients undergoing PCI with DES, smoking at baseline is associated with an increased risk of death, MI, and ST, but a lower risk of repeat revascularization through to 10 years.

Drug-eluting resorbable coronary scaffolds: a review of recent advances

INTRODUCTION

Device-related persistent adverse events with current DES-use have refocused the attention on a 'leave-nothing-behind' philosophy, in which it is hypothesized that treating coronary stenosis without permanently caging the vessel with a metallic implant would lead to superior clinical outcomes. One of these uncaging technologies is bioresorbable scaffolds (BRS).

AREAS COVERED

In this article, we describe the technical specifications and clinical data of currently available BRS devices.

EXPERT OPINION

Newer BRS devices have thinner struts and more biocompatible scaffold backbones (either polymer-based or metal-based), resulting in improved radial strength, faster resorption times, and more antithrombogenic properties (e.g. magnesium-based scaffolds). Results of BRS in the treatment of simple coronary artery disease demonstrate favorable clinical efficacy and safety outcome data. It is probable that over the next 5 years more fourth-generation devices with ever-increasing biocompatibility and safety profiles will be investigated and released commercially, resulting in a much more prominent role for BRS, especially in the treatment of simple coronary artery disease in younger patients.

Drug-Coated Balloon-Based Intervention for Coronary Artery Disease: The Second Report of Asia-Pacific Consensus Group

Drug-coated balloons (DCBs) provide a stent-free alternative, reducing risks like stent thrombosis and in-stent restenosis and the need for prolonged dual antiplatelet therapy. Recent studies show that DCBs can be effective and safe across various coronary artery diseases (CADs) when lesions are adequately prepared. Specifically, all coronary lesions are treated using the provisional approach, where active lesion preparation is followed by DCB or drug-eluting stent treatment, depending on the results. This approach means DCB is considered the default device before initiating intervention, with efforts focused on obtaining adequate lesion preparation. Depending on the result, DCB or drug-eluting stent is selected, which is termed DCB-based percutaneous coronary intervention. Therefore, this second report of the Asia-Pacific Consensus Group provides practical guidelines (DCB-based percutaneous coronary intervention) based on the latest evidence for DCB treatment in CAD and aims to expand its application across various CADs, facilitating its effective use in real-world clinical practice.

Sex-related outcomes after percutaneous coronary intervention of in-stent restenosis

Limited data are available for sex-related long-term outcomes of patients treated for coronary drug-eluting stent (DES) restenosis. The aim of this observational, retrospective analysis was to close this lack of evidence. Between January 2007 and February 2021, a total of 3511 patients with 5497 in-stent restenosis (ISR) lesions were treated at two large-volume centers in Munich, Germany, of which 763 (21.7%) were female. Endpoints of interest were all-cause mortality and rates of repeat revascularization. Outcomes are presented as Kaplan-Meier event rates. Univariate and multivariate analyses were performed. Female patients were older (72.1 ± 10.4 versus 68.4 ± 10.4 years, p < 0.001) and suffered more often from diabetes (38.8% versus 34.4%, p = 0.029). There was no statistical difference regarding the clinical presentation and interventional treatment strategy. After 10 years, the risk of all-cause mortality was higher in female patients [hazard ratio (HR) 1.18 (1.02-1.35); p = 0.022]; however, after adjustment for age, the risk did not differ significantly between both sexes [adjusted HR 0.96 (0.83-1.11); p = 0.6]. Regarding target vessel revascularization (TVR) and non-target vessel revascularization (NTVR), the risk was lower in female patients [HR 0.73 (0.61-0.87); p < 0.001 and HR 0.74 (0.64-0.86); p < 0.001] even after age adjustment. No statistical differences were found regarding the risk of target lesion revascularization, target vessel myocardial infarction and stent thrombosis. In the long term, all-cause mortality after percutaneous coronary intervention of DES-ISR did not differ between both sexes after age adjustment. The risk of TVR and NTVR was lower in female patients even after age adjustment.

Randomized Trial of Biolimus DCB for In-Stent Restenosis: The Primary Results of the REFORM Study

BACKGROUND

In recent years, drug-coated balloon (DCB) angioplasty has become an established treatment option for the treatment of coronary in-stent restenosis (ISR).

OBJECTIVES

The aim of this study was to compare the angiographic and clinical performance of the Biolimus A9-coated balloon (BCB; Biosensors Europe) with that of the paclitaxel-coated balloon (PCB; SeQuent Please, Braun Melsungen).

METHODS

REFORM (Prospective, Randomized, Non-Inferiority Trial to Determine the Safety and Efficacy of the Biolimus A9™ Drug Coated Balloon for the Treatment of In-Stent Restenosis: First-in-Man Trial) was a multicenter, assessor-blinded, noninferiority, 2:1 randomized controlled trial comparing the BCB and the PCB for the treatment of coronary ISR. The primary endpoint was in-segment percentage diameter stenosis at 6 months. Secondary endpoints included target lesion failure. The trial was registered prospectively at ClinicalTrials.gov (NCT04079192).

RESULTS

A total of 202 patients were randomized at 20 centers in 6 countries, with 135 in the BCB group and 67 in the PCB group. The mean patient age was 68.5 ± 10 years. At 6 months, in-segment percentage diameter stenosis was 43.3% ± 22.9% in the BCB group compared with 31.4% ± 17.7% in the PCB group (95% CI for the difference: 4.9%-18.8%; prespecified noninferiority margin 12%, noninferiority P = 0.48). At 1 year, target lesion failure was observed in 23.7% of patients in the BCB group vs 17.1% in the PCB group (HR: 1.44; 95% CI: 0.72-2.88; P = 0.28).

CONCLUSIONS

In patients with ISR, the REFORM study failed to demonstrate noninferiority of the investigational biolimus DCB compared with the standard paclitaxel DCB.

10-year follow-up of patients with titanium-nitride-oxide-coated stents versus everolimus-eluting stents in acute coronary syndrome

OBJECTIVES

The aim of this study was to compare 10-year clinical outcomes of titanium-nitride-oxide-coated (TiNO)-stent versus permanent polymer everolimus-eluting (EES), for the primary endpoint of major adverse cardiac events (MACE) in patients with acute coronary syndrome (ACS).

BACKGROUND

Previous trials with ACS patients have demonstrated non-inferiority of TiNO-stents compared with EES for clinical events up to 5-year follow-up. Long-term data from randomized clinical stent trials are scarce.

METHODS

BASE-ACS trial randomized 827 ACS patients to receive either TiNO-stent or EES in a 1:1 fashion. The primary endpoint was MACE: a composite of cardiac death, non-fatal myocardial infarction (MI) or ischemia-driven target lesion revascularization (TLR).

RESULTS

MACE was significantly lower in the TiNO group compared to EES group (19.2 % vs. 28.3 %; HR 0.72; CI 0.53-0.99; p = 0.04), driven mainly by reduction in MI (8.5 % vs. 13.9 %; HR 0.59; CI 0.37-0.93; p = 0.02) and cardiac death (3.4 % vs. 7.2 %; HR 0.55; CI 0.27-1.14; p = 0.09 (NS). The rate of TLR tended to be less frequent in the TiNO group (10.2 % vs. 15.1 %; HR 0.73; CI 0.48-1.12; p = 0.15 (NS). The rate of definite stent thrombosis was significantly less frequent in the TiNO group (1.8 % vs. 5.4 %; HR 0.32; CI 0.13-0.81; p = 0.01.

CONCLUSIONS

At 10-year follow-up, the rate of MACE was significantly lower in ACS patients treated with TiNO-stents compared to patients treated with EES.

Body Mass Index and 10-Year Clinical Outcomes After Percutaneous Coronary Intervention-Interaction with Age, Sex, Diabetic Status and Clinical Presentation

Background/Objective: The association of body mass index (BMI) with long-term outcomes following percutaneous coronary intervention (PCI) remains poorly investigated. We undertook this study to assess the association between BMI and long-term outcomes after PCI. Methods: Overall, 5597 patients with coronary artery disease undergoing PCI were included in the study. Patients were categorized in groups according to the following BMI categories: underweight group (BMI <18.5 kg/m2), normal weight group (BMI 18.5 kg/m2 to <25 kg/m2), overweight group (BMI 25 kg/m2 to <30 kg/m2) and obesity group (BMI ≥30 kg/m2). The primary endpoint was all-cause mortality at 10 years. Results: At 10 years, all-cause deaths (primary endpoint) occurred in 1754 patients: 31 deaths (59.7%) in the underweight group, 582 deaths (39.1%) in the normal weight group, 710 deaths (31.1%) in the overweight group and 431 deaths (33.8%) in the obesity group (overall p < 0.001; p for nonlinearity <0.001). Nonsurvivors had a significantly lower BMI compared with survivors (26.5 [24.2-29.9] kg/m2 vs. 27.2 [24.8-30.1] kg/m2, p < 0.001). Interaction testing showed a BMI-by-age interaction denoting a stronger association between higher BMI (≥25 kg/m2) and reduced risk of all-cause mortality in patients ≥75 years of age (Pint = 0.009). The association of BMI with all-cause mortality was U-shaped (p for nonlinearity < 0.001). The C-statistic of the multivariable Cox proportional hazards model for mortality increased from 0.762 [0.751-0.773] with baseline variables only to 0.766 [0.756-0.777], p < 0.001) after the BMI inclusion in the model (baseline variables plus BMI). Conclusions: In patients with coronary artery disease undergoing PCI, BMI was associated with 10-year mortality with a U-shaped relationship.

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

INTRODUCTION AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

One-Year Prognosis for Patients Diagnosed with Acute Coronary Syndrome Compared to Those with Chronic Coronary Syndrome Following Complex Coronary Procedures

Background: Acute coronary syndrome (ACS) remains the primary cause of mortality worldwide. Performing complex coronary intervention in patients with ACS is considered a significant factor for worsening prognosis. This study aimed to evaluate the prognosis of patients with ACS treated with complex procedures compared to patients with chronic coronary syndrome (CCS). Methods: Among 980 patients from the Polish Complex Registry, we enrolled 829 consecutive patients who underwent complex percutaneous coronary intervention (PCI) for acute or chronic coronary syndrome with a completed one-year follow-up. The primary endpoint is defined as the major adverse cardiac event (MACE) at 12 months, a composite endpoint including all-cause death, target lesion revascularization, target vessel revascularization, and non-fatal myocardial infarction. Results: The incidence of the composite endpoint of MACE at one-year follow-up was comparable between the patients with acute and chronic coronary syndrome who underwent complex PCI (12.4% vs. 7.6%, LogRank p = 0.035). Cox multivariate analysis indicated that ACS is an independent risk factor for death at one-year follow-up. Additionally, age and comorbidities, such as heart failure and chronic kidney disease, along with procedural factors, including lesion length and pre-procedural diameter stenosis, are independent predictors of death in patients with complex lesions. Independent risk factors for MACE at one-year follow-up include age, heart failure, previous PCI, in-stent restenosis, and pre-procedural diameter stenosis. Conclusions: The prognosis of patients with acute and chronic coronary syndrome in the annual follow-up is comparable in the context of cardiovascular events. The clinical presentation of ACS is an independent risk factor for all-cause death.

Ten-year clinical outcomes after drug-eluting stents implantation according to clinical presentation-Insights from the DECADE cooperation

BACKGROUND

Investigations of very long-term outcomes after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) according to clinical presentation are scarce. Here, we investigated the 10-year clinical outcomes of patients undergoing DES-PCI according to clinical presentation.

METHODS

Patient-level data from five randomized trials with 10-year follow-up after DES-PCI were pooled. Patients were dichotomized into acute coronary syndrome (ACS) or chronic coronary syndrome (CCS) groups as per clinical presentation. The primary outcome was all-cause death. Secondary outcomes were cardiovascular death, myocardial infarction (MI), definite stent thrombosis (ST) and repeat revascularization involving the target lesion (TLR), target vessel (TVR) or non-target vessel (nTVR).

RESULTS

Of the 9700 patients included in this analysis, 4557 presented with ACS and 5143 with CCS. Compared with CCS patients, ACS patients had a higher risk of all-cause death and nTVR in the first year, but comparable risk thereafter. In addition, ACS patients had a higher risk of MI [adjusted hazard ratio 1.21, 95% confidence interval (1.04-1.41)] and definite ST [adjusted hazard ratio 1.48, 95% confidence interval (1.14-1.92)], while the risk of TLR and TVR was not significantly different up to 10-year follow-up.

CONCLUSIONS

Compared to CCS patients, ACS patients treated with PCI and DES implantation have an increased risk of all-cause death and repeat revascularization of remote vessels up to 1 year, with no significant differences thereafter and up to 10-year follow-up. ACS patients have a consistently higher risk of MI and definite ST. Whether these differences persist with current antithrombotic and secondary prevention therapies requires further investigation.

Sirolimus-coated balloon versus drug-eluting stent for complex coronary lesions. A propensity matched comparison

INTRODUCTION

Percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in complex coronary artery disease (CAD) has been established as the standard of care, but stent-related events are not uncommon. Sirolimus-Coated Balloon (SCB)-based angioplasty is an emerging technology, although it needs to be thoroughly evaluated compared with DES in the complex PCI setting. This study aimed to investigate the safety and efficacy of SCB-based angioplasty compared with new-generation DES in complex PCI.

METHODS

Net adverse cardiovascular events (NACE: all-cause death, target lesion revascularization, non-fatal myocardial infarction, and major bleedings according to BARC classification), as a primary study endpoint was compared between SCB and new-generation DES for complex coronary lesions.

RESULTS

Among 1782 patients with complex CAD, 1076 were treated with a sirolimus-coated balloon (EASTBOURNE Registry) and 706 with new-generation DES (COMPLEX Registry). After propensity score matching, a total of 512 patients in both groups were analyzed. NACE occurred more significantly in the DES group during the 1-year follow-up (10.5% vs. 3.9%, p = 0.003), mainly due to a higher risk of bleeding (6.6% vs. 0.4%, p = 0.001). The Cox model adjusted for lesion length showed a significantly lower hazard of NACE (HR: 0.23, CI [0.10, 0.52], p < 0.001) and all-cause mortality (HR: 0.07, CI [0.01, 0.66], p = 0.020) in SCB compared to DES group.

CONCLUSIONS

SCB angioplasty has an advantage over DES for the treatment of complex CAD regarding NACE, significantly reducing the incidence of major bleeding without increasing ischemic endpoints. SCB may be an alternative to DES in selected patients with complex coronary lesions.

Impaired Kidney Function and 10-Year Outcome After Percutaneous Coronary Intervention-Interaction with Age, Sex, Diabetic Status and Clinical Presentation

Background: Limited evidence exists regarding the association of chronic kidney disease (CKD) with long-term outcomes following percutaneous coronary intervention (PCI). We aimed to assess the association of CKD with 10-year outcome after PCI. Methods: This study included 5571 patients with coronary artery disease (CAD) undergoing PCI. Patients were categorized in groups according to the estimated glomerular filtration rate (eGFR) values: eGFR ≥ 90 mL/min/1.73 m2, (normal kidney function), 60 to <90 mL/min/1.73 m2 (mild kidney impairment), 30 to <60 mL/min/1.73 m2 (mild-to-moderate and moderate-to-severe kidney impairment) and <30 mL/min/1.73 m2 (severe kidney impairment). The primary endpoint was all-cause mortality at 10 years. Results: All-cause deaths occurred in 155 patients (86.3%) with eGFR < 30 mL/min/1.73 m2, 602 patients (59.1%) with eGFR 30 to <60 mL/min/1.73 m2, 775 patients (31.3%) with eGFR 60 to <90 mL/min/1.73 m2 and 220 patients (15.8%) with eGFR ≥ 90 mL/min/1.73 m2 (adjusted hazard ratio = 2.16, 95% confidence interval 1.84 to 2.54, p < 0.001, for 30 mL/min/1.73 m2 decrement in the eGFR). There were CKD-by-age (Pint < 0.001) and CKD-by-clinical presentation (Pint = 0.017) interactions showing a stronger association of CKD with mortality in younger patients and those presenting with acute coronary syndromes. The C statistic of the multivariable model for mortality increased from 0.748 [0.737-0.759] to 0.766 [0.755-0.777] (p < 0.001) after the inclusion of eGFR in the model. Conclusions: In patients with CAD undergoing PCI, CKD was associated with higher mortality at 10 years compared with patients with preserved renal function. The association between CKD and mortality was stronger in patients of younger age and those presenting with acute coronary syndromes.

Drug-Coated Balloon Treatment for De Novo Coronary Lesions: Current Status and Future Perspectives

The outstanding development in contemporary medicine, highlighted by percutaneous coronary intervention (PCI), was achieved through the adoption of drug-eluting stents (DESs). Although DES is the established therapy for patients undergoing PCI for de novo coronary artery disease (CAD), their drawbacks include restenosis, stent thrombosis, and the requirement for dual antiplatelet therapy (DAPT) with an uncertain duration regarding its optimality. Drug-coated balloon (DCB) treatment leaves nothing behind on the vessel wall, providing the benefit of avoiding stent thrombosis and not necessitating obligatory extended DAPT. After optimizing coronary blood flow, DCB treatment delivers an anti-proliferative drug directly coated on a balloon. Although more evidence is needed for the application of DCB treatment in de novo coronary lesions, recent studies suggest the safety and effectiveness of DCB treatment for diverse conditions including small and large vessel diseases, complex lesions like bifurcation lesions or diffuse or multivessel diseases, chronic total occlusion lesions, acute myocardial infarctions, patients at high risk of bleeding, and beyond. Consequently, we will review the current therapeutic choices for managing de novo CAD using DCB and assess the evidence supporting their concurrent application. Additionally, it aims to discuss future important perspectives.

Nanoarchitectonic Engineering of Thermal-Responsive Magnetic Nanorobot Collectives for Intracranial Aneurysm Therapy

Stent-assisted coiling is a main treatment modality for intracranial aneurysms (IAs) in clinics, but critical challenges remain to be overcome, such as exogenous implant-induced stenosis and reliance on antiplatelet agents. Herein, an endovascular approach is reported for IA therapy without stent grafting or microcatheter shaping, enabled by active delivery of thrombin (Th) to target aneurysms using innovative phase-change material (PCM)-coated magnetite-thrombin (Fe3O4-Th@PCM) FTP nanorobots. The nanorobots are controlled by an integrated actuation system of dynamic torque-force hybrid magnetic fields. With robust intravascular navigation guided by real-time ultrasound imaging, nanorobotic collectives can effectively accumulate and retain in model aneurysms constructed in vivo, followed by controlled release of the encapsulated Th for rapid occlusion of the aneurysm upon melting the protective PCM (thermally responsive in a tunable manner) through focused magnetic hyperthermia. Complete and stable aneurysm embolization is confirmed by postoperative examination and 2-week postembolization follow-up using digital subtraction angiography (DSA), contrast-enhanced ultrasound (CEUS), and histological analysis. The safety of the embolization therapy is assessed through biocompatibility evaluation and histopathology assays. This strategy, seamlessly integrating secure drug packaging, agile magnetic actuation, and clinical interventional imaging, avoids possible exogenous implant rejection, circumvents cumbersome microcatheter shaping, and offers a promising option for IA therapy.

3D-printed, citrate-based bioresorbable vascular scaffolds for coronary artery angioplasty

Fully bioresorbable vascular scaffolds (BVSs) aim to overcome the limitations of metallic drug-eluting stents (DESs). However, polymer-based BVSs, such as Abbott's Absorb, the only US FDA-approved BVS, have had limited use due to increased strut thickness (157 μm for Absorb), exacerbated tissue inflammation, and increased risk of major cardiac events leading to inferior clinical performance when compared to metallic DESs. Herein we report the development of a drug-eluting BVS (DE-BVS) through the innovative use of a photopolymerizable, citrate-based biomaterial and a high-precision additive manufacturing process. BVS with a clinically relevant strut thickness of 62 μm can be produced in a high-throughput manner, i.e. one BVS per minute, and controlled release of the anti-restenosis drug everolimus can be achieved by engineering the structure of polymer coatings to fabricate drug-eluting BVS. We achieved the successful deployment of BVSs and DE-BVSs in swine coronary arteries using a custom-built balloon catheter and BVS delivery system and confirmed BVS safety and efficacy regarding maintenance of vessel patency for 28 days, observing an inflammation profile for BVS and DE-BVS that was comparable to the commercial XIENCE™ DES (Abbott Vascular).

Platinum chromium everolimus-eluting stents for the treatment of (complex) coronary artery disease; from SYNERGY™ to the MEGATRON™

INTRODUCTION

The introduction of drug-eluting coronary stents (DES) into clinical practice in 2002 represented a major milestone in the treatment of obstructive coronary artery disease. Over the years, significant advances in polymer coating and in antiproliferative agent technology have further improved the safety and clinical performance of newer-generation DES.

AREAS COVERED

Development of platinum chromium (PtCr) alloys with high radial strength and high radiopacity have enabled the design of new, thin-strut, flexible, and highly trackable stent platforms, while simultaneously improving stent visibility. These advances have facilitated complex percutaneous treatment of a diverse population of patients in clinical practice. This review will provide an overview of the evolution in PtCr everolimus-eluting stents from PROMUS Element™ to SYNERGY™ to the recently introduced SYNERGY MEGATRON™. The clinical data will be summarized and put into perspective, especially focusing on the role of the SYNERGY™ and MEGATRON™ platforms in the treatment of complex coronary artery disease and high-risk patients.

EXPERT OPINION

The SYNERGY™ stent demonstrates favorable clinical efficacy and safety outcome data, and whilst the clinical data on MEGATRON™ are sparse, early experience is promising. The specific overexpansion capabilities, visibility, and radial strength of the MEGATRON™ are attractive features for complex coronary interventions.

Fifteen-Year Clinical Outcomes After Sirolimus-Eluting Stent Implantation

BACKGROUND

Clinical outcomes after percutaneous coronary intervention have improved with the use of drug-eluting stents, but data beyond 10 years are limited. The purpose of this study was to evaluate the clinical outcomes of patients undergoing sirolimus-eluting stent implantation with follow-up beyond 10 years and to determine the impact of clinical and angiographic characteristics on long-term prognosis.

METHODS AND RESULTS

The clinical outcomes of 885 patients who had undergone sirolimus-eluting stent implantation at a single institution were retrospectively reviewed. Primary endpoints included in the analysis were clinically driven target lesion revascularization (cTLR) and target lesion revascularization (TLR). Univariate and multivariate nominal logistic regression was used for data analysis. The incidence rates of cTLR and TLR beyond 10 years after sirolimus-eluting stent implantation were 16.4% and 36.8%, respectively, with cTLR tending to decrease beyond 10 years. Acute coronary syndrome was a predominant trigger for cTLR. Age, statin use, and stent restenosis emerged as predictors of cTLR within 10 years, but no significant predictors other than age were identified beyond 10 years.

CONCLUSIONS

Events continue to occur beyond 10 years after sirolimus-eluting stent implantation, with a trend toward an increase in acute coronary syndromes. It is important to be vigilant about the occurrence of acute coronary syndromes during long-term follow-up.

Ten-year mortality after treating obstructive coronary atherosclerosis with contemporary stents in patients with or without concomitant peripheral arterial disease

BACKGROUND AND AIMS

Previous studies in percutaneous coronary intervention (PCI) patients showed a higher 3-year adverse event risk, including all-cause mortality, in those with concomitant peripheral arterial disease (PADs). Ten-year data of mortality and causes of death are scarce. This analysis assessed PCI patients, treated with contemporary drug-eluting stents, the impact of concomitant PADs on very long-term mortality, and causes of death.

METHODS

We assessed PCI all-comers from our center who participated in the TWENTE and DUTCH PEERS trials (clinicaltrials.gov:NCT01066650, NCT01331707), comparing patients with versus without PADs. Life status was checked in the Dutch Personal Records Database; causes of death were obtained from medical records.

RESULTS

Of 2705 study patients, 668 (24.7%) died during follow-up: 88/212 (41.5%) patients with PADs and 580/2493 (23.1%) without PADs. In PADs patients, the 10-year rate of all-cause mortality was about twice as high as in patients without PADs (41.5% vs.23.1%, HR: 2.05, 95%-CI: 1.64-2.57, p<0.001). For both groups, the rates of patients dying from various causes of death were: cardiac (14.1% vs.6.8%), vascular (2.8% vs. 1.1%), non-cardiovascular (17.4% vs. 9.8%), and unclear causes (7.1% vs. 5.3%), without a statistically significant between-group difference. When multivariate analysis was adjusted for between-group differences in cardiovascular risk profile, PADs remained predictor of all-cause mortality (adjusted HR: 1.38, 95%-CI: 1.08-1.75, p=0.01).

CONCLUSIONS

The 10-year all-cause mortality rate in PCI patients with concomitant PADs was almost twice as high as in those without PADs. Age and other traditional cardiovascular risk factors were higher in patients with PADs, but after correction for these confounders PADs still accounted for almost 40% increase in mortality.

Current Management of In-Stent Restenosis

In-stent restenosis (ISR) remains the primary cause of target lesion failure following percutaneous coronary intervention (PCI), resulting in 10-year incidences of target lesion revascularization at a rate of approximately 20%. The treatment of ISR is challenging due to its inherent propensity for recurrence and varying susceptibility to available strategies, influenced by a complex interplay between clinical and lesion-specific conditions. Given the multiple mechanisms contributing to the development of ISR, proper identification of the underlying substrate, especially by using intravascular imaging, becomes pivotal as it can indicate distinct therapeutic requirements. Among standalone treatments, drug-coated balloon (DCB) angioplasty and drug-eluting stent (DES) implantation have been the most effective. The main advantage of a DCB-based approach is the avoidance of an additional metallic layer, which may otherwise enhance neointimal hyperplasia, provide the substratum for developing neoatherosclerosis, and expose the patient to a persistently higher risk of coronary ischemic events. On the other hand, target vessel scaffolding by DES implantation confers relevant mechanical advantages over DCB angioplasty, generally resulting in larger luminal gain, while drug elution from the stent surface ensures the inhibition of neointimal hyperplasia. Nevertheless, repeat stenting with DES also implies an additional permanent metallic layer that may reiterate and promote the mechanisms leading to ISR. Against this background, the selection of either DCB or DES on a patient- and lesion-specific basis as well as the implementation of adjuvant treatments, including cutting/scoring balloons, intravascular lithotripsy, and rotational atherectomy, hold the potential to improve the effectiveness of ISR treatment over time. In this review, we comprehensively assessed the available evidence from randomized trials to define contemporary interventional treatment of ISR and provide insights for future directions.

A Ten-Year Follow-Up Study of the Association Between Uric Acid and Adverse Cardiovascular Events in Patients With Coronary Artery Disease

The association between uric acid (UA) and long-term mortality in patients with coronary artery disease is poorly investigated. We assessed the association between UA and 10-year mortality after percutaneous coronary intervention (PCI) in 3,998 patients who underwent PCI. Patients were categorized in groups according to UA tertiles: tertile 1 (UA <5.80 mg/100 ml, n = 1,347), tertile 2 (UA 5.80 to 7.04 mg/100 ml, n = 1,340), and tertile 3 (UA >7.94 mg/100 ml, n = 1,311). The primary outcome was 10-year all-cause mortality. All-cause deaths occurred in 1,200 patients: 320 deaths (26.5%) in patients with UA in the first tertile, 325 deaths (26.9%) in patients with UA in the second tertile, and 555 deaths (46.0%) in patients with UA in the third tertile (adjusted hazard ratio 1.22, 95% confidence interval 1.17 to 1.27, p <0.001) for 1 mg/100 ml increment in UA level. Cardiac deaths occurred in 748 patients: 194 deaths (16.5%) in patients with UA in the first tertile, 202 deaths (17.0%) in patients with UA in the second tertile, and 352 deaths (29.7%) in patients with UA in the third tertile (adjusted hazard ratio 1.24 [1.17 to 1.32], p <0.001) for 1 mg/100 ml increment in the UA level. The 10-year rates of target lesion revascularization, target vessel revascularization, or nontarget vessel revascularization did not differ significantly according to the UA level. In conclusion, in patients with coronary artery disease treated with PCI, increased UA level was associated with higher 10-year mortality. Increased UA level was not associated with the progression of atherosclerosis in nontreated coronary vessels or progression of intimal hyperplasia in stented lesions requiring intervention.

Is it time for a retinoic acid-eluting stent or retinoic acid-coated balloon? Insights from experimental studies of systemic and local delivery of retinoids

Although the incidence of restenosis and stent thrombosis has substantially declined during the last decades, they still constitute the two major causes of stent failure. These complications are partially attributed to the currently used cytostatic drugs, which can cause local inflammation, delay or prevent re-endothelialization and essentially cause arterial cell toxicity. Retinoic acid (RA), a vitamin A (retinol) derivative, is a naturally occurring substance used for the treatment of cell proliferation disorders. The agent has pleiotropic effects on vascular smooth muscle cells and macrophages: it influences the proliferation, migration, and transition of smooth muscle cells to other cell types and modulates macrophage activation. These observations are supported by accumulated evidence from in vitro and in vivo experiments. In addition, systemic and topical administration of RA can decrease the development of atherosclerotic plaques and reduce or inhibit restenosis after vascular injury (caused by embolectomy, balloon catheters, or ligation of arteries) in various experimental models. Recently, an RA-drug eluting stent (DES) has been tested in an animal model. In this review, we explore the effects of RA in atherosclerosis and the potential of the local delivery of RA through an RA-DES or RA-coated balloon for targeted therapeutic percutaneous vascular interventions. Despite promising published results, further experimental study is warranted to examine the safety and efficacy of RA-eluting devices in vascular artery disease.

Nanotechnology in development of next generation of stent and related medical devices: Current and future aspects

Coronary stents have saved millions of lives in the last three decades by treating atherosclerosis especially, by preventing plaque protrusion and subsequent aneurysms. They attenuate the vascular SMC proliferation and promote reconstruction of the endothelial bed to ensure superior revascularization. With the evolution of modern stent types, nanotechnology has become an integral part of stent technology. Nanocoating and nanosurface fabrication on metallic and polymeric stents have improved their drug loading capacity as well as other mechanical, physico-chemical, and biological properties. Nanofeatures can mimic the natural nanofeatures of vascular tissue and control drug-delivery. This review will highlight the role of nanotechnology in addressing the challenges of coronary stents and the recent advancements in the field of related medical devices. Different generations of stents carrying nanoparticle-based formulations like liposomes, lipid-polymer hybrid NPs, polymeric micelles, and dendrimers are discussed highlighting their roles in local drug delivery and anti-restenotic properties. Drug nanoparticles like Paclitaxel embedded in metal stents are discussed as a feature of first-generation drug-eluting stents. Customized precision stents ensure safe delivery of nanoparticle-mediated genes or concerted transfer of gene, drug, and/or bioactive molecules like antibodies, gene mimics via nanofabricated stents. Nanotechnology can aid such therapies for drug delivery successfully due to its easy scale-up possibilities. However, limitations of this technology such as their potential cytotoxic effects associated with nanoparticle delivery that can trigger hypersensitivity reactions have also been discussed in this review. This article is categorized under: Implantable Materials and Surgical Technologies > Nanotechnology in Tissue Repair and Replacement Therapeutic Approaches and Drug Discovery > Nanomedicine for Cardiovascular Disease Therapeutic Approaches and Drug Discovery > Emerging Technologies.

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

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.

Ten-year outcomes after percutaneous coronary intervention of in-stent restenosis in saphenous vein grafts

BACKGROUND

Only few data is available for long-term outcomes of patients being treated for in-stent restenosis (ISR) in saphenous vein grafts (SVG).

AIMS

Thus, the aim of this observational, retrospective study was to close this lack of evidence.

METHODS

Between January 2007 and February 2021 a total of 163 patients with 186 ISR lesions located in SVG were treated at two large-volume centers in Munich, Germany. Endpoints of interest were all-cause mortality, target lesion revascularization (TLR) and target vessel myocardial infarction (TVMI). Furthermore, recurrent ISR were assessed. Outcomes are presented as Kaplan-Meier event rates.

RESULTS

Mean age was 72.6 ± 8.6 years, 90.8% were male, 36.8% were diabetics and 42.3% presented an acute coronary syndrome. ISR were treated with DES in 64.0% and with balloon angioplasty (BA) in 36.0%. After 10 years, the rates for all-cause mortality, TVMI and TLR were 58.2%, 15.4%, and 22.6%, respectively. No statistically relevant differences were found between the types of treatment (DES or BA) regarding all-cause mortality (55.7% vs. 63.2%, p = 0.181), TVMI (13.8% vs. 18.6%, p = 0.215) and TLR (21.8% vs. 25.0%, p = 0.764). Median time between first and recurrent ISR was 270.8 days. Recurrent ISR were treated with DES in a comparable proportion as during first ISR (p = 0.075). Independent predictor of TLR is patient age (p = 0.034). The median follow-up duration was 5.1 years (75% CI 2.8; 8.5).

CONCLUSIONS

Clinical event rates after intervention of ISR located in SVG are high without statistically relevant differences regarding the type of treatment. However, further studies are needed.

Ten-year clinical outcomes from a randomized trial comparing new-generation everolimus-eluting stent versus first-generation Sirolimus-eluting stent: Results from the RESET extended study

BACKGROUND

New-generation drug-eluting stents (DES) achieved technological innovations and reported clinical advantages as compared with first-generation DES in clinical trials with 3-5 years follow-up. However, detailed clinical outcome data in very long-term follow-up is still scarce.

OBJECTIVES

To evaluate 10-year clinical outcomes after first- and new-generation DES implantation.

METHODS

In this extende follow-up study of the RESET, which is a largest randomized trial comparing everolimus-eluting stent (EES) with Sirolimus-eluting stent (SES), the study population consisted of 2892 patients from 84 centers. The primary efficacy and safety endpoints were target lesion revascularization (TLR) and a composite of death or myocardial infarction (MI), respectively. Complete 10-year follow-up was achieved in 87.9% of patients.

RESULTS

Cumulative 10-year incidences of TLR and non-TLR were not significantly different between EES and SES (13.9% vs. 15.7%, Log-rank p = 0.20, and 33.4% vs. 31.3%, Log-rank p = 0.30). The cumulative 10-year incidence of death/MI was also not significantly different between the groups (32.5% vs. 34.4%, Log-rank p = 0.18). Cumulative 10-year incidence of definite stent thrombosis was numerically lower in EES than in SES (1.0% vs. 1.7%, Log-rank p = 0.16). The lower risk of EES relative to SES was significant for a composite endpoint of target lesion failure (TLF: 19.6% vs. 24.9%, Log-rank p = 0.001) and target vessel failure (TVF: 26.7% vs. 31.4%, Log-rank p = 0.006).

CONCLUSION

During 10-year of follow-up, the risks for primary efficacy and safety endpoints were not significantly different between new-generation EES and first-generation SES, although EES compared with SES was associated with a lower risk for composite endpoints such as TLF and TVF.

Biodegradable or durable polymer drug-eluting stents in patients with coronary artery disease: ten-year outcomes of the randomised NEXT Trial

BACKGROUND

There are no randomised trials reporting clinical outcomes of biodegradable polymer biolimus-eluting stents (BP-BES) and durable polymer everolimus-eluting stents (DP-EES) at 10 years.

AIMS

We aimed to compare the 10-year clinical outcomes between BP-BES and DP-EES.

METHODS

The randomised NOBORI Biolimus-Eluting Versus XIENCE/PROMUS Everolimus-eluting Stent Trial (NEXT) was originally designed to evaluate the non-inferiority of BP-BES relative to DP-EES with the primary efficacy endpoint of target lesion revascularisation (TLR) at 1 year and the primary safety endpoint of death or myocardial infarction (MI) at 3 years. In this extended follow-up study, clinical outcomes were compared from 1 year after stent implantation up to 10 years between patients with BP-BES and DP-EES.

RESULTS

From May to October 2011, NEXT enrolled a total of 3,241 patients from 98 centres in Japan. The current study population consisted of 2,417 patients (1,204 patients with BP-BES and 1,213 with DP-EES) from 66 centres that agreed to participate in the extended study. Complete 10-year follow-up was achieved in 87.5% of patients. The cumulative 10-year incidence of death or MI was 34.0% in the BP-BES group and 33.1% in the DP-EES group (hazard ratio [HR] 1.04, 95% confidence interval [CI]: 0.90-1.20; p=0.58). TLR occurred in 15.9% of patients in the BP-BES group and in 14.1% of the DP-EES group (HR 1.12, 95% CI: 0.90-1.40; p=0.32). In a landmark analysis at 1 year, the cumulative incidences of death or MI and TLR were not significantly different between the 2 groups.

CONCLUSIONS

The safety and efficacy outcomes for BP-BES were not significantly different from those for DP-EES at 1 year and up to 10 years after stent implantation.

One-year Outcomes of XIENCE Skypoint 48-mm Drug-Eluting Stents in Long Coronary Lesions: The SPIRIT 48 Trial

Background

Diffuse coronary artery disease may need multiple overlapping stents, associated with less favorable outcomes than those of a single stent. The availability of longer stents can circumvent the need for overlapping stents in long lesions. This prospective, single-arm, SPIRIT 48 trial evaluated the safety and effectiveness of Abbott's next-generation drug-eluting stent, XIENCE Skypoint 48, in patients with coronary artery disease with long de novo native coronary lesions.

Methods

SPIRIT 48 enrolled 107 patients at 25 sites in 3 countries. Patients were required to have 1 target lesion treated with XIENCE Skypoint 48 (lesion length of >32.0 mm and ≤44.0 mm). The primary end point was target lesion failure (TLF; composite of cardiac death, target vessel-related myocardial infarction, or clinically indicated target lesion revascularization) at the 1-year compared with a prespecified performance goal of 20%, established through historical control data. This study recently completed its 1-year follow-up.

Results

XIENCE Skypoint 48 was implanted in 105 patients with a device success rate of 97.2%. SPIRIT 48 met its primary end point, with a TLF rate of 5.7%, and the upper bound of 95% CI at 9.5% (

Conclusions

Primary end point data obtained at the 1-year follow-up from the SPIRIT 48 trial present strong evidence supporting the deliverability, safety, and effectiveness of XIENCE Skypoint 48 mm drug-eluting stent in treating long de novo coronary lesions.

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Key Words

• coronary disease
• drug-eluting stents
• percutaneous coronary intervention

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Affiliation(s)

Ki E. Park Division of Cardiovascular Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, Florida
Chiung-Jen Wu Department of Cardiology, Chung-Gung Memorial Hospital, Kaohsiung, Taiwan
Bassem Chehab Department of Medicine, Ascension Via Christi Hospital, University of Kansas, Wichita, Kansas
Aziz Maksoud Department of Medicine, Cardiovascular Research Institute of Kansas, University of Kansas, Wichita, Kansas
Barry Bertolet Cardiac Catheterization Laboratory, North Mississippi Medical Center, Tupelo, Mississippi
Shih-Wa Ying Abbott Vascular, Santa Clara, California
Tiessa Simoes Abbott Vascular, Santa Clara, California
Sandeep C. Pingle Abbott Vascular, Santa Clara, California
Chi-Jen Chang Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Tapei, Taiwan

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Comparison of 7-Year, Real-World Clinical Outcomes between Drug-Coated Balloon Angioplasty versus Drug-Eluting Stent Implantation in Patients with Drug-Eluting Stent In-Stent Restenosis

There are no data available comparing the real-world, long-term clinical outcomes of drug-eluting balloon (DEB) angioplasty and drug-eluting stent (DES) implantation in DES in-stent restenosis (ISR) lesions. We aimed to compare the real-world, long-term data available between DEBs and DESs in DES-ISR lesions. We analyzed consecutive DES-ISR lesions (225 lesions from 205 patients; male: 66.3%; mean age: 62.4 years) treated with either DEB or DES. The primary endpoint was target lesion revascularization (TLR), and the primary safety endpoint was the lesion-oriented composite outcome (LOCO). The LOCO is composed of cardiac death, myocardial infarction, and target lesion thrombosis during follow-up. During the 7-year follow-up period, TLR did not differ significantly between the DEB (n = 108) and the DES groups (n = 117) (HR: 1.07; 95% CI: 0.59-1.93, p = 0.83). The LOCO was significantly lower in the DEB group compared to the DES group (HR: 0.40; 95% CI: 0.16-0.98, p = 0.04), which was mainly driven by the lower levels of myocardial infarction (HR: 0.24; 95% CI: 0.06-0.94, p = 0.04) and the absence of target lesion thrombosis in the DEB group (vs. DES group 6%, p = 0.02). Additionally, cardiac death was found to be similar between the DEB and DES groups (HR: 0.56; 95% CI: 0.18-1.75, p = 0.32). DEB angioplasty showed favorable safety with a similar efficacy to that of DES implantation in DES-ISR lesions during the long-term follow-up period.

Long-Term Clinical Outcomes of Drug-Coated Balloon Treatment for De Novo Coronary Lesions

PURPOSE

Data are limited on the long-term efficacy and safety of drug-coated balloon (DCB) treatment in comparison to drug-eluting stent (DES) for de novo coronary lesions. We investigated the long-term clinical outcomes of DCB treatment in percutaneous coronary intervention (PCI) for de novo coronary lesions.

MATERIALS AND METHODS

A total of 103 patients scheduled for elective PCI for de novo non-small coronary lesions (≥2.5 mm) who were successfully treated with DCB alone were retrospectively compared with 103 propensity-matched patients treated with second-generation DES from the PTRG-DES registry (n=13160). All patients were followed for 5 years. The primary endpoint was major adverse cardiac events [MACE; cardiac death, myocardial infarction, stroke, target lesion thrombosis, target vessel revascularization (TVR), and major bleeding] at 5 years.

RESULTS

At 5-year clinical follow-up, Kaplan-Meier estimates of the rate of MACE were significantly lower in the DCB group [2.9% vs. 10.7%; hazard ratio (HR): 0.26; 95% confidence interval (CI): 0.07-0.96; log-rank p=0.027]. There was a significantly lower incidence of TVR in the DCB group (1.0% vs. 7.8%; HR: 0.12; 95% CI: 0.01-0.98; long-rank p=0.015), and there was major bleeding only in the DES group (0.0% vs. 1.9%; log-rank p=0.156).

CONCLUSION

At 5-year follow-up, DCB treatment was significantly associated with reduced incidences of MACE and TVR, compared with DES implantation, for de novo coronary lesions.

Endothelial Cell Behavior and Nitric Oxide Production on a-C:H:SiOx-Coated Ti-6Al-4V Substrate

This paper focuses on the surface modification of the Ti-6Al-4V alloy substrate via a-C:H:SiOx coating deposition. Research results concern the a-C:H:SiOx coating structure, investigated using transmission electron microscopy and in vitro endothelization to study the coating. Based on the analysis of the atomic radial distribution function, a model is proposed for the atomic short-range order structure of the a-C:H:SiOx coating, and chemical bonds (C-O, C-C, Si-C, Si-O, and Si-Si) are identified. It is shown that the a-C:H:SiOx coating does not possess prolonged cytotoxicity in relation to EA.hy926 endothelial cells. In vitro investigations showed that the adhesion, cell number, and nitric oxide production by EA.hy926 endothelial cells on the a-C:H:SiOx-coated Ti-6Al-4V substrate are significantly lower than those on the uncoated surface. The findings suggest that the a-C:H:SiOx coating can reduce the risk of endothelial cell hyperproliferation on implants and medical devices, including mechanical prosthetic heart valves, endovascular stents, and mechanical circulatory support devices.

Morphofunctional reaction of leukocytes and platelets in in vitro contact with a-C:H:SiOx -coated Ti-6Al-4V substrate

The article deals with the plasma-assisted chemical vapor deposition of 0.3-1.4 μm thick a-C:H:SiO_x films in a mixture of argon and polyphenylmethylsiloxane vapor onto the Ti-6Al-4V alloy substrate, which is often used as an implant material. The a-C:H:SiO_x film structure is studied by the Fourier-transform infrared and Raman spectroscopies. The pull-off adhesion test assesses the adhesive strength of a-C:H:SiO_x films, and the ball-on-disk method is employed to measure their wear rate and friction coefficient. According to these studies, a-C:H:SiO_x films are highly adhesive to the Ti-6Al-4V substrate, have low (0.056) friction coefficient and wear rate (9.8 × 10^-8  mm³  N^-1  m^-1 ) in phosphate-buffered saline at 40°C. In vitro studies show neither thrombogenicity nor cytotoxicity of the a-C:H:SiO_x film for the human blood mononuclear cells (hBMNCs). The in vitro contact between the hBMNC culture and a-C:H:SiO_x films 0.8-1.4 μm thick deposited onto Ti-6Al-4V substrates reduces a 24-hour secretion of pro-inflammatory cytokines and chemokines IL-8, IL-17, TNFα, RANTES, and MCP-1. This reduction is more significant when the film thickness is 1.4 μm and implies its potential anti-inflammatory effect and possible application in cardiovascular surgery. The dependence is suggested for the concentration of anti-inflammatory cytokines and chemokines and the a-C:H:SiO_x film thickness, which correlates with the surface wettability and electrostatic potential. The article discusses the possible applications of the anti-inflammatory effect and low thrombogenicity of a-C:H:SiO_x films in cardiovascular surgery.

Ten-year clinical outcomes of drug-eluting stents with different polymer coating strategies by degree of coronary calcification: a pooled analysis of the ISAR-TEST 4 and 5 randomised trials

BACKGROUND

Long-term data concerning the efficacy of different polymer-coating strategies of new-generation drug-eluting stents (DES) in patients with coronary artery calcification (CAC) are scant.

AIMS

We aimed to investigate 10-year outcomes by degree of CAC after new-generation DES implantation with different polymer-coating strategies.

METHODS

We analysed individual patient and lesion characteristics of patients randomised to treatment with polymer-free sirolimus-eluting, biodegradable-polymer sirolimus-eluting and permanent-polymer zotarolimus- or everolimus-eluting stents. Endpoints of interest at 10 years were all-cause mortality, myocardial infarction (MI), target lesion revascularisation (TLR) and definite or probable stent thrombosis (ST) according to the degree of CAC (no, mild, moderate or severe) and coating strategy (polymer-free vs biodegradable-polymer vs permanent-polymer).

RESULTS

A total of 4,953 patients with 6,924 lesions were included. No, mild, moderate or severe CAC was present in 24.5%, 41.8%, 25.8% and 8.0% of patients, respectively. At 10-year follow-up, overall event rates were high, with an incremental increase according to the degree of CAC (all-cause mortality: no 25.3%, mild 32.1%, moderate 41.7%, severe CAC 46.5%; adjusted [adj.] p=0.004; TLR: no 17.4%, mild 16.5%, moderate 19.8%, severe CAC 28.7%; adj. p=0.001; MI: no 4.9%, mild 5.9%, moderate 6.0%, severe CAC 10.5%; adj. p=0.02; and ST: no 1.3%, mild 1.4%, moderate 1.8%, severe CAC 3.6%; adj. p=0.57). In patients with moderate-severe CAC, event rates were comparable, regardless of the DES polymer-coating strategy.

CONCLUSIONS

At 10 years after PCI with new-generation DES, there was an incremental increase in adverse events by degree of coronary calcification. These detrimental effects do not seem to be impacted by different polymer-coating strategies.

Sex Differences in 10-Year Outcomes After Percutaneous Coronary Intervention With Drug-Eluting Stents: Insights From the DECADE Cooperation

BACKGROUND

Although some studies have investigated sex-related outcomes up to 5 years after percutaneous coronary intervention (PCI), analyses at longer follow-up (ie, to 10 years) in large cohorts treated exclusively with drug-eluting stent (DES) platforms are lacking. Therefore, this study aimed to define whether sex-related differences in long-term outcomes after PCI persist both in the DES era and at longer-term follow-up.

METHODS

Individual data of patients treated with DES in 5 randomized controlled trials with 10-year follow-up were pooled. Patients were divided into 2 groups by sex. The analysis of individual participant data was performed using a 1-stage approach by entering a clustering effect by parent study in all univariable and multivariable models focusing on sex. The main outcomes of interest for this analysis included cardiovascular death, myocardial infarction, repeat revascularization, and definite stent thrombosis to 10 years after PCI. Survival was analyzed by the Kaplan-Meier method to estimate the time to first event, and differences between the 2 groups were tested with the log-rank test. Hazard ratios (HRs) and 95% CIs were calculated with a Cox proportional hazards model. Conventional multivariable analyses with adjustment for relevant variables were performed.

RESULTS

Among 9700 patients undergoing PCI with DES implantation included in the present analysis, 2296 were women and 7404 were men. Through to 10 years, cardiovascular death occurred in 407 of the 2296 female patients and 1012 of the 7404 male patients (adjusted HR [HR_adj], 0.94 [95% CI, 0.80-1.11]). Female sex was associated with a lower risk of repeat revascularization of the target lesion (HR_adj, 0.80 [95% CI, 0.74-0.87]), target vessel (HR_adj, 0.81 [95% CI, 0.76-0.87]), and nontarget vessels (HR_adj, 0.69 [95% CI, 0.62-0.77]). Compared with male patients, female patients displayed an increased risk of myocardial infarction in the first 30 days after PCI with DES (HR_adj, 1.65 [95% CI, 1.24-2.19]) but a comparable risk of myocardial infarction thereafter. The risk of definite stent thrombosis was not significantly different between female and male patients (HR_adj, 1.14 [95% CI, 0.89-1.47]).

CONCLUSIONS

Through to 10-year follow-up after PCI with DES, female patients are at increased risk of early myocardial infarction, receive fewer repeat revascularizations, and have no difference in cardiovascular mortality compared with male patients.

Four-year outcomes of a single-center experience with coronary everolimus-eluting bioresorbable scaffolds

BACKGROUND

Bioresorbable scaffolds (BRS) have been introduced to overcome the limitations of drug-eluting stents and the ABSORB (Everolimus-Eluting BRS, Abbott Vascular, Santa Clara, CA, USA) was the most extensively tested. Nevertheless, major RCTs reported higher rates of target lesion failures and BRS thrombosis at 3 years follow-up, bringing to the withdrawing of the device from the market. It has been suggested that a better lesions selection and an optimized implantation technique could mitigate the displayed adverse results.

METHODS

Consecutive patients undergoing BRS implantation were included in this observational, single center study. Clinical follow-up was conducted up to 4 years. Endpoint of interest was the target lesion failure (TLF), a composite outcome including cardiac death, target vessel myocardial infarction and target lesion revascularization.

RESULTS

A total of 62 patients with a mean age of 55±8.5 years were analyzed of which 70.9% presented with an acute coronary syndrome and 59.6% with myocardial infarction. A total of 100 lesions were treated and 51.6% were complex (B2/C). Predilatation was performed in all the case, post-dilatation in 74.1%. All the target vessel reference diameter (RVD) were >2.5 mm (average RVD 3.2±0.24 mm). At 4 years, the rate for TLF was 6.9%. Subgroup's analysis did not show significative differences among groups although consistently higher event rates were found for RVD <2.5 mm (12.6% vs. 6.4%, P=0.5), BRS overlapping (11.8% vs. 5%, P=0.2) and ticagrelor instead of clopidogrel on top of cardioaspirin (9.1% vs. 3%, P=0.2).

CONCLUSIONS

This small-sized real-world registry displays lower rates of clinical events during long-term follow-up in respect to previous studies. The avoidance of implantation in small vessels, inclusion of acute myocardial infarction and extensive performance of BRS post-dilatation could explain the observed better results. Long-term outcomes of the ongoing ABSORB IV Trial are needed to confirm this data.

Biodegradable polymer everolimus-eluting stents versus contemporary drug-eluting stents: a systematic review and meta‑analysis

In spite of similar efficacy and safety in pilot studies, compared with the contemporary durable polymer drug-eluting stent (DP-DES), the bioabsorbable polymer drug-eluting stent (BP-DES) may be more superior in promoting blood vessel healing. We sought to compare the safety and efficacy of everolimus-eluting BP-DES (BP-EES) with contemporary DP-DES through a meta-analysis. We performed this meta-analysis to provide further evidence of the safety and efficacy of BP-EES. Medline, Embase and the Cochrane library databases were searched for randomized controlled trials comparing clinical efficacy and safety of BP-EES versus contemporary DP-DES. Fifteen RCTs with a total of 15,572 patients were selected. The rate of MACE was 9.4% in patients receiving BP-EES and 7.3% receiving DP-EES (RR 1.13, 95% CI 0.99-1.29, p = 0.05; I² = 46%). TLF and MI were also similar in both groups. Based on the available data, this review demonstrates that BP-EES displays a clinically comparable efficacy and safety profile to that of contemporary DP-DES at years of follow-up in patients undergoing PCI.

24-Month Clinical Follow-Up and Mechanistic Insights From Intravascular Imaging Following Coronary Implantation of the Novel DynamX Bioadaptor Platform

BACKGROUND/PURPOSE

Conventional stents "cage" the coronary arteries, impairing vascular function and physiology. The DynamX Bioadaptor is a cobalt‑chromium platform with uncaging elements, designed to improve arterial pulsatility, vasomotion, compliance, and positive adaptive remodelling which may attenuate late clinical events associated with the caging of arteries through conventional stents. We present the first 24-month outcomes of this device.

METHODS/MATERIALS

This European multicenter study enrolled 50 patients with 50 de novo lesions treated with the DynamX Bioadaptor. Clinical follow-up is scheduled until 36 months and imaging follow-up was performed at 9-12 months.

RESULTS

24-month endpoints were target lesion failure (2 cardiac deaths), myocardial infarction (1 non-target vessel myocardial infarction), target vessel revascularisation (n = 0), and definite or probable device thrombosis (n = 0). No endpoint events occurred beyond 9 months. Paired intravascular ultrasound analysis of 18 patients from a single center revealed a 0.22 mm² increase in device cross-sectional area at 9-12 months. Pulsatility analysis showed an increase of in-device lumen area change by 46 % compared to the caged post-procedural configuration, reducing the compliance mismatch between the treated and not-treated vessel segments (segmental compliance). Likewise, vasomotion in response to nitroglycerin improved from 0.03mm² post-procedure to 0.17mm² at follow-up.

CONCLUSIONS

24-month clinical data demonstrate promising safety and efficacy of the DynamX Bioadaptor. Imaging data confirmed its unique capacity to improve arterial pulsatility, vasomotion, compliance and positive adaptive remodelling after "uncaging" which might have led to the promising clinical outcomes that need to be confirmed in larger studies.

Microporous surface as a new solution for stent surface modification: A review

The introduction of coronary stents into clinical practice has reduced repeated patient visits compared with balloon angioplasty alone. Also, drug-eluting stents substantially reduced the restenosis incidence. Therefore, later complications related to the implantation of a stent coated with a cytostatic-containing polymer became more relevant. The mechanism of late stent complications is multifactorial. It is mainly due to the body's response to the prolonged indwelling of the drug carrier polymer on the coronary stent's surface. There is a trend towards the return of polymer-free drug coating technologies, which are implemented through certain modifications of stent surfaces for better drug retention and proper drug distribution. It is mainly achieved using drug depots in various reservoirs: grooves, nanoparticles in the matrix compound, micropores, through and blind micro reservoirs, etc. New promising technologies for crystallizing cytostatic drugs or depositing them in specially designed reservoirs show good preclinical and clinical results, comparable or even superior to approved coronary stents. Micropores as carriers for antiproliferative agents on the stent surface are a promising direction to rejecting the use of polymers in stents.

Ten-year patterns of stent thrombosis after percutaneous coronary intervention with new- versus early-generation drug-eluting stents: insights from the DECADE cooperation

INTRODUCTION AND OBJECTIVES

The DECADE cooperation is a pooled analysis of individual patient data from drug-eluting stent (DES) trials with a 10-year follow-up. This analysis reports the risk of definite stent thrombosis (ST) through to 10 years after percutaneous coronary intervention (PCI) in patients treated with early- and new-generation DES.

METHODS

Individual patient data from 5 DES trials with a 10-year follow-up were pooled. The primary endpoint was definite ST up to 10 years after PCI. Patients were divided into 2 groups as per the generation of DES implanted (early and new DES). Individual participant data were analyzed using a 1-stage approach.

RESULTS

We included 9700 patients, 6866 in the new DES group and 2834 in the early DES group. Through to 10 years, definite ST occurred in 69 of 6866 patients treated with new DES and in 91 of 2834 patients treated with early DES (1.0% vs 3.5%, adjusted hazard ratio, 0.32; 95%CI, 0.23-0.45). The rate of definite ST was lower in the new DES group than in the early DES group from 1 to 5 years (rate ratio, 0.14; 95%CI, 0.08-0.26) and from 5 to 10 years (rate ratio, 0.23; 95%CI, 0.08-0.61) after PCI.

CONCLUSIONS

The incidence of definite ST through to 10 years after PCI with new-generation DES was 1%. New-generation DES are associated with a lower 10-year incidence of definite ST than early-generation DES, particularly beyond 1 year after PCI.

Outcomes of paclitaxel-coated balloon angioplasty for in-stent calcified nodule: An optical coherence tomography study

BACKGROUND

Paclitaxel-coated balloon (PCB) angioplasty emerges as an effective therapeutic option for in-stent restenosis (ISR). However, whether PCB angioplasty would be effective for in-stent calcified nodule (ISCN) lesions remain fully understood. This study aimed to evaluate the frequency and outcomes of ISCN in patients undergoing PCB angioplasty for ISR after second-generation drug-eluting stents (G2-DES) implantation.

METHODS

This study enrolled 179 lesions (160 patients) undergoing PCB angioplasty for G2-DES restenosis with optical coherence tomography guidance. According to the presence of ISCN at the minimum lumen area, the lesions were divided into two groups: the ISCN (n = 16) and the non-ISCN groups (n = 163). The primary study endpoint was the cumulative 3-year incidence of target lesion failure (TLF; a composite of cardiac death, clinically driven target vessel revascularization, and definite stent thrombosis) on a lesion basis.

RESULTS

ISCN was observed in 16 of 179 lesions (8.9%). Cumulative 3-year incidence of TLF was significantly higher in the ISCN group than in the non-CN group (85.3% vs. 16.9%, inverse probability weighted hazard ratio [HR] 4.46, 95% confidence intervals [CIs]: 2.42-8.22, p < 0.001). Risk factors associated with TLF were ISCN (HR 4.55, 95% CI: 1.56-13.3, p = 0.005), recurrent ISR (HR 2.82, 95% CI: 1.50-3.30, p = 0.001), and early ISR (HR 2.18, 95% CI: 1.21-3.92, p = 0.009).

CONCLUSION

ISCN was observed in 8.3% of G2-DES restenosis. PCB angioplasty had little effect on ISCN lesions compared with non-ISCN lesions, suggesting the need for careful clinical follow-up of patients with ISCN lesions after PCB angioplasty.

Ticagrelor monotherapy versus aspirin monotherapy at 12 months after percutaneous coronary intervention: a landmark analysis of the GLOBAL LEADERS trial

BACKGROUND

The optimal antiplatelet strategy in the second year after percutaneous coronary intervention (PCI) remains unclear.

AIMS

We aimed to compare ticagrelor monotherapy with aspirin monotherapy on clinical outcomes beyond 1 year post-PCI.

METHODS

This post hoc subanalysis of the open-label, all-comers, randomised GLOBAL LEADERS trial, which compared 23-month ticagrelor monotherapy following 1-month dual antiplatelet therapy (DAPT) with 12-month aspirin monotherapy following 12-month DAPT, only included patients who, at 12 months, were free from ischaemic and bleeding events and were adherent to their assigned antiplatelet therapy. The incidences of ischaemic events (all-cause death, any myocardial infarction, or any stroke) and bleeding events (Bleeding Academic Research Consortium [BARC] type 3 or 5 bleeding) during the second year (12-24 months) were compared between patients receiving either ticagrelor or aspirin monotherapy.

RESULTS

The present analysis included 11,121 (ticagrelor monotherapy n=5,308, and aspirin monotherapy n=5,813) of the 15,991 patients enrolled in GLOBAL LEADERS. During the second year, the ischaemic composite endpoint was lower with ticagrelor monotherapy compared to aspirin monotherapy (1.9% vs 2.6%: log-rank p=0.014, adjusted hazard ratio [HR] 0.74, 95% confidence interval [CI]: 0.58-0.96; p=0.022), which was primarily driven by a reduced risk of myocardial infarction. In contrast, BARC type 3 or 5 bleeding was numerically higher with ticagrelor monotherapy (0.5% vs 0.3%: log-rank p=0.051, adjusted HR 1.89, 95% CI: 1.03-3.45; p=0.005).

CONCLUSIONS

Patients free from events at the end of the first year post-PCI and who adhered to their prescribed regimen had a reduced risk of ischaemic events compared to aspirin monotherapy in the second year post-PCI.

CLINICALTRIALS

gov: NCT01813435.

Safety and Efficacy of Ultra Short-Duration Dual Antiplatelet Therapy After Percutaneous Coronary Interventions: A Meta analysis of Randomized Controlled Trials

INTRODUCTION

Dual antiplatelet therapy (DAPT) is required after percutaneous coronary intervention (PCI) to reduce stent thrombosis, but DAPT increases bleeding risks. The optimal duration of DAPT that provides the maximum protective ischemic effect along with the minimum bleeding risk is unclear. This is the first meta-analysis comparing outcomes for 1-month versus longer DAPT strategies following PCI.

METHODS

We searched PubMed, Cochrane, and ClinicalTrials.gov databases (from inception to October 2021) for randomized controlled trials (RCTs) that compared 1-month duration versus > 1-month duration of DAPT following PCI. We used a random-effects model to calculate risk ratio (RR) with 95% confidence interval (CI). The co-primary outcomes for study selection were all-cause mortality, major bleeding, and stent thrombosis. Secondary outcomes included myocardial infarction (MI), cardiovascular mortality, ischemic stroke and target vessel revascularization.

RESULTS

A total of five RCTs were included [n=29,355; 1-month DAPT(n=14,662) vs > 1-month DAPT (n=14,693)]. There was no statistically significant difference between the two groups in terms of all-cause mortality (RR 0.89; 95% CI 0.78-1.03; p = 0.12) and stent thrombosis (RR 1.07; 95% CI 0.80-1.43; p = 0.65). Similarly, there were no significant differences in MI, cardiovascular mortality, ischemic stroke, and target vessel revascularization. The rate of major bleeding was significantly lower in the group treated with DAPT for 1-month (RR 0.74; 95% CI 0.56-0.99, p = 0.04).

CONCLUSION

There is no difference in all-cause mortality, cardiovascular mortality, MI, stent thrombosis, ischemic stroke and target vessel revascularization with 1-month of DAPT following PCI with contemporary drug eluting stents compared to longer DAPT duration.

Five-Year Impacts of Antithrombotic Therapy Based on 10-Year Clinical Outcomes of Cypher™ Stent Implantation

Introduction

Few researchers have investigated the optimal long-term antithrombotic therapy regimen, especially after first-generation drug-eluting stent (DES) use. This study aimed to evaluate the impact of mid-term antithrombotic therapy on long-term outcomes in patients treated with the first sirolimus-eluting coronary stent (Cypher™).

Methods

Between 2004 and 2009, 1021 patients underwent Cypher™ implantation at our institute; among them, 567 patients had available data on antithrombotic therapy at year 5. We assessed patients’ antithrombotic therapy at year 5 post Cypher™ implantation and examined their association with adverse events from year 5 to year 10 post Cypher™ implantation.

Results

Patients with dual-antiplatelet therapy (DAPT) at year 5 had significantly lower risk of stent thrombosis (ST) than those with single-antiplatelet therapy (SAPT) (hazard ratio [HR] 0.24, p = 0.034). The HR of major bleeding in DAPT, compared to SAPT, was high, but the difference was not significant (HR 1.72, p = 0.26). Risk of major bleeding was significantly higher in patients on oral anticoagulants (OAC) than in those in other groups (OAC/SAPT; HR 5.31, p = 0.0048, OAC/DAPT; HR 3.08, p = 0.022), without significant reduction in the risk of cardiovascular events.

Conclusions

The incidence of ST after Cypher™ implantation in patients with DAPT at year 5 was significantly lower than that in SAPT. However, the risk of bleeding was higher with DAPT than with SAPT. Moreover, the risk of major bleeding was significantly higher in patients on anticoagulant therapy than in other patients. New options for the use of antithrombotic drugs after percutaneous coronary intervention warrant further studies on the optimal antithrombotic therapy for first-generation DES.