Influence of stent treatment strategies in the long-term outcome of patients with long diffuse coronary lesions

Long-term results of stenting of long coronary artery stenosis with consecutive implantation of stents of different types with overlapping edges in patients with acute coronary syndrome without ST-segment elevation and multivessel coronary artery disease

Introduction. In urgent interventional cardiology practice, combinations of drug-eluting stents and bare-metal stents are sometimes forced to treat extended stenosis in a clinic-dependent artery. Objective. A comparison of long-term results of treatment of patients with coronary heart disease and multivessel coronary lesions, which performed stenting of the clinic-dependent artery by two successive partially overlapping stents using stents of the 3rd generation with drug coating or a combination of the 3rd generation stent with drug coating and a bare-metal stent for acute coronary syndrome without St segment elevation and later — complete functional myocardial revascularization by endovascular method. Methods. The minimum overall length sentiremos section was made 55 mm. In main group included 32 patients for whom revascularization clinic-dependent artery performed endovascular intervention with the use of 2 stents 3-generation drug-coated sirolimus and biodegradable polymer implanted overlap. In 30 patients (control group), clinic-dependent artery revascularization was also performed by a combination of implanted overlap stents, one of which was a 3rd generation stent with sirolimus drug coating and biodegradable polymer, and the other was a bare-metal stent. There were no statistically significant differences between the groups in clinical, demographic and operational characteristics. Results. The analysis of the results revealed a significant difference between the groups in the frequency of repeated revascularization of the target artery, which were observed more often in the control group. Conclusion. When performing an extended stenting of the clinic-dependent artery in patients with acute coronary syndrome without ST segment elevation, overlapping of the drug-coated stent and the bare-metal stent should be avoided, since the antirestenotic effect of the drug-coated stent is leveled when overlapping with the bare-metal stent, but this strategy can be used in case of full coverage of the stenotic lesion or closure of the dissection.

Successful Treatment of Symptomatic Intracranial Carotid Artery Stenosis Using a 24-mm Long Bare Metal Coronary Stent

BACKGROUND

Intracranial arterial atherosclerosis represents a common cause of stroke. Despite aggressive and optimal medical management, many patients will unfortunately suffer additional cerebrovascular events. The role of endovascular intervention for intracranial atherosclerotic disease continues to be uncertain, particularly in regard to extensive, symptomatic stenosis.

CASE DESCRIPTION

We present a case of a 42-year-old man with a complex medical history who presented with recurrent ischemic stroke in the ipsilateral hemisphere despite optimal medical management. Given the length of stenosis and the luminal size of the intracranial cavernous and petrous segments of the internal carotid artery, we used a bare metal coronary stent (4.0 mm × 24 mm). This represents one of the longest stents deployed for intracranial disease reported in the literature.

CONCLUSIONS

This case illustrates that a long coronary stent might be successfully used to manage extensive intracranial lesions. We also review the efficacy of using 1 very long stent versus multiple overlapping stents, with reference to the coronary angiography literature.

Interfacial biology of in-stent restenosis

Percutaneous angioplasty is a nonsurgical method able to restore patency in atherosclerotic blood vessels through the expansion of a balloon. The clinical outcome of this technique has been significantly enhanced by the combined deployment of a stent. Although stents are successful in the majority of cases, a large percentage of patients (20-30%) still suffer a second vessel lumen reduction known as in-stent restenosis. In-stent restenosis is recognized to be caused by the mechanical and foreign body challenges elicited by the device. Drug-eluting stents have been recently made available to tackle restenosis, but their short clinical history and high costs may limit their future use. The present review links the most recent biologic findings related to in-stent restenosis to the devices' phyisico-chemical features in an attempt to demonstrate that a new generation of stents may be developed without the need of drug elution.

The stenting strategy of drug-eluting stents for coronary artery disease in patients on dialysis

Background:

Reports regarding the relationship between the length and diameter of implanted drug-eluting stents and clinical and angiographic outcomes in dialysis patients are limited.

Aim:

We investigated the efficiency of drug-eluting stents for coronary artery disease in patients on dialysis from the viewpoint of stent sizing.

Methods:

Sirolimus-eluting stents were implanted in 88 lesions and bare metal stents were implanted in 43 lesions. We compared stenting strategy, major adverse cardiac events, and angiographic results between sirolimus-eluting stent and bare metal stent groups.

Results:

Stent diameter was smaller and stent length was longer in the sirolimus-eluting stent group than in the bare metal stent group in our routine practices. There was no significant between-group difference in late diameter loss. Rates of angiographic restenosis and target lesion revascularization were significantly higher in the sirolimus-eluting stent group than in the bare metal stent group. Although stent length was significantly longer and stent diameter was smaller in the sirolimus-eluting stent group, sirolimus-eluting stents did not improve the subsequent clinical and angiographic results compared with bare metal stents in dialysis patients.

Conclusion:

In dialysis patients, a longer length and/or smaller diameter sirolimus-eluting stent implantation was associated with high rates of restenosis and target lesion revascularization compared with bare metal stents.

Outcomes of stenting with overlapping drug-eluting stents versus overlapping drug-eluting and bare-metal stents for the treatment of diffuse coronary lesions

INTRODUCTION

we investigated the outcomes of stenting with overlapping drug-eluting stents (DES) versus overlapping stenting with a combination of drug-eluting and bare metal stents (BMS) in very long coronary lesions (≥ 25 mm).

METHODS AND RESULTS

fifty-two patients treated with either overlapping DES-DES (n = 22) or DES-BMS (n = 30) were selected from a registry of 588 patients with very long coronary lesions. Patients with acute myocardial infarction (MI) within the preceding 48 hours were excluded. The DES-DES combination was more frequently used for longer lesions compared with the DES-BMS group (47.95 ± 9.25 vs 39.98 ± 9.15 mm, p = 0.003). Left anterior descending artery lesions were also more frequently treated with the DES-DES combination (95.5 vs 66.7%, p = 0.02). In four patients in the DES-BMS group, overlapping stents were used for the coverage of dissections. Peri-procedural non-Q-wave MI occurred in one patient in the DES-BMS group. On follow up, only one case of non-fatal MI occurred in a patient with overlapping DES-DES.

CONCLUSION

overlapping a BMS in the proximal part of a long DES instead of exclusive deployment of two or more overlapped DES seems to be a safe and feasible therapeutic strategy in our practice.

Clinical outcomes for single stent and multiple stents in contemporary practice

BACKGROUND

Stents had been demonstrated to be safe and effective in the treatment of severe coronary artery disease (CAD); however, the current knowledge on percutaneous coronary intervention (PCI) in treating patients requiring 2 or more stents placements is still limited.

HYPOTHESIS

Patients who required 2 or more stents might have worse clinical outcomes.

METHODS

A total of 2371 patients who underwent stenting were divided into a single stenting group (n = 1233) and a multiple stenting group (n = 1138). We assessed the cumulative incidence of major adverse cardiac events (death, acute myocardial infarction, and target-vessel revascularization) and stent thrombosis during 1-year follow-up.

RESULTS

The 1-year unadjusted cumulative incidence of major adverse cardiac events was 7.7% in the multiple stenting group and 5.4% in the single stenting group (P = 0.02 by log-rank test). After adjustment, there was a trend toward a lower rate of 1-year major adverse cardiac events in the single stenting group than in the multiple stenting group (P = 0.09). A nonsignificant trend was also detected in favor of the single stenting group, as compared with the multiple stenting group, at the rate of acute myocardial infarction (1.3% vs 1.7%, P = 0.89) and at the rate of target-vessel revascularization (4.5% vs 5.4%, P = 0.08).

CONCLUSIONS

Although the use of a single stent in coronary artery disease has less incidence of adverse cardiac events at 1 year as compared with the use of multiple stents, the difference was not statistically significant.

Periprocedural and Late Consequences of Overlapping Cypher Sirolimus-Eluting Stents

OBJECTIVES

The purpose of this research was to determine the relative safety and efficacy of multiple (> or =2) overlapping Cypher sirolimus-eluting stents (SES) (Johnson & Johnson, New Brunswick, New Jersey).

BACKGROUND

Overlapping coronary stents are common. The periprocedural and late clinical and angiographic consequences of overlapped coronary stents are not clearly defined, particularly for drug-eluting stents.

METHODS

All patients enrolled into five clinical trials of the SES were analyzed. Three of these trials were prospective randomized comparisons of the SES to the bare-metal stent (BMS), and two were prospective non-randomized trials of SES-treated patients with historical controls. All clinical and angiographic outcomes in overlap-stent-treated patients were compared by stent type and with single-stent-treated patients for the same stent device.

RESULTS

In all, 575 patients with stent overlap (337 SES, 238 BMS) and 1,162 patients with single stents (697 SES, 465 BMS) were analyzed. Stent overlap was associated with a greater late lumen loss in stent and more frequent angiographic restenosis regardless of stent type. Among overlap-stent-treated patients, the SES provided similar magnitude of restenosis benefit as observed for single-stent-treated patients. Overlapped SES was not associated with an increase in myocardial infarction.

CONCLUSIONS

The strategy of SES overlap, when required, is both safe and efficacious in reducing restenosis with no increase in the incidence of myocardial infarction or major adverse cardiovascular events, when compared with a bare metal coronary stent prosthesis.

Recovery of left ventricular systolic function after left anterior descending coronary artery stenting

Our objective was to determine the factors affecting recovery of left ventricular (LV) contractility and myocardial perfusion after percutaneous coronary intervention (PCI). We selected 60 consecutive patients who underwent successful left anterior descending coronary artery (LAD) stenting. The mean stent diameter and length were 3.37+/-0.47 mm and 17.4+/-6 mm, respectively. Supporting a functional impact of successful PCI, myocardial perfusion and LV ejection fraction (LVEF) improved at 6+/-3 months after the procedure (48.8+/-11.6% vs 52.5+/-11.5%, P=0.05). Patient related factors such as diabetes mellitus, presentation with acute coronary syndrome, and age did not seem to affect LVEF change after the procedure. On univariate analysis, the change in LVEF after PCI was only related to the stent diameter. The increase in LVEF was higher in patients who received a stent>3 mm in diameter (P=0.041). There was a weak but statistically positive correlation between the stent diameter and the LVEF change after the procedure (R=0.267, P=0.049). Other procedure related factors such as multivessel PCI or stent length did not affect the percent ejection fraction change after stenting.

Overlapping vs. one long stenting in long coronary lesions

Intervention of long coronary lesions remains problematic, and optimal treatment strategy is yet to be determined. Despite advancement of stent technology, data are few regarding the efficacy of overlapping stents vs. a single long stent in long coronary lesions. This study was performed to evaluate the results of those strategies for long coronary lesions and to determine the predictors of in-stent restenosis (ISR). Sixty-four lesions (> 20 mm) in 64 patients were treated with either one long stent (group 1, n = 32) or two overlapping stents (group 2, n = 32). Overlapping stents were used at tortuous or calcified lesions and at lesions with diameter discrepancy or significant dissection. Immediate results, follow-up clinical and angiographic outcomes, and predictors of ISR were evaluated. Procedures were successful in all patients in both groups. Clinical and angiographic follow-ups were performed in 54 (84%) cases and 50 (78%) cases, respectively. During the follow-up, major adverse cardiac event occurred in 36% of group 1 and 29% of group 2 (P = 0.56). Six-month ISR rates were 39% in group 1 and 41% in group 2 (P = 0.91). Age (>/= 65 years old) was an independent risk factor of ISR (54% vs. 23%; OR = 4.4; P = 0.04), and distal reference diameter (RD) of less than 2.5 mm tended to predict ISR in multivariate analysis (60% vs. 25%; OR = 3.5; P = 0.06). In conclusion, stent overlapping can be used with outcome similar to that of one long stent in long coronary lesions. The optimal result may be obtained by considering the patient's age and the distal vessel diameter of the lesion.