A call for provisional stenting: the balloon is back!

Impact of an aggressive stenting strategy on initial and one-year follow-up costs in patients undergoing coronary angioplasty

BACKGROUND

Although stents have been shown in randomised trials to reduce restenosis rates compared with balloon angioplasty, there are concerns regarding the cost-effectiveness of an aggressive stenting strategy. Stents were shown to increase medical costs over 12 months in the early trials.

AIM

Our aim was to determine the economic impact of an aggressive stenting strategy using current stenting techniques compared with a conservative stenting strategy.

METHODS

Initial and one year follow-up costs were determined in all patients who underwent successful revascularisation during June to December 1996 (aggressive stenting, n = 401), and compared to all patients treated in the corresponding months in 1995 (conservative stenting, n = 347). All patients had clinical follow-up for one year.

RESULTS

The proportion of patients receiving a stent increased from 22.5% in 1995 to 66.1% in 1996 (p < 0.0001). Requirement for repeat procedures in the 1995 group compared with 1996 was coronary angiography in 31% vs 16% (p < 0.001), coronary angioplasty in 11% vs 6% (p = 0.0044) and bypass surgery in 4.8% vs 2.5% (p = 0.054). The mean initial cost of the procedure was higher in the aggressive stenting group ($4319 +/- 1276 in 1995 vs $5131 +/- 1491 in 1996, p < 0.0001), but after 12 months follow-up, total medical costs were equivalent ($5975 +/- 4143 in 1995 vs $5994 +/- 3476 in 1996, p = NS).

CONCLUSION

An aggressive coronary stenting strategy is associated with higher initial costs compared with a conservative strategy, but lower costs during follow-up due to reduced need for repeat procedures, resulting in equivalent one year total medical costs.

Clinical and angiographic predictors of recurrent restenosis after percutaneous transluminal rotational atherectomy for treatment of diffuse in-stent restenosis

Due to the widespread use of stents in complex coronary lesions, stent restenosis represents an increasing problem, for which optimal treatment is under debate. "Debulking" of in-stent neointimal tissue using percutaneous transluminal rotational atherectomy (PTRA) offers an alternative approach to tissue compression and extrusion achieved by balloon angioplasty. One hundred patients (70 men, aged 58 +/- 11 years) with a first in-stent restenosis underwent PTRA using an incremental burr size approach followed by adjunctive angioplasty. The average lesion length by quantitative angiography was 21 +/- 8 mm (range 5 to 68) including 22 patients with a length > or = 40 mm. Twenty-nine patients had complete stent occlusions with a lesion length of 44 +/- 23 mm. Baseline diameter stenosis measured 78 +/- 17%, was reduced to 32 +/- 9% after PTRA, and further reduced to 21 +/- 10% after adjunctive angioplasty. Primary PTRA was successful in 97 of 100 patients. Clinical success was 97%, whereas 2 patients developed non-Q-wave infarctions without clinical sequelae. Clinical follow-up was available for all patients at 5 +/- 4 months without any cardiac event. Angiography in 72 patients revealed restenosis in 49%, with necessary target lesion reintervention in 35%. The incidence of rerestenosis correlated with the length of the primarily stented segment and the length of a first in-stent restenosis. Thus, PTRA offers an alternative approach to treat diffuse in-stent restenosis. Neointimal debulking of stenosed stents can be achieved effectively and safely. PTRA resulted in an acceptable recurrent restenosis rate in short and modestly diffuse lesion, whereas the restenosis rate in very long lesions remains high despite debulking.

Coronary artery surgery: the end of the beginning

In each of the first three decades of myocardial revascularization, conventional treatment has been revised completely. This lecture comments on three areas of discovery that have shaped the evolution of myocardial revascularization: science, technology development, and revascularization. The discoveries in all three areas are inexorably interrelated. The single greatest lesson learned so far is that conduit performance carries more prognostic weight than any other factor. We have observed that vein graft atherosclerosis is predictable, and that the first-generation lipid lowering drugs have a favorable effect in patients who achieve marked LDL reduction. Biologically better revascularization begins with use of the internal thoracic artery for grafting to the anterior descending coronary artery. As the results of internal thoracic artery grafting are widely reported, arterial bypass revascularization has expanded, notably by radial and gastroepiploic arteries. The results of bilateral internal thoracic artery grafting are discussed, including large-scale registry results of internal thoracic artery usage in the United States. The internal thoracic artery is significantly underutilized. Diabetes affects both endoluminal and surgical revascularization. The new pharmacology in cardiology interventions shows promise in diminishing restenosis and thrombosis even in diabetic patients. Conversely, extended internal thoracic artery grafting may also benefit diabetic patients. Now we are entering a new age of minimally invasive coronary surgery. We have passed through the early stages of mini-thoracotomy, and we are moving on to access through 1-cm ports, intrathoracic cannulation, antegrade and retrograde myocardial protection, and computer guided three-dimensional vision and instrumentation. The potential for robotic control adds greater precision, ease of use, and safety. This new technology will be integrated with diagnostic information, intraoperative monitoring, anesthesia and perfusion data, cost accounting, and surgical note transcription. The operating room of the future will package intraoperative information and is adaptable to all surgical specialties. The future of coronary artery surgery will depend on minimally invasive techniques, all-arterial grafting, and selective lipid modification to reduce progressive atherosclerosis. The conclusion of this decade marks the end of the beginning. The new generation of cardiothoracic surgeons will share in an array of technology and research unmatched in previous decades.

Vascular gene transfer for the treatment of restenosis and atherosclerosis

Local gene transfer into the vascular wall offers a promising alternative to treat atherosclerosis-related diseases at cellular and molecular levels. Blood vessels are among the easiest targets for gene therapy because of novel percutaneous, catheter-based treatment methods. On the other hand, gene transfer to the artery wall can also be accomplished from adventitia, and in some situations intramuscular gene delivery is also a possibility. In most conditions, such as postangioplasty restenosis, only a temporary expression of the transfected gene will be required. Promising therapeutic effects have been obtained in animal models of restenosis with the transfer of genes for vascular endothelial growth factor, fibroblast growth factor, thymidine kinase, p53, bcl-x, nitric oxide synthase and retinoblastoma. Also, growth arrest homeobox gene and antisense oligonucleotides against transcription factors or cell cycle regulatory proteins have produced beneficial therapeutic effects. Angiogenesis is an emerging new target for gene therapy of ischemic diseases. In addition, hyperlipoproteinemias may be improved by transferring functional lipoprotein-receptor genes into hepatocytes of affected individuals. First experiences of gene transfer methods in the human vascular system have been reported. However, further studies regarding gene delivery methods, vectors and safety of the procedures are needed before a full therapeutic potential of gene therapy in vascular diseases can be evaluated.