Very long-term (15 to 23 years) outcomes of successful balloon angioplasty compared with bare metal coronary stenting

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.

Clinical expert consensus document on drug-coated balloon for coronary artery disease from the Japanese Association of Cardiovascular Intervention and Therapeutics

Drug-coated balloon (DCB) technology was developed to deliver the antiproliferative drugs to the vessel wall without leaving any permanent prosthesis or durable polymers. The absence of foreign material can reduce the risk of very late stent failure, improve the ability to perform bypass-graft surgery, and reduce the need for long-term dual antiplatelet therapy, potentially reducing associated bleeding complications. The DCB technology, like the bioresorbable scaffolds, is expected to be a therapeutic approach that facilitates the "leave nothing behind" strategy. Although newer generation drug-eluting stents are the most common therapeutic strategy in modern percutaneous coronary interventions, the use of DCB is steadily increasing in Japan. Currently, the DCB is only indicated for treatment of in-stent restenosis or small vessel lesions (< 3.0 mm), but potential expansion for larger vessels (≥ 3.0 mm) may hasten its use in a wider range of lesions or patients with obstructive coronary artery disease. The task force of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) was convened to describe the expert consensus on DCBs. This document aims to summarize its concept, current clinical evidence, possible indications, technical considerations, and future perspectives.

Serial quantitative angiographic study of target lumen enlargement after drug-coated balloon angioplasty for native coronary artery disease

BACKGROUND

Target lumen enlargement (TLE) or "late lumen enlargement" is often encountered after percutaneous coronary intervention (PCI) with drug-coated balloons (DCB). To date, the prognosis of coronary arterial lesions with or without TLE has not been clearly elucidated.

AIMS

This study aimed to assess the long-term prognosis of coronary arterial lesions with or without TLE observed within 1 year (early TLE) after DCB angioplasty using serial quantitative angiographic follow-up.

METHODS

One hundred and ninety-three consecutive patients (de novo coronary arterial lesions, 251) who underwent follow-up angiography within 1 year after DCB angioplasty (early follow-up, median: 6 months) were retrospectively evaluated. Of these, 97 patients (125 lesions) also underwent angiography more than 1 year after DCB angioplasty (late follow-up, median: 37 months). TLE was defined as an increase in minimal lumen diameter (MLD) after PCI at each follow-up.

RESULTS

Early TLE was detected in 142 lesions (56.6%). Of these, 76 lesions were also evaluated at late follow-up. TLE persisted even at late follow-up in 67 of the 76 lesions (88.2%). An increase in MLD in early TLE (+) lesions was observed in the period between post-PCI and early follow-up (1.84 ± 0.06 vs. 2.12 ± 0.07 mm, p < 0.001) but not between early and late follow-up (2.12 ± 0.07 vs. 2.16 ± 0.07 mm, p = 0.74). In contrast, 49 of 109 lesions without early TLE were evaluated at late follow-up, of which 28 lesions (57.1%) showed TLE at late follow-up. The MLD of early TLE (-) lesions (n = 49) significantly increased from early (1.63 ± 0.061 mm) to late follow-up (1.84 ± 0.06 mm) (p < 0.001). No aneurysms were found in any of these cases.

CONCLUSION

Early TLE was observed in more than half of the lesions, with the majority remaining at late follow-up. Alternatively, half of the lesions without early TLE showed late TLE, occurring biphasically after DCB angioplasty.

Establishment of a Nomogram for Predicting the Suboptimal Angiographic Outcomes of Coronary De Novo Lesions Treated with Drug-Coated Balloons

INTRODUCTION

Factors affecting the angiographic outcomes of coronary de novo lesions treated with drug-coated balloons (DCBs) have not been well illustrated. The aim of the study is to establish a nomogram for predicting the risk of suboptimal diameter stenosis (DS) at angiographic follow-up.

METHODS

A retrospective analysis was performed on a cohort of patients who underwent DCB intervention for coronary de novo lesions with angiographic follow-up data. Multivariable logistic regression analysis was applied to determine the independent predictors of DS ≥ 30% at follow-up, and then a nomogram model was established and validated.

RESULTS

A total of 196 patients (313 lesions) were divided into the suboptimal (DS ≥ 30%) and optimal (DS < 30%) DS groups according to quantitative coronary angiography (QCA) measurements of the target lesions at follow-up. Seven independent factors including calcified lesions, true bifurcation lesions, immediate lumen gain rate (iLG%) < 20%, immediate diameter stenosis (iDS) ≥ 30%, DCB diameter/reference vessel diameter ratio (DCB/RVD) < 1.0, DCB length and mild dissection were identified. The area under the curve (AUC) (95% CI) of the receiver-operating characteristic (ROC) curve of the nomogram was 0.738 (0.683, 0.794). After the internal validation, the AUC (95% CI) was 0.740 (0.685, 0.795). The Hosmer-Lemeshow goodness of fit (GOF) test (χ² = 6.57, P = 0.766) and the calibration curve suggested a good predictive consistency of the nomogram.

CONCLUSIONS

The well-calibrated nomogram could efficiently predict the suboptimal angiographic outcomes at follow-up. This model may be helpful to optimize lesion preparation to achieve optimal outcomes.

Comparative pathological findings between coronary bare-metal stent implantation and balloon angioplasty over 16 years

A 68-year old man underwent bare metal stent (BMS; Palmaz-Shatz stent) implantation in the distal right coronary artery (RCA; #4PL) and balloon angioplasity (BA) in the proximal left circumflex coronary artery (LCX; #11) for stable angina. After 5 years after initial stent implantation, de novo lesion located in mid RCA was treated by BMS (NIR stent) implantation additionally. After 16 years from first BMS implantation, the patient died from heart failure due to cardiac amyloidosis, and pathologic examination was performed for the specimen of stented RCA segment and LCX BA segment. An autopsy demonstrated that the lesions of stented site at RCA and BA site LCX were histopathologically different. In the stented segment, severe luminal stenosis is observed due to marked proliferation of the neointima in all stented sites. In addition, neovascularization and spotty calcification with mild lymphocyte infiltration were observed especially around the struts. In contrast, at the BA site of the proximal LCX lesion, in the neointima, the smooth muscle cells were rather atrophic and abundant collagen fibers were evident in the intercellular spaces, which showed very stable findings. Compared with these BMS implanted portions, the site of BA was associated with a trend for smaller late lumen loss. These findings suggested that in the stented site, chronic inflammatory reaction to the stent struts could evoke continuous proliferation of neointima resulting in severe late lumen loss. <Learning objective: Compared with BMS implantation, BA showed stable lesion with abundant collagen fiber proliferation. It could be possible that remaining inflammatory reactions to the metal of the stent caused the development of late lumen loss in BMS.>.

Systematic review and meta-analysis of short-term outcomes with drug-coated balloons vs. stenting in acute myocardial infarction

The role of drug-coated balloons (DCBs) in patients with acute myocardial infarction (AMI) remains controversial. We performed a meta-analysis of all published studies comparing the outcomes of DCBs vs. stenting in AMI patients. Four studies with 497 patients (534 lesions) were included (three randomized controlled trials and one observational study). During a mean follow-up of 9 months (range 6-12 months), DCBs were associated with similar risk of major adverse cardiovascular events (5% vs. 4.4%; OR 1.24, 95% CI: [0.34, 4.51], p = 0.74, I² = 35%), all-cause mortality (0.02% vs. 0.04%; OR 077, 95% CI: [0.15, 3.91], p = 0.75, I² = 25%), cardiac death (0.01% vs. 0.02%; OR 0.64, 95% CI: [0.16, 2.64], p = 0.54), myocardial infarction (0% vs. 1.4%; OR 0.18, 95% CI: [0.01, 3.56], p = 0.26), and target lesion revascularization (3.7% vs. 2%; OR 1.74, 95% CI: [0.42, 7.13], p = 0.44, I² = 17%) compared with stenting. During a mean follow-up of 7 months (range 6-9 months), DCBs had similar late lumen loss compared with stenting (mean difference 0.04 mm, 95% CI [- 0.21-0.28], p = 0.77, I² = 92%). In patients with AMI, there was no statistical difference in the incidence of clinical and angiographic outcomes between AMI patients treated with DCB and DES. Larger studies with longer-term follow-up are needed to assess the clinical utility of DCBs in this setting.

Coronary Shear Stress after Implantation of Bioresorbable Scaffolds – a Modern Interdisciplinary Concept at the Border between Interventional Cardiology and Cardiac Imaging

Bioresorbable scaffolds/stents offer new and exciting perspectives in the treatment of patients with acute coronary syndromes, especially after the recent development of invasive imaging techniques, such as optical coherence tomography, which allow complete assessment of vascu-lar segments. A particular advantage of bioresorbable scaffolds is that once the biosorption of the scaffold is complete, the vascular segment regains its normal physiological functions, thus eliminating the risk of late complications. New studies show the importance of shear stress in the progression of vascular atherosclerosis or in accelerating endothelial turnover. Based on the current knowledge in this field, a future standardized determination of shear stress may help in the long-term follow-up of patients that have suffered or are at risk of developing an acute coronary syndrome.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Bioresorbable Polymers and Stent Devices

OPINION STATEMENT

Percutaneous coronary interventions will never become obsolete, as evolution is inherent to interventional cardiology. Current drug-eluting platforms have appreciably improved their safety and efficacy profiles in different clinical settings compared to first-generation devices such that it is difficult to consider other alternatives. However, there is definite biological plausibility to consider devices with bioabsorbable polymers and/or scaffolds. It is also an undeniable fact that many patients, based on variety of belief systems, would prefer not to have a permanently implanted device. BP DES with or without bioresorbable scaffolds offer advantages over durable polymer DES in restoring normal coronary physiology and vascular adaptive responses, resulting in late lumen gain and plaque regression. They will likely allow flexibility in treating complex CAD. However, so far, we have been able to prove non-inferiority in a selected population of patients without long-term data. Is "as good as" good enough? Are we ready to reach for the BRS or a BP DES in our catheterization laboratory based on preclinical and mechanistic data (endothelialization, OCT imaging, vasomotion) with limited human experience? I am not. While I will maximize my efforts to recruit patients in related randomized controlled trials, the technology is not ready for prime time. Randomized controlled trials are needed to determine whether any or all of these devices improve long-term outcome compared to best in class DP DES. Most definitive evidence is likely about a decade away. Until then, we can learn to be disciplined implanters not only in selecting the appropriate patient but also in perfecting implantation techniques.

Long-term (8-10 years) outcomes after biodegradable polymer-coated biolimus-eluting stent implantation

OBJECTIVE

Efficacy and safety data on biodegradable polymer-coated biolimus-eluting stent (BP-BES) are currently limited to 5 years. We evaluated longer term (8-10 years) clinical and angiographic outcomes after BP-BES implantation.

METHODS

Between 2005 and 2008, 243 patients (301 lesions) underwent BP-BES implantation. The primary clinical outcome measure was defined as any target lesion revascularisation (TLR). Absolute serial angiographic studies without any concomitant TLR within 2 years after the procedure were performed in 55 patients (65 lesions) at postprocedure, mid-term (within 1 year), late term (between 1 and 2 years) and very late term (beyond 2 years).

RESULTS

The median follow-up duration was 9.4 years (IQR 8.2-10.2 years). The 8-year cumulative incidence of any TLR was 20.3%. The increase rate was approximately 7% per year in the first 2 years, but decelerated to approximately 1.2% per year beyond 2 years after the procedure. The minimal lumen diameter significantly decreased from postprocedure (2.63±0.44 mm) to mid-term (2.43±0.59 mm, p=0.002) and from late term (2.27±0.63 mm) to very late term (1.98±0.73 mm, p=0.002). The 8-year cumulative incidences of definite or probable stent thrombosis (ST) and major bleeding (Bleeding Academic Research Consortium (BARC) ≥3) were 0.5% and 12.0%, respectively. Definite ST was none within 10 years in the entire cohort.

CONCLUSIONS

The long-term clinical outcomes after BP-BES implantation were favourable, although angiographic late progression of luminal narrowing did not reach a plateau. The incidence of ST remained notably low, whereas that of major bleeding gradually increased.

Are BVS suitable for ACS patients? Support from a large single center real live registry

OBJECTIVES

To investigate one-year outcomes after implantation of a bioresorbable vascular scaffold (BVS) in patients presenting with acute coronary syndrome (ACS) compared to stable angina patients.

BACKGROUND

Robust data on the outcome of BVS in the setting of ACS is still scarce.

METHODS

Two investigator initiated, single-center, single-arm BVS registries have been pooled for the purpose of this study, namely the BVS Expand and BVS STEMI registries.

RESULTS

From September 2012-October 2014, 351 patients with a total of 428 lesions were enrolled. 255 (72.6%) were ACS patients and 99 (27.4%) presented with stable angina/silent ischemia. Mean number of scaffold/patient was 1.55±0.91 in ACS group versus 1.91±1.11 in non-ACS group (P=0.11). Pre- and post-dilatation were performed less frequent in ACS patients, 75.7% and 41.3% versus 89.0% and 62.0% respectively (P=0.05 and P=0.001). Interestingly, post-procedural acute lumen gain and percentage diameter stenosis were superior in ACS patients, 1.62±0.65mm (versus 1.22±0.49mm, P<0.001) and 15.51±8.47% (versus 18.46±9.54%, P=0.04). Major adverse cardiac events (MACE) rate at 12months was 5.5% in the ACS group (versus 5.3% in stable group, P=0.90). One-year definite scaffold thrombosis rate was comparable: 2.0% for ACS population versus 2.1% for stable population (P=0.94), however, early scaffold thromboses occurred only in ACS patients.

CONCLUSIONS

One-year clinical outcomes in ACS patients treated with BVS were similar to non-ACS patients. Acute angiographic outcomes were better in ACS than in non-ACS, yet the early thrombotic events require attention and further research.

Neoatherosclerosis: Coronary stents seal atherosclerotic lesions but result in making a new problem of atherosclerosis

Chronic inflammation of the native vessel wall with infiltration of lipid-laden foamy macrophages through impaired endothelium results in atherosclerosis. Percutaneous coronary intervention, including metallic stent implantation, is now widely utilized for the treatment of atherosclerotic lesions of the coronary artery. Bare-metal stents and the subsequently developed drug-eluting stents seal the atherosclerosis and resolve lumen stenosis or obstruction of the epicardial coronary artery and myocardial ischemia. After stent implantation, neointima proliferates within the stented segment. Chronic inflammation caused by a foreign body reaction to the implanted stent and subsequent neovascularization, which is characterized by the continuous recruitment of macrophages into the vessel, result in the transformation of the usual neointima into an atheromatous neointima. Neointima with an atherosclerotic appearance, such as that caused by thin-cap fibroatheromas, is now recognized as neoatherosclerosis, which can sometimes cause in-stent restenosis and acute thrombotic occlusion originating from the stent segment following disruption of the atheroma. Neoatherosclerosis is emerging as a new coronary stent-associated problem that has not yet been resolved. In this review article, we will discuss possible mechanisms, clinical challenges, and the future outlook of neoatherosclerosis.

Bioresorbable scaffolds: rationale, current status, challenges, and future

Current generation of drug-eluting stents has significantly improved the outcomes of percutaneous coronary intervention by substantially reducing in-stent restenosis and stent thrombosis. However, a potential limitation of these stents is the permanent presence of a metallic foreign body within the artery, which may cause vascular inflammation, restenosis, thrombosis, and neoatherosclerosis. The permanent stents also indefinitely impair the physiological vasomotor function of the vessel and future potential of grafting the stented segment. Bioresorbable scaffolds (BRSs) have the potential to overcome these limitations as they provide temporary scaffolding and then disappear, liberating the treated vessel from its cage and restoring pulsatility, cyclical strain, physiological shear stress, and mechanotransduction. While a number of BRSs are under development, two devices with substantial clinical data have already received a Conformité Européenne marking. This review article presents the current status of these devices and evaluates the challenges that need to be overcome before BRSs can become the workhorse device in coronary intervention.