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Kabir AMN, Selvarajah A, Seifalian AM. How safe and how good are drug-eluting stents? Future Cardiol 2011; 7:251-70. [DOI: 10.2217/fca.11.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Percutaneous transluminal coronary angioplasty revolutionized therapy for coronary artery disease. This early promise of a viable alternative to surgical treatment of coronary artery disease was thwarted by the high rates of angiographic restenosis. The advent of stenting reduced the rates of restenosis, although it was hindered by the new problem of in-stent restenosis. It was demonstrated that in-stent restenosis was the result of a new pathology in the form of neointimal hyperplasia, which was a maladaptive healing response to bare-metal stent implantation. Recently, the introduction of drug-eluting stents (DES) technology has offered a new solution to the problem of restenosis. Current evidence suggests that although DES have reduced restenosis rates, important concerns have been raised regarding increased stent thrombosis, myocardial infarction and death. The purpose of this article is to examine the efficacy and safety data of DES as highlighted in recent publications and to further discuss the biomolecular mechanisms of accelerated endothelization and stent thrombosis. In addition, we will examine some of the newer stent technologies available.
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Affiliation(s)
- Alamgir MN Kabir
- Division of Cardiology, University College London, London, UK
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Amalan Selvarajah
- Division of Cardiology, University College London, London, UK
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Alexander M Seifalian
- Centre for Nanotechnology & Regenerative Medicine, University College London, London, UK
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102
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Can intravascular ultrasound guidance modify the efficacy of drug-eluting stent over bare-metal stent in an aorto-ostial lesion? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2011; 12:105-10. [DOI: 10.1016/j.carrev.2010.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 02/08/2010] [Accepted: 02/11/2010] [Indexed: 11/23/2022]
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103
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Kuriyama N, Kobayashi Y, Nakama T, Mine D, Nishihira K, Shimomura M, Nomura K, Ashikaga K, Matsuyama A, Shibata Y. Late restenosis following sirolimus-eluting stent implantation. JACC Cardiovasc Interv 2011; 4:123-8. [PMID: 21251639 DOI: 10.1016/j.jcin.2010.09.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Revised: 07/26/2010] [Accepted: 09/03/2010] [Indexed: 01/24/2023]
Abstract
OBJECTIVES This serial angiographic study evaluated the incidence and predictors of late restenosis after sirolimus-eluting stent (SES) implantation. BACKGROUND Previous studies showed late restenosis (i.e., late catch-up phenomenon) after implantation of 7-hexanoyltaxol-eluting stents and nonpolymeric, paclitaxel-eluting stents. METHODS Between August 2004 and December 2006, SES implantation was performed in 1,393 patients with 2,008 lesions, in whom 8-month and 2-year follow-up coronary angiography were planned. RESULTS Of 2,008 lesions, 1,659 (83%) underwent 8-month follow-up angiography (8.3 ± 2.2 months). Restenosis was observed in 122 lesions (7.4%). Coronary angiography 2 years (1.9 ± 0.4 years) after SES deployment was performed in 1,168 lesions (74% of lesions without restenosis at 8-month follow-up angiography). Late restenosis was observed in 83 lesions (7.1%). There was significant decrease in minimum luminal diameter (MLD) between 8-month and 2-year follow-up (2.56 ± 0.56 mm vs. 2.35 ± 0.71 mm, p < 0.001). Multivariate analysis showed in-stent restenosis before SES implantation and MLD at 8-month follow-up as independent predictors of late restenosis. CONCLUSIONS Between 8-month and 2-year follow-up after SES implantation, MLD decreases, which results in late restenosis in some lesions. In-stent restenosis before SES implantation and MLD at 8-month follow-up are independent predictors of late restenosis.
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Affiliation(s)
- Nehiro Kuriyama
- Department of Cardiology, Miyazaki Medical Association Hospital, Miyazaki, Japan
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104
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Goto I, Itoh T, Kimura T, Fusazaki T, Matsui H, Sugawara S, Komuro K, Nakamura M. Morphological and Quantitative Analysis of Vascular Wall and Neointimal Hyperplasia After Coronary Stenting - Comparison of Bare-Metal and Sirolimus-Eluting Stents Using Optical Coherence Tomography -. Circ J 2011; 75:1633-40. [DOI: 10.1253/circj.cj-10-1237] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Iwao Goto
- Division of Cardiology, Department of Internal Medicine and Memorial Heart Center, Iwate Medical University
| | - Tomonori Itoh
- Division of Cardiology, Department of Internal Medicine and Memorial Heart Center, Iwate Medical University
| | - Takumi Kimura
- Division of Cardiology, Department of Internal Medicine and Memorial Heart Center, Iwate Medical University
| | - Tetsuya Fusazaki
- Division of Cardiology, Department of Internal Medicine and Memorial Heart Center, Iwate Medical University
| | - Hiroki Matsui
- Division of Cardiology, Department of Internal Medicine and Memorial Heart Center, Iwate Medical University
| | - Shoma Sugawara
- Division of Cardiology, Department of Internal Medicine and Memorial Heart Center, Iwate Medical University
| | - Kentaro Komuro
- Division of Cardiology, Department of Internal Medicine and Memorial Heart Center, Iwate Medical University
| | - Motoyuki Nakamura
- Division of Cardiology, Department of Internal Medicine and Memorial Heart Center, Iwate Medical University
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105
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Otsuka Y, Ishiwata S, Inada T, Kanno H, Kyo E, Hayashi Y, Fujita H, Michishita I. Comparison of haemodialysis patients and non-haemodialysis patients with respect to clinical characteristics and 3-year clinical outcomes after sirolimus-eluting stent implantation: insights from the Japan multi-centre post-marketing surveillance registry. Eur Heart J 2010; 32:829-37. [PMID: 21196442 DOI: 10.1093/eurheartj/ehq480] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Long-term outcomes after sirolimus-eluting stent (SES) implantation in haemodialysis (HD) patients have remained controversial. We investigated the impact of HD on outcomes after SES implantation. METHODS AND RESULTS We analysed the data on 2050 patients who underwent SES implantation in a multi-centre prospective registry in Japan. Three-year clinical outcomes were compared between the HD group (n = 106) and the non-haemodialysis (NH) group (n = 1944). At the 3-year clinical follow-up, the rates of unadjusted cardiac mortality (HD: 16.3 vs. NH: 2.3%) and target-lesion revascularization (TLR) (HD: 19.4 vs. NH: 6.6%) were significantly higher in the HD group than the NH group (P < 0.001). Although HD group had a numerically higher stent thrombosis rate, the difference in stent thrombosis between the two groups (HD: 2.0 vs. NH: 0.7%) did not reach statistical significance. Using Cox's proportional-hazard models with propensity score adjustment for baseline differences, the HD group had higher risks of TLR [HD: 16.3 vs. NH: 6.1%; hazard ratio, 2.83; 95% confidence interval (CI): 1.62-4.93, P = 0.0003] and cardiac death (HD: 12.3 vs. NH: 2.3%; hazard ratio, 5.51; 95% CI: 2.58-11.78, P < 0.0001). The consistent results of analyses, whether unadjusted or adjusted for other baseline clinical and procedural differences, identify HD as an independent risk factor for cardiac death and TLR. CONCLUSIONS Percutaneous coronary intervention with SES in HD patients has a higher incidence of repeat revascularization and mortality compared with those in NH patients. Haemodialysis appears to be strongly associated with mortality and repeat revascularization even after SES implantation.
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Affiliation(s)
- Yoritaka Otsuka
- Department of Cardiology, National Cardiovascular Center, Osaka, Japan.
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106
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Serikawa T, Kawasaki T, Koga H, Orita Y, Ikeda S, Goto Y, Shintani Y, Kajiwara M, Tanaka H, Fukuyama T, Koga N. Late catch-up phenomenon associated with stent fracture after sirolimus-eluting stent implantation: incidence and outcome. J Interv Cardiol 2010; 24:165-71. [PMID: 21198850 DOI: 10.1111/j.1540-8183.2010.00614.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the long-term outcome of the stent fracture (SF) and the potential predictive factors contributing to in-stent restenosis (ISR) in the fractured stent. BACKGROUND The SF is thought to be a higher risk of ISR in drug-eluting stent, although SF does not always develop ISR. METHODS The consecutive 1,228 de novo lesions in 1,079 patients who underwent sirolimus-eluting stents implantation and assessed by 8 months follow-up coronary angiography were retrospectively analyzed. RESULTS One hundred and seventeen SFs (9.5%) were identified in 100 patients and 22 (18.8%) SFs revealed ISR at the first follow-up. In addition, 16 (13.7%) developed new ISRs from 95 residual SFs without ISR prior to the second follow-up. Overall, 38 (32.5%) of all 117 SFs developed ISR, and 16 (42.1%) of 38 SFs occurred in a late phase beyond the first 8 months follow-up. A higher risk of ISR in the SF site was associated with the chronic total occlusion (ISR vs. no ISR: 34.2% vs. 16.5%, P = 0.0304), calcified lesions (55.3% vs. 34.2%, P = 0.0299), and correspondence 89.5% versus 43.0%, P < 0.0001 (SF site occurring at the original target lesion site) in the univariate analysis. The correspondence was identified as the only strong predictive factor for ISR at the SF site according to a multivariate logistic regression analysis (odds ratio 12.6, 95% confidence interval 3.82-53.5, P < 0.0001). CONCLUSIONS SF occurring at the site of the original target lesion was a strong independent predictor of ISR. This indicates the need for a careful, long-term follow-up in those situations, even when no significant ISR is initially detected.
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107
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Charytan DM, Varma MR, Silbaugh TS, Lovett AF, Normand SLT, Mauri L. Long-term clinical outcomes following drug-eluting or bare-metal stent placement in patients with severely reduced GFR: Results of the Massachusetts Data Analysis Center (Mass-DAC) State Registry. Am J Kidney Dis 2010; 57:202-11. [PMID: 21186075 DOI: 10.1053/j.ajkd.2010.09.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 09/10/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients with chronic kidney disease have been under-represented in randomized trials of drug-eluting stents relative to bare-metal stents and are at high risk of mortality. STUDY DESIGN Cohort study with propensity score matching. SETTINGS & PARTICIPANTS All adults with chronic kidney disease and severely decreased glomerular filtration rate (GFR; serum creatinine >2.0 mg/dL or dialysis dependence) undergoing percutaneous coronary intervention with stent placement between April 1, 2003, and September 30, 2005, at all acute-care nonfederal hospitals in Massachusetts. PREDICTOR Patients were classified as drug-eluting stent-treated if all stents were drug eluting and bare-metal stent-treated if all stents were bare metal. Patients treated with both types of stents were excluded from the primary analysis. OUTCOMES & MEASUREMENTS 2-year crude mortality risk differences (drug-eluting - bare-metal stents) were determined from vital statistics records, and risk-adjusted mortality, myocardial infraction (MI), and revascularization differences were estimated using propensity score matching of patients with severely reduced GFR based on clinical and procedural information collected at the index admission. RESULTS 1,749 patients with severely reduced GFR (24% dialysis dependent) were treated with drug-eluting (n = 1,256) or bare-metal stents (n = 493) during the study. Overall 2-year mortality was 32.8% (unadjusted drug-eluting stent vs bare-metal stent; 30.1% vs 39.8%; P < 0.001). After propensity score matching 431 patients with a drug-eluting stent to 431 patients with a bare-metal stent, 2-year risk-adjusted mortality, MI, and target-vessel revascularization rates were 39.4% versus 37.4% (risk difference, 2.1%; 95% CI, -4.3 to 8.5; P = 0.5), 16.0% versus 19.0% (risk difference, -3.0%; 95% CI, -8.2 to 2.1; P = 0.3), and 13.0% versus 17.6% (risk difference, -4.6%; 95% CI, -9.5 to 0.3; P = 0.06). LIMITATIONS Observational design, ascertainment of serum creatinine level >2.0 mg/dL and dialysis dependence from case report forms. CONCLUSIONS In patients with severely decreased GFR, treatment with drug-eluting stents was associated with a modest decrease in target-vessel revascularization not reaching statistical significance and was not associated with a difference in risk-adjusted rates of mortality or MI at 2 years compared with bare-metal stents.
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108
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Drug-eluting Tibial Stents: Objective Patency Determination. J Vasc Interv Radiol 2010; 21:1825-9. [DOI: 10.1016/j.jvir.2010.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2009] [Revised: 04/13/2010] [Accepted: 09/05/2010] [Indexed: 11/20/2022] Open
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Garg P, Charytan DM, Novack L, Cutlip DE, Popma JJ, Moses J, Leon MB, Schofer J, Breithardt G, Schampaert E, Mauri L. Impact of moderate renal insufficiency on restenosis and adverse clinical events after sirolimus-eluting and bare metal stent implantation (from the SIRIUS trials). Am J Cardiol 2010; 106:1436-42. [PMID: 21059433 DOI: 10.1016/j.amjcard.2010.07.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 07/14/2010] [Accepted: 07/14/2010] [Indexed: 10/18/2022]
Abstract
Whether drug-eluting stents are effective and safe in patients with moderate renal insufficiency (RI) is unknown. We performed a pooled analysis of data from 3 blinded randomized trials of sirolimus-eluting stents (SESs) versus bare metal stents (BMSs; SIRIUS, C-SIRIUS, E-SIRIUS) that included 1,510 patients. Clinical and angiographic outcomes were stratified by the presence of RI defined by creatinine clearance calculated by the Cockcroft-Gault formula (normal ≥ 90, mild 60 to 89, moderate < 60 ml/min). Patients with baseline creatinine > 3.0 mg/dl were excluded from these trials. Baseline mild RI was present in 517 patients (34.7%, mean creatinine clearance 75.7 ml/min) and moderate RI in 228 patients (15.3%, mean creatinine clearance 47.2 ml/min). Treatment with SESs resulted in lower rates of 8-month angiographic restenosis rates in patients with RI (mild RI 6.7% vs 42.6%, p < 0.001; moderate RI 9.7% vs 39.7%, p < 0.001) and without baseline RI (7.7% vs 37.2%, p < 0.001). One-year target vessel revascularization rates were similarly decreased with SESs in patients with (mild RI 4.7% vs 24.2%, p < 0.001; moderate RI 5.5% vs 26.9%, p < 0.001) and without (8.1% vs 22.4%, p < 0.001) RI, and this benefit was maintained at 5 years. Compared to patients with normal or mild RI, patients with moderate RI had higher rates of overall mortality and cardiac death at 1 year and 5 years (death 2.6% vs 0.6%, p <0.01, and 17.5% vs 6.3%, p < 0.01, at 1 year and 5 years, respectively; cardiac death 1.3% vs 0.2%, p = 0.05, and 6.6% vs 3.4%, p = 0.04, at 1 year and 5 years, respectively). However, there was no differential effect of SESs versus BMSs on any safety end point. In conclusion, patients with moderate RI have a nearly threefold increase in 5-year mortality after percutaneous coronary intervention compared to patients without RI. The effectiveness of SESs in decreasing restenosis compared to BMSs in patients with moderate RI was preserved and rates of death and myocardial infarction were not adversely affected.
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110
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Chen Q, Yang Y, Liu Y, Ke D, Wu Q, Li G. Safety and effectiveness of percutaneous coronary intervention (PCI) in elderly patients. A 5-year consecutive study of 201 cases with PCI. Arch Gerontol Geriatr 2010; 51:312-6. [DOI: 10.1016/j.archger.2010.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 01/08/2010] [Accepted: 01/15/2010] [Indexed: 10/19/2022]
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111
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Long-term angiographic outcomes of post-Sirolimus-eluting stent restenosis in Japanese patients. Heart Vessels 2010; 26:168-75. [DOI: 10.1007/s00380-010-0043-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 03/25/2010] [Indexed: 10/18/2022]
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112
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Wiemer M, Serruys PW, Miquel-Hebert K, Neumann FJ, Piek JJ, Grube E, Haase J, Thuesen L, Hamm C. Five-year long-term clinical follow-up of the XIENCE V everolimus eluting coronary stent system in the treatment of patients with de novo coronary artery lesions: the SPIRIT FIRST trial. Catheter Cardiovasc Interv 2010; 75:997-1003. [PMID: 20517959 DOI: 10.1002/ccd.22428] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Drug-eluting stents have shown to be superior over bare metal stents in clinical and angiographic outcomes after percutaneous treatment of coronary artery stenosis. However, long-term follow-up data are scarce and only available for sirolimus- and paclitaxel-eluting stents. AIM To assess the feasibility and performance of the XIENCE V everolimus-eluting stent (EES) versus an identical bare metal stent after a 5-year follow-up period. METHODS SPIRIT FIRST was a First in Man, multicentre, prospective, single-blind, clinical trial, randomizing 60 patients with a single de novo coronary artery lesion in a ratio of 1:1 to either an everolimus eluting or a bare metal control stent. RESULTS At 5-year clinical follow-up, data were available in 89% and 86% of patients in the everolimus and control arm, respectively. In the everolimus arm, no additional death, myocardial infarction, clinically driven target lesion revascularization (TLR), or clinically driven target vessel revascularization (TVR) events were observed between 1- and 5-year follow-up. The 5-year hierarchical major adverse cardiac events (MACE) and target vessel failure (TVF) rates for the everolimus arm were 16.7% (4/24) for both endpoints. In the control group, no additional cardiac death, myocardial infarction, or clinically driven TLR events were observed between 2- and 5-year follow-up. No additional clinically driven TVR events were observed between 3- and 5-year follow-up. The 5-year hierarchical MACE and TVF rates for the control arm were 28.0% (7/25) and 36.0% (9/25), respectively. No stent thromboses were observed in either the everolimus arm or the control arm up to 5 years. CONCLUSION The favorable 5-year long term clinical outcome of the EES is consistent with the results from other studies of the EES with shorter follow-up.
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Affiliation(s)
- Marcus Wiemer
- Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany.
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113
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Stabilní angina pectoris. Doporučený diagnostický a léčebný postup České kardiologické společnosti. COR ET VASA 2010. [DOI: 10.33678/cor.2010.144] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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114
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Weaver JD, Ku DN. Mechanical Evaluation of Polyvinyl Alcohol Cryogels for Covered Stents. J Med Device 2010. [DOI: 10.1115/1.4001863] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Covered stents could reduce restenosis rates by preventing cellular migration with a physical barrier and may have reduced thrombotic complications if an appropriate material is selected. Previous Dacron™ or poly(tetrafluoroethylene) (PTFE) covered stents have had mixed clinical results in part because they are too thick and too thrombogenic at small diameters. Ideally, the covering should be as thin as a stent strut, mechanically able to expand as much as a stent, and durable enough to withstand deployment. As an alternative to PTFE, thin polyvinyl alcohol (PVA) cryogel membranes were tested for their ability to stretch with uniaxial tension tests and for puncture strength with a modified ASTM method. Additionally, PVA cryogel covered stents were made by coating expanded bare metal stents. These covered stents were then hand-crimped onto a balloon catheter and expanded. PVA cryogel membranes were made as thin as 100 μm—thinner than some stent struts—and stretched to approximately 3.0 times their original diameter (similar to a stent during deployment). PVA cryogel membranes resisted puncture well with an average push-through displacement of 4.77 mm—allowing for safe deployment in vessels of up to 9 mm in diameter. Push-through displacement did not depend on membrane thickness in the range tested—a trait that could reduce stent profile without increased risk of puncture. All the PVA cryogel covered stents tolerated the crimping and expansion process well and there was little to no visible membrane damage. In conclusion, based on the results of these mechanical tests, PVA cryogels are mechanically suitable for covered stent membranes. This work represents a first step toward the creation of a new class of covered stent, which could prevent complications from both restenosis and thrombosis.
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Affiliation(s)
- Jason D. Weaver
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 313 Ferst Drive, Suite 2127, Atlanta, GA 30332
| | - David N. Ku
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 801 Ferst Drive, Atlanta, GA 30332
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115
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Beohar N, Meyers SN, Erdogan A, Harinstein ME, Pieper K, Gagnon S, Davidson CJ. Off-label use of drug-eluting versus bare metal stents: a lesion-specific systematic review of long-term outcomes. J Interv Cardiol 2010; 23:528-45. [PMID: 20735712 DOI: 10.1111/j.1540-8183.2010.00588.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The purpose of this systematic review was to evaluate differences in lesion-specific outcomes with the "off-label" use of drug-eluting stents (DES) versus bare metal stents (BMS). METHODS MEDLINE, PubMed, the Cochrane databases, and other Web were searched for studies evaluating off-label use of DES and BMS with the same characteristics. Of 1,258 abstracts or manuscripts reviewed, 112 studies were included (total N = 23,438). Studies were excluded if patients received both types of stent or no stent; lesion type was unknown; lesion-specific outcomes for ≥6 months were unavailable; or <25 patients were enrolled. RESULTS Overall mortality at 6-12 months was approximately 3% for BMS and DES for off-label use. Increase in mortality was greater from 6-12 months to 2 years with BMS than with DES (3.3%-9.1%; 2.8%-4.1%); however, rates were similar at 3 years (BMS: 18.8%; DES:15.3%). Myocardial Infarction rates were similar for both types at 6-12 months (BMS: 6.5%; DES: 6.0%). Overall rates of stent thrombosis were 1.8% and 1.7% for BMS and DES, respectively. Similar or slightly lower rates of stent thrombosis were seen for most lesion types, except higher rates for small vessels for BMS (5.2%) and true bifurcation for DES (3.3%). Rates of target lesion revascularization (TLR) were 7.5% for BMS and 19.6% for DES at 6-12 months. At 2-years TLR remained lower than DES. When the combined group was compared to registry data alone, similar values were seen. CONCLUSIONS Rates of mortality, myocardial infarction (MI), and stent thrombosis were similar in patients receiving BMS or DES, while TLR rates were lower in DES patients.
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Affiliation(s)
- Nirat Beohar
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA.
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116
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Prediction of late restenosis after sirolimus-eluting stent implantation using serial quantitative angiographic and intravascular ultrasound analysis. Cardiovasc Interv Ther 2010; 26:26-32. [DOI: 10.1007/s12928-010-0030-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 07/14/2010] [Indexed: 10/19/2022]
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117
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Garg S, Serruys PW. Coronary Stents. J Am Coll Cardiol 2010; 56:S1-42. [PMID: 20797502 DOI: 10.1016/j.jacc.2010.06.007] [Citation(s) in RCA: 307] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 06/01/2010] [Accepted: 06/15/2010] [Indexed: 01/07/2023]
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118
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Ploegmakers MMJ, Viscaal AM, Finch L, Mayo NE, Brophy JM. The disutility of restenosis--the impact of repeat percutaneous coronary intervention on quality of life. Can J Cardiol 2010; 26:197-200. [PMID: 20548981 DOI: 10.1016/s0828-282x(10)70399-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) with coronary stenting is a common medical procedure that is used to treat the symptoms of both stable angina and acute coronary syndromes. Drugeluting stents (DES) decrease restenosis and repeat revascularization procedures but are more expensive than bare-metal stents. A proper cost-effectiveness analysis of DES requires an understanding of the health value patients place on the avoidance of restenosis accompanied by a repeat PCI. OBJECTIVE To estimate quality-of-life (QoL) benefits ascribed to avoiding the return of coronary symptoms and the need for a repeat revascularization procedure. METHODS A prospective, single-centre study was conducted involving PCI patients. A time trade-off (TTO) question, based on a hypothetical restricted lifespan of 10 years, was used to estimate the QoL benefits patients attach to the avoidance of recurrent symptoms and a repeat PCI. This was accomplished by interviewing the patients by telephone, two weeks post-PCI. The TTO question was also administered to the catheterization laboratory staff. RESULTS Between January and March 2007, and between April and June 2008, 103 interviews were completed. The median TTO was zero weeks (interquartile range zero to 1.7 weeks). Six interventional cardiologists and eight cardiac catheterization nurses reported a similar median disutility. CONCLUSION Despite acknowledgement of the substantial clinical benefits of DES, the results of the present study suggest that patients do not place a great disutility on avoiding restenosis, thereby providing little QoL justification for the large incremental cost associated with this technology.
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Affiliation(s)
- Marleen M J Ploegmakers
- Department of Epidemiology, Biostatistics and Health Technology Assessment, University Medical Centre Nijmegen, The Netherlands
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119
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Percutaneous coronary intervention for small vessel coronary artery disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2010; 11:189-98. [PMID: 20599174 DOI: 10.1016/j.carrev.2009.04.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2008] [Revised: 04/03/2009] [Accepted: 04/06/2009] [Indexed: 02/05/2023]
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Chitkara K, Pujara K. Drug-eluting Stents in Acute Coronary Syndrome: Is There a Risk of Stent Thrombosis with Second-Generation Stents? ACTA ACUST UNITED AC 2010; 1:20-24. [PMID: 21766004 DOI: 10.5083/ejcm.20424884.10] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Over the past decade, the advent of drug-eluting stents (DES) has revolutionised the field of interventional cardiology by having a major impact on patient care through their efficacy in reducing the need for repeat revascularisation. A number of stents capable of delivering an anti-proliferative agent designed to prevent neointimal hyperplasia, the principal mechanism of restenosis after stenting, have been evaluated; four of these devices are currently approved by the U.S. Food and Drug Administration (FDA). Bare metal stent (BMS) and first-generation DES, such as sirolimus-eluting (SES-Cypher(®)) and paclitaxel-eluting stents (PES-Taxus(®)), have further improved results of percutaneous coronary intervention (PCI) by improving early results and reducing the risk of restenosis. However, there is currently debate on the safety of these first-generation DES, given the potential for late stent thrombosis (LST), especially after discontinuation of dual anti-platelet therapy. Second-generation DES, such as zotarolimus-eluting (ZES-Endeavor(®)) and everolimus-eluting stents (EES-Xience V(®)), are become available in the USA and/or Europe. Recently, long-term results comparing DES with BMS in patients with ST-segment-elevation MI (STEMI) have raised some questions about the long-term risks of the drug-eluting devices. It may be useful to pause, reflect for a moment, and consider some recent pertinent results regarding their wider use. This systematic review tries to provide a concise and critical appraisal of the data available to compare first and second generation stents especially to assess risk of stent thrombosis (ST) with second-generation DES.
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Affiliation(s)
- Kamal Chitkara
- Department of Cardiology, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester
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Gertz ZM, Wilensky RL. Local Drug Delivery for Treatment of Coronary and Peripheral Artery Disease. Cardiovasc Ther 2010; 29:e54-66. [DOI: 10.1111/j.1755-5922.2010.00187.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Stojkovic S, Ostojic M, Nedeljkovic M, Stankovic G, Beleslin B, Vukcevic V, Orlic D, Arandjelovic A, Kostic J, Dikic M, Tomasevic M. Systemic rapamycin without loading dose for restenosis prevention after coronary bare metal stent implantation. Catheter Cardiovasc Interv 2010; 75:317-25. [PMID: 20049961 DOI: 10.1002/ccd.22301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The aim of this study was to assess the role of short oral administration of rapamycin, without loading dose, in the reduction of restenosis rate after bare metal stent implantation. BACKGROUND Previous studies suggest that the administration of oral rapamycin reduces angiographic restenosis after bare metal stent implantation. METHODS This was prospective, open-label study of 80 patients randomized to either oral rapamycin (2 mg/day for 30 days, starting within 24 hr of stent implantation) or no therapy after implantation of a coronary bare metal stent. The primary study end point was incidence of angiographic binary restenosis and late loss at six months. The secondary end points were target lesion revascularization (TLR), target vessel revascularization (TVR), and incidence of major adverse cardiovascular events (MACE) at 6 months. RESULTS Angiographic follow up was completed in 72/80 (90%) of patients. In the rapamycin group, the drug was well tolerated (22.5% minor side effects) and was maintained in 100% of patients. At six months, the in-segment binary restenosis was 10.5% in rapamycin group vs. 51.4% in no-therapy group, P < 0.001) and the in-stent binary restenosis was 7.9% in rapamycin group vs. 48.7% in no-therapy group, P < 0.001. The in-segment late loss was also significantly reduced with oral therapy (0.29 + or - 0.39 vs. 0.86 + or - 0.64 mm, respectively, P < 0.001). Similarly, after six months, patients in the oral rapamycin group also showed a significantly lower incidence of TLR and TVR (7% vs. 22.7%, respectively, P = 0.039) and MACE (7% vs. 22.7%, respectively, P = 0.039). CONCLUSIONS This study showed that the administration of oral rapamycin (2 mg/day, without loading dose) during 30 days after stent implantation significantly reduces angiographic and clinical parameters of restenosis.
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Affiliation(s)
- Sinisa Stojkovic
- Department of Diagnostics and Catheterization Laboratories, Division of Cardiology, Clinical Center of Serbia, Medical School of Belgrade
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Tiroch KA, Byrne RA, Kastrati A. Pharmacological prevention and management of restenosis. Expert Opin Pharmacother 2010; 11:1855-72. [DOI: 10.1517/14656566.2010.485610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Greenhalgh J, Hockenhull J, Rao N, Dundar Y, Dickson RC, Bagust A. Drug-eluting stents versus bare metal stents for angina or acute coronary syndromes. Cochrane Database Syst Rev 2010:CD004587. [PMID: 20464732 DOI: 10.1002/14651858.cd004587.pub2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Coronary artery stents are tiny tubular devices used to 'scaffold' vessels open during percutaneous transluminal coronary angioplasty (PTCA). Restenosis (re-narrowing) of vessels treated with stents is a problem; in order to reduce restenosis, stents that elute drugs over time are now available. However these drug-eluting stents are more expensive and there is a need to assess their clinical benefits prior to recommending their use. OBJECTIVES To examine evidence from randomised controlled trials (RCTs) to assess the impact of drug eluting stents (DES) compared to bare metal stents (BMS) in the reduction of cardiac events. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 4), MEDLINE (1990 - April 2009) and EMBASE (1980 - January 2009) were searched. We carried out handsearching (electronic and manual) up to January 2008. SELECTION CRITERIA We included RCTs comparing DES with BMS used in conjunction with PTCA techniques in the review. Participants were adults with stable angina or acute coronary syndrome (ACS). We considered published and unpublished sources and included them if they reported outcome data of interest. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data, assessed trial quality assessment and checked decisions within the group. Data extraction included composite event rates (major adverse cardiac event, target vessel failure); death; acute myocardial infarction (AMI); target lesion revascularisation (TLR); target vessel revascularisation (TVR) and thrombosis. Data synthesis included meta-analysis of composite event rate, death, AMI and revascularisation rates, presented as odds ratios with 95% confidence intervals (CI) using a fixed-effect model. We assessed heterogeneity between trials. MAIN RESULTS We included more than 14,500 patients in 47 RCTs. There were no statistically significant differences in death, AMI or thrombosis between DES and BMS. For composite events, TLR and TVR reductions were evident with use of sirolimus, paclitaxel, everolimus, dexamethasone, zotarolimus and (to a limited extent) tacrolimus-eluting stents. These effects are demonstrated in the longer term follow up. Subgroup analyses (e.g. diabetics) largely mirrored these findings. AUTHORS' CONCLUSIONS Drug-eluting stents releasing sirolimus, paclitaxel, dexamethasone and zotarolimus reduce composite cardiac events. However, this reduction is due largely to reductions in repeat revascularisation rates as there is no evidence of a significant effect on rates of death, MI or thrombosis. The increased cost of drug-eluting stents and lack of evidence of their cost-effectiveness means that various health funding agencies are having to limit or regulate their use in relation to price premium.
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Affiliation(s)
- Janette Greenhalgh
- Liverpool Reviews and Implementation Group, University of Liverpool, Sherrington Building, Ashton Street, Liverpool, UK, L69 3GE
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Lombo B, Rendón I, Satizábal C, Rivas C, Sarmiento D, Carvajal C, Mor J, Diez JG. Incidencia de trombosis de stents coronarios en el «mundo real». REVISTA COLOMBIANA DE CARDIOLOGÍA 2010. [DOI: 10.1016/s0120-5633(10)70227-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Recent progress in percutaneous coronary intervention: evolution of the drug-eluting stents, focus on the XIENCE V drug-eluting stent. Coron Artery Dis 2010; 21:46-56. [PMID: 19952925 DOI: 10.1097/mca.0b013e328333f550] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although originally the practice of using balloon catheters proved successful in the short term, the long-term prognosis was less promising because of restenosis, which occurred in >or=30% of patients. This prompted the development of new techniques and mechanical adjuncts, or stents, to maintain lumen patency after balloon angioplasty. Bare metal stents (BMS), the first type of stent used in percutaneous coronary intervention, were designed to address the issues met by balloon angioplasty. BMS reduced the angiographic and clinical restenosis rates in de novo lesions compared to percutaneous transluminal coronary angioplasty alone and decreased the need for emergency coronary artery bypass graft surgery. BMS substantially reduced the incidence of abrupt artery closure, but restenosis still occurred after 6 months in about 20% of cases, necessitating repeat procedures. Drug-eluting stents (DES) improved on the principle of BMS by also delivering drugs locally to inhibit neointimal hyperplasia. DES greatly reduced the incidence of restenosis and resulted in a better safety profile as compared to radiation or systemic drug administration. These advantages and a lower cost compared to surgical interventions make DES an attractive option to treat coronary artery disease. Currently, five DES are available in the USA: the CYPHER sirolimus-eluting stent from Cordis (approved by FDA on 24 April 2003), the TAXUS Express(2) and Liberté paclitaxel-eluting stents from Boston Scientific (approved by FDA on 4 March 2004 and 10 October 2008, respectively) (hereafter TAXUS Express is referred to as TAXUS), the ENDEAVOR zotarolimus-eluting stent from Medtronic (approved by FDA on 1 February 2008), and the XIENCE V everolimus-eluting stent from Abbott Vascular (approved by FDA on 2 July 2008). Following the approval of CYPHER and TAXUS, the clinical data suggested a potential small increase in the rate of stent thrombosis (ST) in DES compared with BMS after implantation. To determine the differences in ST and other rare events between different stents, some modifications have been made to DES clinical trial design, and postmarket surveillance programs have been included to further evaluate the safety and efficacy of each DES. In this review, we will discuss the key clinical outcomes of DES clinical trials, design and key features of the current coronary stents, and major clinical development programs. Postmarket trials, designed to establish long-term safety around ST and other rare clinical events, are also discussed. The future of DES design technologies will also be outlined.
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Meerkin D, Marom H, Cohen-Biton O, Einav S. Three-dimensional vessel analyses provide more accurate length estimations than the gold standard QCA. J Interv Cardiol 2010; 23:152-9. [PMID: 20236215 DOI: 10.1111/j.1540-8183.2010.00533.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES The aim of this study was to compare lesion dimensions as determined by a three-dimensional quantitative coronary angiographic (QCA) system to that of a validated two-dimensional QCA system. BACKGROUND In an era of drug-eluting stents, device sizing has become an important clinical application of online QCA. The CardiOp-B system integrates two standard angiographic projections to provide a three-dimensional reconstruction of the arterial segment of interest. METHODS Phase 1 - 47 stenoses from consecutive coronary angiograms were assessed in two projections with both systems providing two data sets for the CMS-Medis system and a single data set for CardiOp-B. Phase 2--a perspex phantom with a known lesion length, was analyzed at increasing degrees of foreshortening with acceptance criteria set at 5% from the absolute value. RESULTS Phase 1 demonstrated an adequate correlation between the CardiOp-B and Medis systems when minimal luminal diameter was measured in the optimal view (1.32 +/- 0.47 mm vs 1.42 +/- 0.49 mm respectively; r = 0.82). A stronger correlation was noted when length was measured (25.27 +/- 10.76 mm and 21.32 +/- 8.08 mm, respectively; r = 0.95); however CardiOp-B provided a consistently longer length (P < 0.0001). On phantom length measurements the mean accuracy result for the CardiOp-B system was -1.3%. This compared favorably with the two-dimensional system where all measures performed at greater than 20 degrees of for shortening were beyond the 5% criteria from the known length. CONCLUSIONS Three-dimensional QCA provides accurate and precise vessel diameter assessments. Length assessments are consistently longer than two-dimensional measures and are significantly less affected by foreshortened projections.
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Affiliation(s)
- David Meerkin
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel.
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Gupta N, Nayak R, Grisolano SW, Buckles DC, Tadros PN. Defining patients at high risk for gastrointestinal hemorrhage after drug-eluting stent placement: a cost utility analysis. J Interv Cardiol 2010; 23:179-87. [PMID: 20236217 DOI: 10.1111/j.1540-8183.2010.00530.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The study goal was to evaluate the cost-effectiveness of drug-eluting stent (DES) placement with consideration of gastrointestinal (GI) bleeding risk. DES reduce the need for future coronary revascularization, but require prolonged dual anti-platelet (DAT) therapy, which may increase the risk for GI bleeding. While DES have been found to be cost-effective in patients at average risk for GI bleeding, they may not be the most cost-effective strategy in higher risk patients. METHODS A Markov model was created to compare DES with bare metal stents (BMS). Patients were a hypothetical cohort of 60-year-old individuals with coronary artery stenosis that required nonemergent percutaneous coronary revascularization (PCI). The primary outcomes were the threshold incremental risks of GI bleeding from DAT based on willingness to pay (WTP) of $50,000, $100,000, and $150,000 per quality adjusted life year (QALY) gained. RESULTS For a WTP of $100,000, the relative risk of GI bleeding from DAT could be as high as 10.8 (when compared to aspirin alone) before DES would no longer be cost-effective. In patients with two risk factors for GI bleeding, the threshold relative risk could be as low as 1.6. CONCLUSION In average-risk patients, the risk of GI bleeding from DAT can be substantial without affecting the cost-effectiveness of DES. However, DES are unlikely to be cost-effective in patients with two or more risk factors for GI bleeding.
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Affiliation(s)
- Neil Gupta
- Division of Gastroenterology/Hepatology, University of Kansas Medical Center, Kansas City, KS 66160, USA.
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Sakhuja R, Mauri L. Controversies in the Use of Drug-Eluting Stents for Acute Myocardial Infarction: A Critical Appraisal of the Data. Annu Rev Med 2010; 61:215-31. [DOI: 10.1146/annurev.med.051508.221014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Rahul Sakhuja
- Division of Cardiology, Massachusetts General Hospital and
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; ,
| | - Laura Mauri
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; ,
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Impact of Multiple and Long Sirolimus-Eluting Stent Implantation on 3-Year Clinical Outcomes in the j-Cypher Registry. JACC Cardiovasc Interv 2010; 3:180-8. [DOI: 10.1016/j.jcin.2009.11.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Accepted: 11/13/2009] [Indexed: 12/17/2022]
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Bartorelli AL, Serruys PW, Miquel-Hébert K, Yu S, Pierson W, Stone GW. An everolimus-eluting stent versus a paclitaxel-eluting stent in small vessel coronary artery disease: A pooled analysis from the SPIRIT II and SPIRIT III trials. Catheter Cardiovasc Interv 2010; 76:60-6. [DOI: 10.1002/ccd.22452] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Meredith I, Worthley S, Whitbourn R, Walters D, McClean D, Ormiston J, Horrigan M, Wilkins G, Hendriks R, Matsis P, Muller D, Cutlip D. Long-term clinical outcomes with the next-generation Resolute Stent System: a report of the two-year follow-up from the RESOLUTE clinical trial. EUROINTERVENTION 2010; 5:692-7. [DOI: 10.4244/eijv5i6a114] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lee K, Lee SW, Lee JW, Kim SY, Youn YJ, Ahn MS, Kim JY, Yoo BS, Yoon J, Choe KH. The significance of clopidogrel low-responsiveness on stent thrombosis and cardiac death assessed by the verifynow p(2)y(12) assay in patients with acute coronary syndrome within 6 months after drug-eluting stent implantation. Korean Circ J 2009; 39:512-8. [PMID: 20049136 PMCID: PMC2801458 DOI: 10.4070/kcj.2009.39.12.512] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Accepted: 05/19/2009] [Indexed: 12/31/2022] Open
Abstract
Background and Objectives Clopidogrel resistance or low-responsiveness may be associated with recurrent atherothrombotic events after drug-eluting stent (DES) implantation. We prospectively evaluated the association between clopidogrel resistance assessed by the Verifynow™ P2Y12 assay (Accumetrics, San Diego, CA, USA) and stent thrombosis (ST) or cardiac death (CD) in patients with acute coronary syndrome (ACS) within 6 months after DES implantation. Subjects and Methods We enrolled 237 consecutive patients (160 males, 65.2±10.3 years) with ACS who received a DES implantation. The composite endpoint was defined to CD or ST by Academic Research Consortium definitions within 6 months post-implantation. Clopidogrel resistance was defined as <20% inhibition of the P2Y12 receptor. Results Baseline demographic characteristics were similar between 142 normal individuals and 95 clopidogrel resistant patients. CD occurred in one case (0.7%) in the normal group and two cases (2.13%) in the resistant group (p=0.344). There was no episode of ST in the normal group and four episodes in the resistant group (4.2%, four definite ST) (p=0.035). Univariate logistic regression revealed an adjusted odds ratio (OR) for composite end point of CD or ST of 9.646 {95% confidence interval (CI) 1.139-81.679}, and multivariate logistic regression for composite end point revealed an OR of 12.074 (95% CI 1.205-120.992). Conclusion Clopidogrel low-responsiveness assessed by the Verifynow™ P2Y12 assay is an independent predictor of ST and composite end point of ST or CD in patients with ACS within 6 months after DES implantation.
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Affiliation(s)
- Kyounghoon Lee
- Division of Cardiology, Gachon University of Medicine and Science, Gil Medical Center, Incheon, Korea
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Hecht HS, Polena S, Jelnin V, Jimenez M, Bhatti T, Parikh M, Panagopoulos G, Roubin G. Stent gap by 64-detector computed tomographic angiography relationship to in-stent restenosis, fracture, and overlap failure. J Am Coll Cardiol 2009; 54:1949-59. [PMID: 19909876 DOI: 10.1016/j.jacc.2009.06.045] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Revised: 05/29/2009] [Accepted: 06/02/2009] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The goal of this study was to define the frequency of stent gaps by 64-detector computed tomographic angiography (CTA) and their relation to in-stent restenosis (ISR), stent fracture (SF), and overlap failure (OF). BACKGROUND SF defined by catheter angiography or intravascular ultrasound has been implicated in ISR. METHODS A total of 292 consecutive patients, with 613 stents, who underwent CTA were evaluated for stent gaps associated with decreased Hounsfield units. Correlations with catheter coronary angiography (CCA) were available in 143 patients with 384 stents. RESULTS Stent gaps were noted in 16.9% by CTA and 1.0% by CCA. ISR by CCA was noted in 46.1% of the stent gaps (p < 0.001) as determined by CCA, and stent gaps by CTA accounted for 27.8% of the total ISR (p < 0.001). In univariate analysis, stent diameter > or =3 mm was the only CCA characteristic significantly associated with stent gaps (p = 0.002), but was not a significant predictor by multivariate analysis. Bifurcation stents, underlying calcification, stent type, location, post-dilation, and overlapping stents were not observed to be predisposing factors. Excessive tortuosity and lack of conformability were not associated with stent gaps; however, their frequency was insufficient to permit meaningful analysis. CONCLUSIONS Stent gap by CTA: 1) is associated with 28% of ISR, and ISR is found in 46% of stent gaps; 2) is associated with > or =3-mm stents by univariate (p = 0.002) but not by multivariate analysis; 3) is infrequently noted on catheter angiography; and 4) most likely represents SF in the setting of a single stent, and may represent SF or OF in overlapping stents.
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Affiliation(s)
- Harvey S Hecht
- Lenox Hill Heart & Vascular Institute, New York, New York, USA.
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Moreno R, Martin-Reyes R, Jimenez-Valero S, Sanchez-Recalde A, Galeote G, Calvo L, Plaza I, Lopez-Sendon JL. Determining clinical benefits of drug-eluting coronary stents according to the population risk profile: a meta-regression from 31 randomized trials. Int J Cardiol 2009; 148:23-9. [PMID: 19962771 DOI: 10.1016/j.ijcard.2009.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 07/24/2009] [Accepted: 10/18/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of drug-eluting stents (DES) in unfavourable patients has been associated with higher rates of clinical complications and stent thrombosis, and because of that concerns about the use of DES in high-risk settings have been raised. OBJECTIVE This study sought to demonstrate that the clinical benefit of DES increases as the risk profile of the patients increases. METHODS A meta-regression analysis from 31 randomized trials that compared DES and bare-metal stents, including overall 12,035 patients, was performed. The relationship between the clinical benefit of using DES (number of patients to treat [NNT] to prevent one episode of target lesion revascularization [TLR]), and the risk profile of the population (rate of TLR in patients allocated to bare-metal stents) in each trial was evaluated. RESULTS The clinical benefit of DES increased as the risk profile of each study population increased: NNT for TLR=31.1-1.2 (TLR for bare-metal stents); p<0.001. The use of DES was safe regardless of the risk profile of each study population, since the effect of DES in mortality, myocardial infarction, and stent thrombosis, was not adversely affected by the risk profile of each study population (95% confidence interval for β value 0.09 to 0.11, -0.12 to 0.19, and -0.03 to-0.15 for mortality, myocardial infarction, and stent thrombosis, respectively). CONCLUSIONS The clinical benefit of DES increases as the risk profile of the patients increases, without affecting safety.
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Camenzind E, Wijns W, Mauri L, Boersma E, Parikh K, Kurowski V, Gao R, Bode C, Greenwood JP, Gershlick A, O'Neill W, Serruys PW, Jorissen B, Steg PG. Rationale and design of the Patient Related OuTcomes with Endeavor versus Cypher stenting Trial (PROTECT): randomized controlled trial comparing the incidence of stent thrombosis and clinical events after sirolimus or zotarolimus drug-eluting stent implantation. Am Heart J 2009; 158:902-909.e5. [PMID: 19958855 DOI: 10.1016/j.ahj.2009.10.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 10/02/2009] [Indexed: 12/17/2022]
Abstract
Drug-eluting stents (DES) reduce restenosis rates compared to bare-metal stents. Most trials using DES enrolled selected patient and lesion subtypes, and primary endpoint focused on angiographic metrics or relatively short-term outcomes. When DES are used in broader types of lesions and patients, important differences may emerge in long-term outcomes between stent types, particularly the incidence of late stent thrombosis. PROTECT is a randomized, open-label trial comparing the long-term safety of the zotarolimus-eluting stent and the sirolimus-eluting stent. The trial has enrolled 8,800 patients representative of those seen in routine clinical practice, undergoing elective, unplanned, or emergency procedures in native coronary arteries in 196 centers in 36 countries. Indications for the procedure and selection of target vessel and lesion characteristics were at the operator's discretion. Procedures could be staged, but no more than 4 target lesions could be treated per patient. Duration of dual antiplatelet therapy was prespecified to achieve similar lengths of treatment in both study arms. The shortest predefined duration was 3 months, as per the manufacturer's instructions. The primary outcome measure is the composite rate of definite and probable stent thrombosis at 3 years, centrally adjudicated using Academic Research Consortium definitions. The main secondary end points are 3-year all-cause mortality, cardiac death, large nonfatal myocardial infarction, and all myocardial infarctions. This large, international, randomized, controlled trial will provide important information on comparative rates of stent thrombosis between 2 different DES systems and safety as assessed by patient-relevant long-term clinical outcomes.
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Clinical and angiographic comparison of everolimus-eluting and paclitaxel-eluting stents in small coronary arteries: a post hoc analysis of the SPIRIT III randomized trial. Am Heart J 2009; 158:1005-10. [PMID: 19958868 DOI: 10.1016/j.ahj.2009.09.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Accepted: 09/03/2009] [Indexed: 01/09/2023]
Abstract
BACKGROUND Drug-eluting stents with low late loss may be particularly beneficial in small coronary arteries. We therefore examined whether the everolimus-eluting stent is superior to the paclitaxel-eluting stent in patients treated with 2.5-mm stents in the SPIRIT III trial. METHODS The SPIRIT III trial was a prospective, multicenter, randomized (2:1; XIENCE V: TAXUS Express) trial in which 1002 patients were enrolled. One or more 2.5-mm stents were implanted in 160 patients in the XIENCE V arm, and 59 patients, in the TAXUS arm. Mean vessel diameter was 2.36 +/- 0.30 and 2.34 +/- 0.33 mm in the XIENCE V and TAXUS groups, respectively (P = .69). RESULTS At 9 months, XIENCE V compared to TAXUS reduced the rates of major adverse cardiac events (cardiac death, myocardial infarction, or ischemic target lesion revascularization) from 12.5% to 3.2% (P = .02) and target vessel failure (cardiac death, reinfarction, or ischemic target vessel revascularization) from 16.1% to 5.2% (P = .02), the differences being driven primarily by reductions in target lesion revascularization (12.5% vs 1.3%; P = .002). In-stent late loss was significantly reduced by XIENCE V when compared to TAXUS (0.54 +/- 0.74 vs 0.11 +/- 0.43 mm, P = .01), as was In-segment binary angiographic restenosis (20.8% vs 4.1%, P = .02). CONCLUSIONS In this post hoc analysis from the SPIRIT III trial, the XIENCE V 2.5-mm stent significantly reduced clinical and angiographic restenosis compared to the TAXUS 2.5-mm stent, further supporting the hypothesis that lower late loss is beneficial in small vessel disease.
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Seo JB, Jeon HK, Park KW, Park JS, Bae JH, Kim SW, Moon KW, Choi JW, Lee SG, Chung WY, Youn TJ, Kim SJ, Kim DI, Kim BO, Hyon MS, Park KS, Cha TJ, Hwang HK, Hur SH, Kim HS. Efficacies of the new paclitaxel-eluting Coroflex Please stent in percutaneous coronary intervention; comparison of efficacy between Coroflex Please and Taxus (ECO-PLEASANT) trial: study rationale and design. Trials 2009; 10:98. [PMID: 19849864 PMCID: PMC2773780 DOI: 10.1186/1745-6215-10-98] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2009] [Accepted: 10/23/2009] [Indexed: 11/11/2022] Open
Abstract
Background Previous randomized trials have showed the superiority of Paclitaxel-eluting stent over bare metal stent in angiographic and clinical outcomes. Coroflex Please™ stent is a newly developed drug eluting stent using the Coroflex™ stent platform combined with the drug paclitaxel contained in a polymer coating. PECOPS I trial, one-arm observational study, showed that the clinical and angiographic outcomes of Coroflex Please™ stent were within the range of those of Taxus, the 1st generation paclitaxel-eluting stent (PES). However, there have been no studies directly comparing the Coroflex Please™ stent with the Taxus Liberte™ stent that is the newest version of Taxus. Therefore, prospective, randomized trial is required to demonstrate the non-inferiority of Coroflex Please™ stent compared with Taxus Liberte™ stent in a head-to-head manner. Methods In the comparison of Efficacy between COroflex PLEASe™ ANd Taxus™ stent(ECO-PLEASANT) trial, approximately 900 patients are being prospectively and randomly assigned to the either type of Coroflex Please™ stent and Taxus Liberte™ stent via web-based randomization. The primary endpoint is clinically driven target vessel revascularization at 9 months. The secondary endpoints include major cardiac adverse events, target vessel failure, stent thrombosis and angiographic efficacy endpoints. Discussion The ECO-PLEASANT trial is the study not yet performed to directly compare the efficacy and safety of the Coroflex Please™ versus Taxus Liberte™ stent. On the basis of this trial, we will be able to find out whether the Coroflex Please™ stent is non-inferior to Taxus Liberte™ stent or not. Trial registration ClinicalTrials.gov number, NCT00699543.
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Affiliation(s)
- Jae-Bin Seo
- Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.
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Ishii H, Toriyama T, Aoyama T, Takahashi H, Amano T, Hayashi M, Tanaka M, Kawamura Y, Yasuda Y, Yuzawa Y, Maruyama S, Matsuo S, Matsubara T, Murohara T. Prognostic values of C-reactive protein levels on clinical outcome after implantation of sirolimus-eluting stents in patients on hemodialysis. Circ Cardiovasc Interv 2009; 2:513-8. [PMID: 20031768 DOI: 10.1161/circinterventions.109.889915] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) using drug-eluting stents significantly reduces the risk of restenosis in the general population. However, in patients on hemodialysis, adverse cardiac events are frequently seen even if treated with drug-eluting stents. Recent studies suggest that C-reactive protein (CRP) reflects vascular wall inflammation and can predict adverse cardiac events. We evaluated possible prognostic values of CRP on outcomes in patients on hemodialysis undergoing PCI with drug-eluting stents. METHODS AND RESULTS A total of 167 patients undergoing PCI with sirolimus-eluting stents for stable angina (322 lesions) were enrolled. They were divided into tertiles according to serum CRP levels. We analyzed the incidence of major adverse cardiovascular events including cardiovascular death, nonfatal myocardial infarction, and target lesion revascularization after PCI as well as quantitative coronary angiographic data. The mean follow-up was 31 months (SD, 14). Major adverse cardiac events occurred in 11 patients (19.6%) of the lowest tertile, in 22 patients (39.3%) of the middle tertile, and in 28 patients (50.9%) of the highest tertile during follow-up period (P=0.0009). There was a progressive increase in neointimal growth after sirolimus-eluting stent implantation during follow-up because preprocedural CRP levels were higher, despite similar angiographic data just after PCI. Angiographic restenosis at 6 to 8 months after PCI was seen in 10.6% in the lowest tertile, 17.9% in the middle tertile, and 32.0% in the highest tertile (P=0.0007). CONCLUSIONS Increased preprocedural serum CRP levels would predict higher major adverse cardiac events and restenosis rates after sirolimus-eluting stents implantation in patients on hemodialysis.
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Affiliation(s)
- Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
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Sharp AS, Latib A, Ielasi A, Larosa C, Godino C, Saolini M, Magni V, Gerber RT, Montorfano M, Carlino M, Michev I, Chieffo A, Colombo A. Long-Term Follow-Up on a Large Cohort of “Full-Metal Jacket” Percutaneous Coronary Intervention Procedures. Circ Cardiovasc Interv 2009; 2:416-22. [PMID: 20031751 DOI: 10.1161/circinterventions.109.886945] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Limited long-term data exist on patients who have undergone drug-eluting stenting of very long lesions (requiring ≥60 mm of continuous stent) in native coronary arteries (“full-metal jacket”).
Methods and Results—
We examined consecutive procedures taking place between March 2002 and 2007 at 2 high-volume centers in Milan, Italy. Exclusion criteria were percutaneous coronary intervention for restenosis, percutaneous coronary intervention to a bypass graft, or percutaneous coronary intervention for acute ST-elevation myocardial infarction (MI). We identified 658 full-metal jacket lesions in 617 patients. Average age of the cohort was 62.0�10.6; 32.8% were diabetic, 51.5% had a previous MI, and 33.4% had undergone a previous percutaneous transluminal coronary angioplasty. Mean ejection fraction was 52.1�10.4%. The lesion was a chronic total occlusion in 33.0%. Median duration of clinical follow-up was 39 months (interquartile range, 28 to 50). Six-month follow-up was achieved in 97% of patients; 2-year follow-up was achieved in 91%. All-cause mortality rate was 7.3%; cardiac death rate was 3.6%. Non–procedure-related MI rates were 3.5%. Target lesion revascularization rates were 23.4%. There were 17 cases of Academic Research Consortium–defined definite or probable stent thrombosis (2.6%): 5 acute, 2 subacute, 6 late, and 4 very late. Ten of the 17 cases occurred while the patient was receiving dual antiplatelet therapy; 4 of the 17 after premature termination of 1 or both antiplatelets, and 3 of the 17 occurred while the patient was receiving single-antiplatelet therapy, after having completed the prescribed course of dual antiplatelet therapy.
Conclusion—
When very long lesions (≥60 mm) were treated using overlapping drug-eluting stents, 23.4% required a further procedure for restenosis at 3-year follow-up. However, MI, stent thrombosis, and cardiac mortality rates were relatively low.
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Affiliation(s)
- Andrew S.P. Sharp
- From the San Raffaele Scientific Institute and EMO-GVM Centro Cuore, Columbus Hospital, Milan, Italy; (A.S.P.S., A.L., A.I., C.L., C.G., M.S., V.M., R.T.G., M.M., M.C., I.M., A.C., A.C.) and Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, United Kingdom (A.S.P.S.)
| | - Azeem Latib
- From the San Raffaele Scientific Institute and EMO-GVM Centro Cuore, Columbus Hospital, Milan, Italy; (A.S.P.S., A.L., A.I., C.L., C.G., M.S., V.M., R.T.G., M.M., M.C., I.M., A.C., A.C.) and Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, United Kingdom (A.S.P.S.)
| | - Alfonso Ielasi
- From the San Raffaele Scientific Institute and EMO-GVM Centro Cuore, Columbus Hospital, Milan, Italy; (A.S.P.S., A.L., A.I., C.L., C.G., M.S., V.M., R.T.G., M.M., M.C., I.M., A.C., A.C.) and Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, United Kingdom (A.S.P.S.)
| | - Claudio Larosa
- From the San Raffaele Scientific Institute and EMO-GVM Centro Cuore, Columbus Hospital, Milan, Italy; (A.S.P.S., A.L., A.I., C.L., C.G., M.S., V.M., R.T.G., M.M., M.C., I.M., A.C., A.C.) and Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, United Kingdom (A.S.P.S.)
| | - Cosmo Godino
- From the San Raffaele Scientific Institute and EMO-GVM Centro Cuore, Columbus Hospital, Milan, Italy; (A.S.P.S., A.L., A.I., C.L., C.G., M.S., V.M., R.T.G., M.M., M.C., I.M., A.C., A.C.) and Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, United Kingdom (A.S.P.S.)
| | - Marta Saolini
- From the San Raffaele Scientific Institute and EMO-GVM Centro Cuore, Columbus Hospital, Milan, Italy; (A.S.P.S., A.L., A.I., C.L., C.G., M.S., V.M., R.T.G., M.M., M.C., I.M., A.C., A.C.) and Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, United Kingdom (A.S.P.S.)
| | - Valeria Magni
- From the San Raffaele Scientific Institute and EMO-GVM Centro Cuore, Columbus Hospital, Milan, Italy; (A.S.P.S., A.L., A.I., C.L., C.G., M.S., V.M., R.T.G., M.M., M.C., I.M., A.C., A.C.) and Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, United Kingdom (A.S.P.S.)
| | - Robert T. Gerber
- From the San Raffaele Scientific Institute and EMO-GVM Centro Cuore, Columbus Hospital, Milan, Italy; (A.S.P.S., A.L., A.I., C.L., C.G., M.S., V.M., R.T.G., M.M., M.C., I.M., A.C., A.C.) and Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, United Kingdom (A.S.P.S.)
| | - Matteo Montorfano
- From the San Raffaele Scientific Institute and EMO-GVM Centro Cuore, Columbus Hospital, Milan, Italy; (A.S.P.S., A.L., A.I., C.L., C.G., M.S., V.M., R.T.G., M.M., M.C., I.M., A.C., A.C.) and Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, United Kingdom (A.S.P.S.)
| | - Mauro Carlino
- From the San Raffaele Scientific Institute and EMO-GVM Centro Cuore, Columbus Hospital, Milan, Italy; (A.S.P.S., A.L., A.I., C.L., C.G., M.S., V.M., R.T.G., M.M., M.C., I.M., A.C., A.C.) and Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, United Kingdom (A.S.P.S.)
| | - Iassen Michev
- From the San Raffaele Scientific Institute and EMO-GVM Centro Cuore, Columbus Hospital, Milan, Italy; (A.S.P.S., A.L., A.I., C.L., C.G., M.S., V.M., R.T.G., M.M., M.C., I.M., A.C., A.C.) and Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, United Kingdom (A.S.P.S.)
| | - Alaide Chieffo
- From the San Raffaele Scientific Institute and EMO-GVM Centro Cuore, Columbus Hospital, Milan, Italy; (A.S.P.S., A.L., A.I., C.L., C.G., M.S., V.M., R.T.G., M.M., M.C., I.M., A.C., A.C.) and Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, United Kingdom (A.S.P.S.)
| | - Antonio Colombo
- From the San Raffaele Scientific Institute and EMO-GVM Centro Cuore, Columbus Hospital, Milan, Italy; (A.S.P.S., A.L., A.I., C.L., C.G., M.S., V.M., R.T.G., M.M., M.C., I.M., A.C., A.C.) and Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, United Kingdom (A.S.P.S.)
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Klomp M, Beijk MA, Verouden NJ, Tijssen JG, de Winter RJ. Design and rationale of the TRI-stent adjudication study (TRIAS) program. Am Heart J 2009; 158:527-532.e1. [PMID: 19781410 DOI: 10.1016/j.ahj.2009.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 07/13/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND In the treatment of coronary artery disease, a "pro-healing" approach for prevention of in-stent restenosis and late stent thrombosis is intuitively favored over the use of cytotoxic or cytostatic drugs released from a drug-eluting stent (DES). Promoting accelerated endothelial coverage of the stent surface, the endothelial progenitor cell (EPC) capturing stent has shown its safety and efficacy in the HEALING observational studies; however, randomized trials evaluating the device are lacking. METHODS The multicenter, randomized, controlled, 2-armed TRIAS program aims to include a total of 2560 patients. In the TRIAS Low Risk trial, a total of 1300 patients with lesions carrying a low risk of restenosis are randomized between the EPC capturing stent and a bare metal stent, assuming superiority in the incidence of target lesion failure (TLF) at 1 year. In the TRIAS High Risk trial, 1260 patients with lesions carrying a high risk of restenosis are randomized, assuming the noninferiority in TLF at 1 year of the EPC capturing stent as compared to DES. TLF is defined as the composite of cardiac death, myocardial infarction, and clinically driven target lesion revascularization. In addition, the duration of clinical follow-up is extended to 5 years to capture late events. Angiographic follow-up at 13 months is performed as part of the TRIAS Program ancillary study. IMPLICATION The results of the TRIAS Program will provide information on a relevant patient population with coronary artery lesions, comprising the full spectrum of low risk and high risk of restenosis treated with a novel stent technology in a randomized, controlled manner (TRIAS Low Risk trial: ISRCTN 47701105 and TRIAS High Risk trial: ISRCTN 74297220).
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Caixeta A, Leon MB, Lansky AJ, Nikolsky E, Aoki J, Moses JW, Schofer J, Morice MC, Schampaert E, Kirtane AJ, Popma JJ, Parise H, Fahy M, Mehran R. 5-Year Clinical Outcomes After Sirolimus-Eluting Stent Implantation. J Am Coll Cardiol 2009; 54:894-902. [DOI: 10.1016/j.jacc.2009.04.077] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 04/06/2009] [Accepted: 04/07/2009] [Indexed: 11/24/2022]
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Byrne RA, Sarafoff N, Kastrati A, Schömig A. Drug-Eluting Stents in Percutaneous Coronary Intervention. Drug Saf 2009; 32:749-70. [DOI: 10.2165/11316500-000000000-00000] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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145
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Mani G, Chandrasekar B, Feldman MD, Patel D, Agrawal CM. Interaction of endothelial cells with self-assembled monolayers for potential use in drug-eluting coronary stents. J Biomed Mater Res B Appl Biomater 2009; 90:789-801. [DOI: 10.1002/jbm.b.31348] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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146
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Lazar HL. Detrimental effects of coronary stenting on subsequent coronary artery bypass surgery: Is there another flag on the field? J Thorac Cardiovasc Surg 2009; 138:276-7. [DOI: 10.1016/j.jtcvs.2009.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Accepted: 04/11/2009] [Indexed: 10/20/2022]
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147
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Atherosclerotic and thrombogenic neointima formed over sirolimus drug-eluting stent: an angioscopic study. JACC Cardiovasc Imaging 2009; 2:616-24. [PMID: 19442950 DOI: 10.1016/j.jcmg.2008.12.026] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 11/26/2008] [Accepted: 12/05/2008] [Indexed: 12/31/2022]
Abstract
OBJECTIVES We sought to examine by angioscopy the neointima formation and thrombogenic potential of the neointima after deployment of a drug-eluting stent (DES). BACKGROUND Late stent thrombosis after DES implantation, a major safety concern, has been associated with poor strut coverage by neointima. Intracoronary angioscopy provides a method for visual evaluation of stent coverage by neointima and detection of thrombus in the stented coronary segment. METHODS Patients undergoing implantation of a sirolimus DES (n = 57) were serially examined by angioscopy immediately after (baseline) and again at 10 months (follow-up) after implantation. The angioscopic color grade of the neointima from white to yellow was assessed in a semiquantitative manner. Stent coverage was classified into not covered (Grade 0), covered by a thin layer (Grade 1), or buried under neointima (Grade 2). The thrombogenic potential of the neointima was evaluated by the prevalence of thrombus on the neointima. RESULTS The maximum yellow color grade of the neointima within DES-implanted lesions increased significantly from baseline to follow-up (1.4 +/- 1.1 vs. 1.9 +/- 0.6, p = 0.0008). Even among lesions without yellow color at baseline, yellow color was detected in 94% (17 of 18) of lesions at follow-up. The prevalence of thrombus was significantly higher on the yellow than on the white neointimal areas. Thrombus was detected on yellow and/or Grade-0/1 neointima, but never on the white Grade-2 neointima. CONCLUSIONS Sirolimus DES promoted formation of atherosclerotic yellow neointima in the stent-implanted lesion at 10-month follow-up. Thrombus was detected more often on the yellow area than on the white area and was never detected where a stent was buried under white neointima. These data suggest that the increased potential risk of late stent thrombosis in DES lesions may be due to the newly formed yellow neotima and cholesterol-laden plaque.
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Fuchs AT, Kuehnl A, Pelisek J, Rolland PH, Mekkaoui C, Netz H, Nikol S. Meta-Analysis Shows Similar Risk of Thrombosis After Drug-Eluting Stent, Bare-Metal Stent, or Angioplasty. ACTA ACUST UNITED AC 2009; 15:93-100. [DOI: 10.1080/10623320802092534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Roguin A, Grenadier E. Stent‐based percutaneous coronary interventions in small coronary arteries. ACTA ACUST UNITED AC 2009; 8:70-4. [PMID: 16885069 DOI: 10.1080/17482940600750382] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A third to half of all percutaneous coronary interventions involve small diameter vessels of less than 3 mm. Small vessel size is a predictor of restenosis after balloon angioplasty, as well as after stent placement. Stents deployed in small arteries, have a higher metal-to-artery ratio; this may increase the risk of sub-acute thrombosis or restenosis. Various studies have shown that stent design, stent coating, and stent strut thickness may determine event-free survival. Dedicated stents for small vessels with less amount of metal, appropriate expansion to the vessel size with correct radial force and cells morphology, and less prothrombotic properties, may further improve the results of stenting in this setting (thinner struts, fewer cells, or loops per circumference). This review provides an update on the current status, review the major trials and define the clinical utility of small vessel stenting, particularly in the era of drug-eluting stents.
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Affiliation(s)
- Ariel Roguin
- Department of Cardiology, Rambam Medical Center, B. Rappaport-Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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Brodie BR, Stuckey T, Downey W, Humphrey A, Bradshaw B, Metzger C, Hermiller J, Krainin F, Juk S, Cheek B, Duffy P, Smith H, Edmunds J, Varanasi J, Simonton CA. Outcomes and complications with off-label use of drug-eluting stents: results from the STENT (Strategic Transcatheter Evaluation of New Therapies) group. JACC Cardiovasc Interv 2009; 1:405-14. [PMID: 19463338 DOI: 10.1016/j.jcin.2008.06.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2008] [Revised: 05/22/2008] [Accepted: 06/12/2008] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This study evaluates outcomes and complications in patients treated with drug-eluting stents (DES) for "off-label" indications. BACKGROUND Drug-eluting stents have been effective in randomized trials, but their safety and efficacy for off-label indications has not been well studied. METHODS The STENT (Strategic Transcatheter Evaluation of New Therapies) Registry is the largest multicenter U.S. registry evaluating outcomes of DES. Off-label indications included ostial, left main, long, bifurcation, and in-stent restenotic lesions, saphenous vein grafts, chronic total occlusions, small or large vessels, multilesion or multivessel percutaneous coronary interventions, and ST-segment elevation myocardial infarction. Outcomes were adjusted using Cox proportional hazards regression and propensity analyses. RESULTS Drug-eluting stents were used in an off-label manner in 59% of patients. The patients who received off-label treatment were more often male, had a higher incidence of prior infarction and bypass surgery, and lower ejection fractions. Off-label versus "on-label" use of DES was associated with higher rates of death, myocardial infarction, target vessel revascularization, major adverse cardiac events, and stent thrombosis at 9 months and 2 years. Off-label use of DES compared with off-label use of bare-metal stents (BMS) had lower rates of death, myocardial infarction, target vessel revascularization, and major adverse cardiac events at 9 months and 2 years and lower rates of stent thrombosis at 9 months. CONCLUSIONS Off-label use of DES is associated with higher event rates compared with on-label use of DES, which is consistent with a higher risk clinical and lesion profile. However, event rates with off-label use of DES are lower compared with off-label use of BMS. Pending results from randomized trials, our data support the use of DES for off-label indications in selected patients.
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Affiliation(s)
- Bruce R Brodie
- LeBauer Cardiovascular Research Foundation, Greensboro, North Carolina, USA.
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