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Xue W, Ma J, Yu X, Ruan Z, Sun Y, Wu T, Zhang X, Wu L. Analysis of the incidence and influencing factors associated with binary restenosis of target lesions after drug-coated balloon angioplasty for patients with in-stent restenosis. BMC Cardiovasc Disord 2022; 22:493. [PMID: 36404303 PMCID: PMC9677633 DOI: 10.1186/s12872-022-02923-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 10/27/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Drug-coated balloon (DCB) is a novel and effective device for coronary artery disease patients with in-stent restenosis (ISR). However, the incidence and possible influencing factors associated with binary restenosis have not yet been adequately assessed. METHODS The data are extracted from a prospective, multicenter, randomized controlled trial. A total of 211 patients with ISR were enrolled at 13 centers from August 2017 to October 2018 and treated with DCB. At the 9-month coronary angiographic follow-up, patients were divided into restenosis and non-restenosis groups, and demographic data, lesion features, and laboratory tests were retrospectively reviewed. Furthermore, logistic regression analysis was used to identify possible influencing factors. RESULTS All patients successfully underwent treatment, and 166 patients with 190 lesions took part in angiography follow-ups at 9 months. Of these, 41 patients with 44 target lesions developed restenosis following treatment, and the incidence of ISR was 24.7%. There were significant differences in the average length of target lesions and the number of multivessel lesions and fasting plasma glucose (FBG) between the two groups (p < 0.05). Demographic data, cardiac risk factors, left ventricular ejection fractions (LVEF), blood routine tests, biochemical tests, and other features of devices and lesions showed no difference. Logistic regression analyses showed that FBG > 6.1 mmol/L (OR: 7.185 95% CI: 2.939-17.567 P < 0.001) and length of lesion (OR:1.046 95% CI: 1.001-1.093 P = 0.046) were associated risk factors. CONCLUSIONS The longer length of lesions, more target lesions and FBG > 6.1 mmol/L per individual may be characteristics of patients showing ISR following treatment. Studies with larger sample size, and more complete follow-up data are needed in the future to expend on these findings. TRIAL REGISTRATION No.: NCT04213378, first posted date (30/12/2019).
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Affiliation(s)
- Weihao Xue
- grid.417384.d0000 0004 1764 2632Department of Cardiology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, 325027 China
| | - Jun Ma
- grid.417384.d0000 0004 1764 2632Department of Cardiology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, 325027 China
| | - Xiaojie Yu
- grid.417384.d0000 0004 1764 2632Department of Cardiology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, 325027 China
| | - Zhisheng Ruan
- grid.417384.d0000 0004 1764 2632Department of Cardiology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, 325027 China
| | - Yuanxue Sun
- grid.417384.d0000 0004 1764 2632Department of Cardiology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, 325027 China
| | - Tianbo Wu
- grid.417384.d0000 0004 1764 2632Department of Cardiology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, 325027 China
| | - Xinmin Zhang
- grid.417384.d0000 0004 1764 2632Department of Cardiology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, 325027 China
| | - Lianpin Wu
- grid.417384.d0000 0004 1764 2632Department of Cardiology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, 325027 China
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Megaly M, Glogoza M, Xenogiannis I, Vemmou E, Nikolakopoulos I, Willson L, Monyak DJ, Sullivan P, Stanberry L, Sorajja P, Chavez I, Mooney M, Traverse J, Wang Y, Garcia S, Poulose A, Burke MN, Brilakis ES. Outcomes of intravascular brachytherapy for recurrent drug-eluting in-stent restenosis. Catheter Cardiovasc Interv 2020; 97:32-38. [PMID: 31943747 DOI: 10.1002/ccd.28716] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/25/2019] [Accepted: 12/29/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To examine the outcomes of vascular brachytherapy (VBT) for recurrent drug-eluting stents (DES) in-stent restenosis (ISR). BACKGROUND Recurrent DES-ISR can be challenging to treat. VBT has been used with encouraging results. METHODS We report the long-term outcomes of patients with recurrent DES-ISR treated with VBT between January 2014 and September 2018 at a tertiary care institution. The main outcome was target lesion failure (TLF), defined as the composite of clinically driven target lesion revascularization (TLR), target lesion myocardial infarction (MI), and target lesion-related cardiac death. Cox proportional hazards analysis was performed to identify variables associated with recurrent TLF. RESULTS During the study period, 116 patients (143 lesions) underwent VBT. Median follow-up was 24.7 (14.5-35.4) months. The incidence of TLR, target-lesion MI, and TLF was 18.9%, 5.6%,and 20.1% at 1 year, and 29.4%, 10.5%, and 32.9% at 2 years.Initial presentation with acute coronary syndrome (ACS) was independently associated with TLF (hazard ratio = 1.975, 95% CI [1.120, 3.485], p = .019). Lesions treated with intravascular ultrasound (IVUS) guidance had a lower incidence of TLR (14.3% vs. 39.6%, log-rank p = .038), and a trend toward lower incidence of TLF (19% vs. 42.6%, log-rank p = .086). CONCLUSIONS VBT can improve the treatment of recurrent DES-ISR, but TLF occurs in approximately one in three patients at 2 years. Initial presentation with ACS was associated with higher TLF and the use of IVUS with a trend for lower incidence of TLF.
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Affiliation(s)
- Michael Megaly
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota.,Department of Cardiovascular Medicine, Hennepin Healthcare, Minneapolis, Minnesota
| | - Matthew Glogoza
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Iosif Xenogiannis
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Evangelia Vemmou
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Ilias Nikolakopoulos
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Laura Willson
- Department of Radiation Oncology, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - David J Monyak
- Department of Radiation Oncology, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Patsa Sullivan
- Department of Radiation Oncology, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Larissa Stanberry
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Paul Sorajja
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Ivan Chavez
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Michael Mooney
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Jay Traverse
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Yale Wang
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Santiago Garcia
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Anil Poulose
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | - Emmanouil S Brilakis
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
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4
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Her AY, Shin ES. Current Management of In-Stent Restenosis. Korean Circ J 2018; 48:337-349. [PMID: 29737639 PMCID: PMC5940640 DOI: 10.4070/kcj.2018.0103] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/10/2018] [Indexed: 12/31/2022] Open
Abstract
Despite the advent of the drug-eluting stents (DES) and improved stent design, in-stent restenosis (ISR) remains a challenging problem. The currently available options for treatment of ISR include angioplasty alone, repeat stenting with DES or drug-coated balloons. Several recent studies have compared the available options for treating ISR in an attempt to identify the preferred therapeutic strategy. In this review, we will discuss the currently available therapeutic strategies for the management of patients with ISR and the evidence supporting their use.
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Affiliation(s)
- Ae Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Eun Seok Shin
- Division of Cardiology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
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5
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Batyraliev TA, Pershukov IV, Niyazova-Karben ZA, Karaus A, Calenici O, Guler N, Eryonucu B, Temamogullari A, Ozgul S, Akgul F, Sengul H, Dogru O, Demirbas O, Timoshin IS, Gaigukov AV, Petrakova LN, Peresypko MK, Sidorenko BA. Current Role of Laser Angioplasty of Restenotic Coronary Stents. Angiology 2016; 57:21-32. [PMID: 16444453 DOI: 10.1177/000331970605700104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Treatment of in-stent restenosis (ISR) with conventional percutaneous transluminal coronary angioplasty (PTCA) causes significant recurrent neointimal tissue growth in 30-85%. Therefore, laser ablation of intrastent neointimal hyperplasia before balloon dilation can be an attractive alternative. However, the long-term outcomes of such treatment have not been studied thoroughly enough. This prospective case-control study evaluated angiographic and clinical outcomes of PTCA alone and a combination of excimer laser coronary angioplasty (ELCA) and adjunct PTCA in 125 patients with ISR. ELCA was performed before balloon dilation in 67 patients, PTCA alone was performed in 58 patients. Basic demographic and clinical data were comparable in both groups. Lesions included in ELCA group were longer (17.1 ±9.9 vs 13.6 ±9.1 mm; p=0.034), more complex (36.5% type C stenoses vs 14.3%; p=0.006), and more frequently had reduced distal blood flow (TIMI <3: 18.9% vs 4.8%; p=0.025) compared to lesions in the PTCA group. Immediate angiographic results of PTCA and ELCA + PTCA appeared to be comparable. PTCA alone was successful in 57 patients (98.3%), ELCA + PTCA, in 66 patients (98.5%). The rates of hospital complications were comparable (3.0% in ELCA group vs 8.6% in PTCA group). The 1-year follow-up showed that the rates of major adverse cardiac events (MACE) were comparable in the 2 groups (37.3% in ELCA group vs 46.6% in PTCA group). The rates of target vessel revascularization (TVR) within 1 year after the intervention were also similar in the 2 groups (32.8% vs 34.5%). The data mean that ELCA in patients with complex ISR is efficient and safe. Despite a higher complexity of lesions in the ELCA group, no increase in the rate of complications was registered.
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6
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Current treatment of in-stent restenosis. J Am Coll Cardiol 2014; 63:2659-73. [PMID: 24632282 DOI: 10.1016/j.jacc.2014.02.545] [Citation(s) in RCA: 380] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 01/31/2014] [Accepted: 02/11/2014] [Indexed: 01/04/2023]
Abstract
Management of patients with in-stent restenosis (ISR) remains an important clinical problem. Although drug-eluting stents (DES) have drastically reduced the incidence of ISR, treatment of DES-ISR is particularly challenging. ISR mainly results from aggressive neointimal proliferation, but recent data also suggest that neoatherosclerosis may play an important pathophysiological role. Intracoronary imaging provides unique insights to unravel the underlying substrate of ISR and may be used to guide repeated interventions. In this paper, we systematically reviewed clinical trial data with currently available therapeutic modalities, including DES and drug-coated balloons, in patients presenting with ISR within bare-metal stents or DES.
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7
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Abstract
The introduction of coronary stents marked a major turning point in the practice of interventional cardiology. Whereas the efficacy of balloon angioplasty was challenged both by immediate mechanical complications and by a high incidence of restenosis, coronary stents offered cardiologists a means by which to not only augment immediate procedural success, but also to reduce the incidence of restenosis following coronary intervention. However, despite technological advances and an improved understanding of the restenotic process, the overall rate of in-stent restenosis following bare metal stent implantation remains high. Although the introduction of drug-eluting stents has further reduced the incidence of restenosis, the "real-world" application of drug-eluting stents in increasingly complex lesion and patient subsets has given way to the even greater clinical challenge of managing drug-eluting stent restenosis. Although the standard treatment of bare metal stent restenosis typically involves placement of a drug-eluting stent, the optimal therapeutic approach to drug-eluting stent restenosis remains less defined. The issue of in-stent restenosis (especially following implantation of a drug-eluting stent) remains a clinical challenge, and investigation into therapeutic options remains ongoing. As technology evolves, such investigation will likely incorporate novel approaches including drug-coated balloons novel stent designs.
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Affiliation(s)
- Michael S Kim
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA 98195-6116, USA.
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8
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Galassi AR, Foti R, Azzarelli S, Condorelli G, Coco G, Ragusa A, Russo G, Grasso A, Bonaccorso C, Tamburino C, Giuffrida G. Long-term angiographic follow-up after successful repeat balloon angioplasty for in-stent restenosis. Clin Cardiol 2009; 24:334-40. [PMID: 11303704 PMCID: PMC6654783 DOI: 10.1002/clc.4960240415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Coronary stent implantation is associated with improved angiographic short-term and mid-term clinical outcome. However, restenosis rate still remains between 20 and 30%. HYPOTHESIS The purpose of the study, performed as a prospective angiographic follow-up to detect restenosis, was to evaluate the immediate and the 6-month angiographic results of repeat balloon angioplasty for in-stent restenosis. METHODS From April 1996 to September 1997, 335 stenting procedures performed in 327 patients underwent prospectively 6-month control angiography. Of the 96 lesions that showed in-stent restenosis (> 50% diameter stenosis) (29%), 72 underwent balloon angioplasty. RESULTS The primary success rate was 100%. Follow-up angiogram at a mean of 6.9 +/- 2.4 months was obtained in 54 patients. Recurrent restenosis was observed in 24 of the 55 stents (44%). Repeat intervention for diffuse and body location in-stent restenosis before repeat intervention was associated with significantly higher rates of recurrent restenosis (p < 0.001 and p < 0.05, respectively). Of the 19 patients who underwent further balloon angioplasty (100% success rate), coronary angiography was performed in 18 (95%) at a mean of 8.2 +/- 2.0 months and showed recurrent restenosis in 12 patients (67%). Further repeat intervention for diffuse and severe in-stent restenosis before the second repeat intervention was associated with significantly higher rates of further recurrent restenosis (p < 0.05 and p < 0.005, respectively). CONCLUSIONS Although balloon angioplasty can be safely, successfully, and repeatedly performed after stent restenosis, it carries a progressively high recurrence of angiographic restenosis rate during repeat 6-month follow-ups. The subgroup of patients with diffuse, severe, and/or body location in-stent restenosis proved to be at higher risk of recurrent restenosis.
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Affiliation(s)
- A R Galassi
- Institute of Cardiology, Ferrarotto Hospital, University of Catania, Italy
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9
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Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB, Morrison DA, O'Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 2006; 47:e1-121. [PMID: 16386656 DOI: 10.1016/j.jacc.2005.12.001] [Citation(s) in RCA: 309] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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10
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Klauss V, Erdin P, Rieber J, Leibig M, Stempfle HU, König A, Baylacher M, Theisen K, Haufe MC, Sroczynski G, Schiele T, Siebert U. Fractional flow reserve for the prediction of cardiac events after coronary stent implantation: results of a multivariate analysis. Heart 2005; 91:203-6. [PMID: 15657233 PMCID: PMC1768692 DOI: 10.1136/hrt.2003.027797] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the prognostic value of fractional flow reserve (FFR) measurements after coronary stent implantation including multiple clinical and angiographic parameters collected in one centre. METHODS 119 consecutive patients were enrolled who had a stent implanted with the use of a pressure wire as a guidewire. Patients were followed up for at least six months. Any death, myocardial infarction, and target vessel revascularisation were considered major adverse cardiac events (MACE). Multivariate logistic regression was used to determine adjusted odds ratios (OR) and 95% confidence intervals (CI) for FFR and covariates. RESULTS Complete follow up data were available for all 119 patients. Pre-interventional FFR increased from 0.65 (0.15) to 0.94 (0.06) (p < 0.0001) after stent implantation. Eighteen MACE (15%) occurred during follow up including 15 (12.6%) target vessel revascularisations. Final FFR was significantly higher in patients without than in patients with an event (0.95 (0.05) v 0.88 (0.08), p = 0.001). In the multivariate logistic regression analysis, only final FFR < 0.95 (OR 6.22, 95% CI 1.79 to 21.62, p = 0.004) and reduced left ventricular function (OR 0.95, 95% CI 092 to 0.99, p = 0.021) remained as significant independent predictors for MACE. CONCLUSION These results including multiple parameters underline that FFR after coronary stenting is a strong and independent predictor for subsequent cardiac events after six months' follow up.
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Affiliation(s)
- V Klauss
- Department of Cardiology, Medizinische Poliklinik-Innenstadt, University of Munich, Ziemssenstrasse 1, D-80336 Munich, Germany.
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11
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Pershukov IV, Vural A, Batyraliev TA, Niyazova-Karben ZA, Karaus A, Calenici O, Petrakova LN, Peresypko MK, Preobrazhenskii DV, Sidorenko BA. Clinical and Angiographic Results of Percutaneous Excimer Laser Versus Balloon Angioplasty for Coronary Intra-Stent Restenosis. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2004. [DOI: 10.29333/ejgm/82232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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12
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Sanchez PL, Rodriguez-Alemparte M, Colon-Hernandez PJ, Pomerantsev E, Inglessis I, Mahdi NA, Leinbach RC, Palacios IF. Directional coronary atherectomy vs. rotational atherectomy for the treatment of in-stent restenosis of native coronary arteries. Catheter Cardiovasc Interv 2003; 58:155-61. [PMID: 12552536 DOI: 10.1002/ccd.10399] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Management of in-stent restenosis has become a significant challenge in interventional cardiology. Since the mechanism of in-stent restenosis is predominantly intimal hyperplasia, debulking techniques have been used to treat this condition. This study is a nonrandomized comparison of the immediate and long-term results of directional coronary atherectomy (DCA; n = 58) vs. high-speed rotational atherectomy (ROTA; n = 61) for the treatment of in-stent restenosis of native coronary arteries. There were no in-hospital deaths, Q-wave myocardial infarctions, or emergency coronary artery bypass surgery in either group. DCA resulted in a larger postprocedural minimal luminal diameter of (2.57 +/- 0.51 vs. 2.14 +/- 0.37 mm; P < 0.0001) and a larger acute gain (1.83 +/- 0.52 vs. 1.42 +/- 0.48 mm; P < 0.0001). Furthermore, 12-month clinically indicated target lesion revascularization (39% vs. 21%; P = 0.02) and long-term follow-up MACE (44% vs. 28%; P = 0.03) was greater in the ROTA group. The present study suggests that DCA appears to be superior to ROTA for the treatment of in-stent restenosis of native coronary arteries. Compared to ROTA, the debulking effect of DCA leads to a larger postprocedure minimal luminal diameter, and a lower incidence of subsequent target lesion revascularization and MACE.
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Affiliation(s)
- Pedro L Sanchez
- Cardiac Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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13
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Schiele TM, König A, Rieber J, Theisen K, Siebert U, Klauss V. Comparison of volumetric intravascular ultrasound analysis of acute results and underlying mechanisms from cutting balloon and conventional balloon angioplasty for the treatment of coronary in-stent restenotic lesions. Am J Cardiol 2002; 90:539-42. [PMID: 12208420 DOI: 10.1016/s0002-9149(02)02532-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Thomas M Schiele
- Cardiology Division, Medizinische Klinik-Innenstadt, University of Munich, Munich, Germany.
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14
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Neil N, Ramsey SD, Cohen DJ, Every NR, Spertus JA, Weaver WD. Resource utilization, cost, and health status impacts of coronary stent versus "optimal" percutaneous coronary angioplasty: results from the OPUS-I trial. J Interv Cardiol 2002; 15:249-55. [PMID: 12238418 DOI: 10.1111/j.1540-8183.2002.tb01099.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
In the OPUS-I trial, primary coronary stent implantation reduced 6-month composite incidence of death, myocardial infarction, cardiac surgery, or target vessel revascularization relative to a strategy of initial PTCA with provisional stenting in patients undergoing single vessel coronary angioplasty. The purpose of this research was to compare the economic and health status impacts of each treatment strategy. Resource utilization data were collected for the 479 patients randomized in OPUS-I. Itemized cost estimates were derived from primary hospital charge data gathered in previous multicenter trials evaluating coronary stents, and adjusted to approximate 1997 Medicare-based costs for a cardiac population. Health status at 6 months was assessed using the Seattle Angina Questionnaire (SAQ). Initial procedure related costs for patients treated with a primary stent strategy were higher than those treated with optimal PTCA/provisional stent ($5,389 vs $4,339, P < 0.001). Costs of initial hospitalization were also higher for patients in the primary stent group ($9,234 vs $8,434, P < 0.01) chiefly because of the cost differences in the index revascularization. Mean 6-month costs were similar in the two groups; however, there was a slight cost advantage associated with primary stenting. Bootstrap replication of 6-month cost data sustained the economic attractiveness of the primary stent strategy. There were no differences in SAQ scores between treatment groups. In patients undergoing single vessel coronary angioplasty, routine stent implantation improves important clinical outcomes at comparable, or even reduced cost, compared to a strategy of initial balloon angioplasty with provisional stenting.
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Affiliation(s)
- Nancy Neil
- Virginia Mason Medical Center, University of Washington School of Public Health, Seattle, Washington.
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15
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Oberhoff M, Herdeg C, Al Ghobainy R, Cetin S, Küttner A, Horch B, Baumbach A, Karsch KR. Local delivery of paclitaxel using the double-balloon perfusion catheter before stenting in the porcine coronary artery. Catheter Cardiovasc Interv 2001; 53:562-8. [PMID: 11515014 DOI: 10.1002/ccd.1223] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Paclitaxel is a new cancer chemotherapeutic agent that has been approved for clinical use in patients with a variety of different cancers. Paclitaxel inhibits cell proliferation by an action on microtubules. The aim of this study was to evaluate the safety and efficacy of locally delivered paclitaxel after coronary stent implantation. A novel double-balloon perfusion catheter was used to deliver the drug locally in the pig coronary artery. Twenty-seven domestic pigs underwent stent implantation of the left anterior descending artery. In the treatment group (n = 11), paclitaxel (10 ml; 10 micromol/l) was delivered using the double-balloon perfusion catheter prior to stent implantation. The control group received stent implantation only (n = 16). The animals were sacrificed 4 weeks later. Vessels were perfusion-fixed and morphometric analysis was performed using conventional techniques. In addition, the extent of injury was determined at each stent-strut area. Correlation of local injury and neointimal thickness was evaluated by linear regression. Neointimal thickness (paclitaxel 1.0 +/- 0.4 vs. control 0.7 +/- 0.3 mm), neointimal area (paclitaxel 4.1 +/- 2.2 vs. control 2.4 +/- 1.1 mm(2)), and the lumen area (paclitaxel 2.1 +/- 1.9 vs. control 2.5 +/- 0.9 mm(2)) did not show significant differences between both groups. Medial area (3.3 +/- 2.3 vs. 1.6 +/- 0.4 mm(2)) was larger in the vessels treated with paclitaxel (P < 0.05). Linear regression failed to show any difference in the response to injury between the two groups. Local delivery of paclitaxel with the double-balloon-perfusion catheter did not reduce neointima formation following stent implantation in native pig coronary arteries.
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Affiliation(s)
- M Oberhoff
- Bristol Heart Institute, University of Bristol, Bristol, UK.
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Smith SC, Dove JT, Jacobs AK, Ward Kennedy J, Kereiakes D, Kern MJ, Kuntz RE, Popma JJ, Schaff HV, Williams DO, Gibbons RJ, Alpert JP, Eagle KA, Faxon DP, Fuster V, Gardner TJ, Gregoratos G, Russell RO, Smith SC. ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines)31This document was approved by the American College of Cardiology Board of Trustees in April 2001 and by the American Heart Association Science Advisory and Coordinating Committee in March 2001.32When citing this document, the American College of Cardiology and the American Heart Association would appreciate the following citation format: Smith SC, Jr, Dove JT, Jacobs AK, Kennedy JW, Kereiakes D, Kern MJ, Kuntz RE, Popma JJ, Schaff HV, Williams DO. ACC/AHA guidelines for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1993 Guidelines for Percutaneous Transluminal Coronary Angioplasty). J Am Coll Cardiol 2001;37:2239i–lxvi.33This document is available on the ACC Web site at www.acc.organd the AHA Web site at www.americanheart.org(ask for reprint no. 71-0206). To obtain a reprint of the shorter version (executive summary and summary of recommendations) to be published in the June 15, 2001 issue of the Journal of the American College of Cardiology and the June 19, 2001 issue of Circulation for $5 each, call 800-253-4636 (US only) or write the American College of Cardiology, Educational Services, 9111 Old Georgetown Road, Bethesda, MD 20814-1699. To purchase additional reprints up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1,000 or more copies, call 214-706-1466, fax 214-691-6342, or E-mail: pubauth@heart.org(ask for reprint no. 71-0205). J Am Coll Cardiol 2001. [DOI: 10.1016/s0735-1097(01)01345-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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17
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Moustapha A, Assali AR, Sdringola S, Vaughn WK, Fish RD, Rosales O, Schroth G, Krajcer Z, Smalling RW, Anderson HV. Percutaneous and surgical interventions for in-stent restenosis: long-term outcomes and effect of diabetes mellitus. J Am Coll Cardiol 2001; 37:1877-82. [PMID: 11401126 DOI: 10.1016/s0735-1097(01)01231-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE We examined long-term outcomes of patients with in-stent restenosis (ISR) who underwent different percutaneous interventions at the discretion of individual operators: balloon angioplasty (BA), repeat stent or rotational atherectomy (RA). We also examined long-term outcomes of patients with ISR who underwent coronary artery bypass surgery (CABG). BACKGROUND In-stent restenosis remains a challenging problem, and its optimal management is still unknown. METHODS Symptomatic patients (n = 510) with ISR were identified using cardiac catheterization laboratory data. Management for ISR included BA (169 patients), repeat stenting (117 patients), RA (107 patients) or CABG (117 patients). Clinical outcome events of interest included death, myocardial infarction, target vessel revascularization (TVR) and a combined end point of these major adverse cardiovascular events (MACE). Mean follow-up was 19+/-12 months (range = 6 to 61 months). RESULTS Patients with ISR treated with repeat stent had significantly larger average post-procedure minimal lumen diameter compared with BA or RA (3.3+/-0.4 mm vs. 3.0+/-0.4 vs. 2.9+/-0.5, respectively, p < 0.05). Incidence of TVR and MACE were similar in the BA, stent and RA groups (39%, 40%, 33% for TVR and 43%, 40%, 33% for MACE, p = NS). Patients with diabetes who underwent RA had similar outcomes as patients without diabetes, while patients with diabetes who underwent BA or stent had worse outcomes than patients without diabetes. Patients who underwent CABG for ISR, mainly because of the presence of multivessel disease, had significantly better outcomes than any percutaneous treatment (8% for TVR and 23% for MACE). CONCLUSIONS In this large cohort of patients with ISR and in the subset of patients without diabetes, long-term outcomes were similar in the BA, repeat stent and RA groups. Tissue debulking with RA yielded better results only in diabetic patients. Bypass surgery for patients with multivessel disease and ISR provided the best outcomes.
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Affiliation(s)
- A Moustapha
- University of Texas Medical School at Houston, USA
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18
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Okmen E, Cakmak M, Celik S, Yapici F, Erdinler I, Ozturk R, Cam N. Laser angioplasty in a right coronary artery stent restenosis with the guidance of left internal mammary artery contrast injection: case report. Catheter Cardiovasc Interv 2001; 53:71-4. [PMID: 11329222 DOI: 10.1002/ccd.1133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A 43-years-old male who underwent right coronary artery stent implantation 6 months ago presented with total occlusion of right coronary artery at proximal part of the stent without antegrade flow. We successfully used the left internal mammary artery contrast injections for guidance in all stages of the right coronary laser angioplasty intervention.
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Affiliation(s)
- E Okmen
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey.
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19
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Islam MA, Blankenship JC, Iliadis EA. Effectiveness of transluminal extraction atherectomy for debulking saphenous vein graft in-stent restenosis. Am J Cardiol 2001; 87:785-8, A8. [PMID: 11249906 DOI: 10.1016/s0002-9149(00)01506-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Treatment of in-stent restenosis in saphenous vein grafts often requires initial debulking, but transluminal extraction catheter (TEC) atherectomy is seldom used for this purpose, and most discussions omit this option. Our experience with 6 episodes of TEC used successfully for saphenous vein graft in-stent restenosis and review of 7 other reported cases suggests TEC may be safe and effective for debulking saphenous vein graft restenosis lesions.
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Affiliation(s)
- M A Islam
- Department of Cardiology, Geisinger Medical Center, Danville, Pennsylvania 17822, USA
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20
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Giri S, Ito S, Lansky AJ, Mehran R, Margolis J, Gilmore P, Garratt KN, Cummins F, Moses J, Rentrop P, Oesterle S, Power J, Kent KM, Satler LF, Pichard AD, Wu H, Greenberg A, Bucher TA, Kerker W, Abizaid AS, Saucedo J, Leon MB, Popma JJ. Clinical and angiographic outcome in the laser angioplasty for restenotic stents (LARS) multicenter registry. Catheter Cardiovasc Interv 2001; 52:24-34. [PMID: 11146517 DOI: 10.1002/1522-726x(200101)52:1<24::aid-ccd1007>3.0.co;2-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In-stent restenosis (ISR), when treated with balloon angioplasty (PTCA) alone, has an angiographic recurrence rate of 30%-85%. Ablating the hypertrophic neointimal tissue prior to PTCA is an attractive alternative, yet the late outcomes of such treatment have not been fully determined. This multicenter case control study assessed the angiographic and clinical outcomes of 157 consecutive procedures in 146 patients with ISR at nine institutions treated with either PTCA alone (n = 64) or excimer laser assisted coronary angioplasty (ELCA, n = 93)) for ISR. Demographics were similar except more unstable angina at presentation in ELCA-treated patients (74.5% vs. 63.5%; P = 0.141). Lesions selected for ELCA were longer (16.8 +/- 11.2 mm vs. 11.2 +/- 8.6 mm; P < 0.001), more complex (ACC/AHA type C: 35.1% vs. 13.6%; P < 0.001), and with compromised antegrade flow (TIMI flow < 3: 18.9% vs. 4.5%; P = 0.008) compared to PTCA-treated patients. ELCA-treated patients had similar rate of procedural success [93 (98.9% vs. 62 (98.4%); P = 1.0] and major clinical complications [1 (1.1%) vs. 1 (1.6%); P = 1.0]. At 30 days, repeat target site coronary intervention was lower in ELCA-treated patients (1.1% vs. 6.4% in PTCA-treated patients; P = 0.158), but not significantly so. At 1 year, ELCA-treated patients had similar rate of major cardiac events (39.1% vs. 45.2%; P = 0.456) and target lesion revascularization (30.0% vs. 32.3%; P = 0.646). These data suggest that ELCA in patients with complex in-stent restenosis is as safe and effective as balloon angioplasty alone. Despite higher lesion complexity in ELCA-treated patients, no increase in event rates was observed. Future studies should evaluate the relative benefit of ELCA over PTCA alone for the prevention of symptom recurrence specifically in patients with complex in-stent restenosis.
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Affiliation(s)
- S Giri
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts 02215, USA
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21
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Goldberg SL, Berger P, Cohen DJ, Shawl F, Buchbinder M, Fortuna R, O'Neill W, Leon M, Braden GA, Teirstein PS, Reisman M, Bailey SR, Dauerman HL, Bowers T, Mehran R, Colombo A. Rotational atherectomy or balloon angioplasty in the treatment of intra-stent restenosis: BARASTER multicenter registry. Catheter Cardiovasc Interv 2000; 51:407-13. [PMID: 11108670 DOI: 10.1002/1522-726x(200012)51:4<407::aid-ccd7>3.0.co;2-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The BARASTER registry was formed to evaluate the initial success and long-term results of rotational atherectomy in the management of in-stent restenosis. Rotational atherectomy was used in 197 cases of in-stent restenosis: 46 with stand-alone rotational atherectomy or at most 1 atmosphere of balloon inflation (Rota strategy), and 151 with rotational atherectomy and adjunctive balloon angioplasty <1 atmosphere (Combination strategy). These were compared with 107 episodes of in-stent restenosis treated with balloon angioplasty alone. In this observational study, the use of Combination therapy was associated with a slightly higher initial success rate (95% vs. 87% with the Rota strategy and 89% with Balloons, P = 0.08). There was a reduction in one year clinical outcomes (death, myocardial infarction or target lesion revascularization) in the combination group (38% vs. 60% with Rota and 52% with balloons, P = 0.02). These data support a benefit of the strategy of debulking with rotational atherectomy followed by adjunctive balloon angioplasty, in the management of in-stent restenosis.
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Affiliation(s)
- S L Goldberg
- Harbor-UCLA Medical Center, Torrance, California, USA.
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22
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Abstract
To determine the feasibility and safety of an intracoronary beta-radiation device in preventing the recurrence of in-stent restenosis (ISR) after successful angioplasty, we studied 37 patients treated with beta-radiation (30-mm strontium-90 source) after angioplasty. The mean reference diameter was 2.9 +/- 0.5 mm, and 62% of lesions were diffuse, including four total occlusions. Beta-radiation was successfully delivered in 36 of 37 (97%) cases. Over the course of 7.1 +/- 4.5 mo follow-up, there were no myocardial infarctions and three deaths: one from preexisting malignancy, one from progressive cardiac failure, and one from sudden cardiac death. Target vessel revascularization (TVR) was performed in seven of 36 (19%) patients. Thirty patients underwent angiography at 6 mo; three (10%) experienced restenosis (diameter stenosis > 50%) at the target site, four (13%) had edge stenoses, and two (7%) had late (> 1 mo) thrombotic occlusions. Beta-radiation for ISR is associated with encouragingly low rates of target lesion restenosis and TVR. Further improvements are needed to solve the limitations of the edge effect and late occlusion.
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Affiliation(s)
- D R Latchem
- Divisions of Cardiology and Radiation Oncology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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23
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Höpp HW, Baer FM, Ozbek C, Kuck KH, Scheller B. A synergistic approach to optimal stenting: directional coronary atherectomy prior to coronary artery stent implantation--the AtheroLink Registry. AtheroLink Study Group. J Am Coll Cardiol 2000; 36:1853-9. [PMID: 11092656 DOI: 10.1016/s0735-1097(00)00967-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The AtheroLink registry sought to observe the effect of plaque burden reduction by directional coronary atherectomy (DCA) prior to stenting on acute lesion success rate, on the clinical success rate and on the incidence of in-stent restenosis six months after intervention. BACKGROUND Although coronary stenting has reduced restenosis, its effect has been less favorable in complex lesions with a high plaque burden that results from suboptimal stent expansion. Therefore, plaque removal by DCA may improve the results of coronary stenting. METHODS A total of 167 patients with >60% stenosis in a native coronary artery of 2.8 to 4.0 mm in diameter were enrolled in 10 study centers on an intention-to-treat basis. All patients underwent DCA aimed at an optimal result (residual diameter stenosis <20%) followed by stenting. Angiographic follow-up was performed in 120 (71.8%) patients at 5.3+/-2.8 months. RESULTS Lesion success was achieved in 164/167 (98.2%) patients, and the clinical success rate was 95.2% (159/167 patients). The overall restenosis rate in the 120 patients with angiographic follow-up was 10.8% (13/120). Incidence of restenosis was lower (8.4%) in patients with optimal stent deployment following DCA compared to patients with a persisting caliber reduction >15% (restenosis rate 15.3.%) and restenosis occurred with a significantly higher frequency (p<0.04) in distal lesions (37.5%) compared to proximal stenoses (9.0%). CONCLUSIONS This observational multicenter registry points to a potential reduction in restenosis by a synergistic approach of DCA and stenting performed under routinely accessible angiographic guidance. Therefore, multicenter-based randomized clinical trials are clearly warranted to finally clarify the validity of this complex approach versus conventional angioplasty plus stenting.
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Affiliation(s)
- H W Höpp
- Klinik III für Innere Medizin der Universität zu Köln, Cologne, Germany.
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24
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Di Mario C, Marsico F, Adamian M, Karvouni E, Albiero R, Colombo A. New recipes for in-stent restenosis: cut, grate, roast, or sandwich the neointima? Heart 2000; 84:471-5. [PMID: 11040001 PMCID: PMC1729462 DOI: 10.1136/heart.84.5.471] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- C Di Mario
- Department of Interventional Cardiology, San Raffaele Hospital, Via Olgettina 60, 20140 Milan, Italy.
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25
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TAN HUAYCHEEM, CROWLEY JAMES, TCHENG JAMESE, SNG LIWAH, SKETCH MICHAELH, PHILLIPS HARRYR, PETER ROBERTH, BEHAR VICTORS, STACK RICHARDS, ZIDAR JAMESP. Treatment of Palmaz-Schatz In-stent Restenosis: 6?Month Clinical Follow-up. J Interv Cardiol 2000. [DOI: 10.1111/j.1540-8183.2000.tb00309.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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26
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Gross CM, Krämer J, Weingärtner O, Uhlich F, Dietz R, Waigand J. Clinical and angiographic outcome in patients with in-stent restenosis and repeat target lesion revascularisation in small coronary arteries. Heart 2000; 84:307-13. [PMID: 10956297 PMCID: PMC1760961 DOI: 10.1136/heart.84.3.307] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the clinical and angiographic outcome in patients with in-stent restenosis in small coronary arteries and repeat target lesion revascularisation. DESIGN Patients with in-stent restenosis in coronary arteries < or = 2.85 mm were eligible for the study and underwent target lesion revascularisation. Clinical and angiographic variables were assessed during a six month follow up period. RESULTS 73 patients with 79 lesions were treated by percutaneous transluminal coronary angioplasty (47%), excimer laser angioplasty (25%), or restenting (28%). The mean (SD) reference diameter before target lesion revascularisation was 2.12 (0.5) mm. Procedural success was achieved in all cases, but 57% of the patients had restenosis after six months. The rate of further restenosis was higher with laser angioplasty (78%) than with restenting (47%) or balloon angioplasty alone (49%, p < 0.05). CONCLUSIONS Treatment for in-stent restenosis in small coronary arteries is feasible and safe, with a second restenosis rate comparable to large coronary artery series. The strategy of target lesion revascularisation influences further in-stent restenosis, with an increased rate with laser angioplasty compared with restenting and repeat dilatation alone.
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Affiliation(s)
- C M Gross
- Franz Volhard Clinic at the Max Delbrück Centre, Charité, Campus Berlin-Buch, Humboldt University, Berlin, Germany.
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27
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Ishikawa S, Asakura Y, Okabe T, Sakamoto M, Shibata M, Asakura K, Mitamura H, Ogawa S. Repeat intervention for in-stent restenosis: re-expansion of the initial stent is a predictor of recurrence of restenosis. Coron Artery Dis 2000; 11:451-7. [PMID: 10966130 DOI: 10.1097/00019501-200009000-00002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In-stent restenosis has become a significant clinical problem as use of stents has increased. The optimal strategy for dealing with in-stent restenosis needs to be evaluated. OBJECTIVE To compare the acute and late results of interventions for in-stent restenosis according to the device used, and to analyze the clinical and procedural variables of the lesions treated and identify the determinants of recurrence of restenosis and target lesion revascularization (TLR). METHODS Procedural and late outcomes for 58 lesions in 50 patients who underwent repeat intervention for in-stent restenosis were analyzed. The results of interventions according to the device employed were compared. The predictors of recurrence of restenosis and TLR within 6 months were analyzed. The ratio of balloon diameter in repeat intervention to minimal lumen diameter after initial stenting (MLD0) was used as an index of re-expansion of stents. Serial intravascular ultrasound imaging was performed before and after repeat intervention for 33 lesions, and re-expansion of the initial stent was evaluated. RESULTS Repeat intervention was successful in treating all lesions. Angiographic follow-up was possible for 49 lesions (84%). The overall incidences of recurrence of restenosis and TLR were 40.1 and 27.6%, respectively. Despite the immediate results having been good, the late results of stenting for in-stent restenosis were not favorable. Diffuse-type in-stent restenosis, early in-stent restenosis, and balloon diameter:MLD0 ratio > 1.25 are independent predictors of poor late results. Intravascular ultrasound findings have shown that expansion of the initial stent leads to recurrence of restenosis and TLR. CONCLUSIONS Re-expansion of the initial stent can cause further vascular injury and there is a risk of recurrence of restenosis. Alternative therapeutic strategies that work without dilating the initial stent may be necessary for treating lesions with high risk of recurrence of restenosis.
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Affiliation(s)
- S Ishikawa
- Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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28
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Franck H, Weber K, Pieper MJ, Frese W. Local heparin delivery for prevention of second in-stent restenosis. Acute and long-term results in 47 consecutive cases. INTERNATIONAL JOURNAL OF CARDIOVASCULAR INTERVENTIONS 2000; 3:181-184. [PMID: 12470369 DOI: 10.1080/14628840050516109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND: Heparin has been shown to reduce intimal thickening after arterial wall injury by inhibiting vascular smooth muscle cell proliferation and migration. The authors studied the acute and long-term results after local delivery of heparin after balloon angioplasty for in-stent restenosis. METHODS AND RESULTS: Forty-seven in-stent restenosis cases, 32 of them longer than 1 cm, were enrolled. After angioplasty local heparin delivery was performed using the Dispatch coronary infusion catheter (Scimed Life Systems/Boston Scientific Corp, Natick, MA, USA); the infusion rate was 99.9 ml per hour and a target dosage of 4000 iu heparin per site was intended to be delivered. In nine cases (19.15%) heparin delivery had to be stopped because of ischemia. One patient died six days after intervention. After a follow-up interval of 6-12 months target vessel revascularization rate was 28.26%. CONCLUSIONS: For the protocol used ischemia occurred more often than previously reported. Considering the fact that most patients had diffuse in-stent restenosis, the target revascularization rate at follow-up was acceptable.
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Affiliation(s)
- Harald Franck
- Klinikum St Marien, Medizinische Klinik I, Amberg, Germany
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29
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Affiliation(s)
- A S Kurbaan
- Department of Cardiology, London Chest Hospital, United Kingdom.
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30
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Köster R, Kähler J, Terres W, Reimers J, Baldus S, Hartig D, Berger J, Meinertz T, Hamm CW. Six-month clinical and angiographic outcome after successful excimer laser angioplasty for in-stent restenosis. J Am Coll Cardiol 2000; 36:69-74. [PMID: 10898415 DOI: 10.1016/s0735-1097(00)00704-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study evaluated the clinical and angiographic six-month follow-up after excimer laser coronary angioplasty (ELCA) for restenosed coronary stents. BACKGROUND Excimer laser coronary angioplasty has recently been shown to be safe and efficient for the treatment of in-stent restenosis. METHODS Ninety-six consecutive patients successfully treated with ELCA within 141 stents were included in a six-month clinical and angiographic follow-up. RESULTS During follow-up there was one sudden death and one patient with documented myocardial infarction. Angina pectoris classified as > or = Canadian Cardiovascular Society II reoccurred in 49 patients. Follow-up angiography was obtained in 89 patients (93%) with 133 stents. Quantitative coronary angiography revealed a mean diameter stenosis of 77 +/- 10% before intervention, 41 +/- 12% after laser treatment and 11% +/- 12% after adjunctive percutaneous transluminal coronary angioplasty (p < 0.001). Six months after ELCA the mean diameter stenosis had increased to 60 +/- 26% (p < 0.001). A > or =50% diameter stenosis was present in 48 patients (54%); in 24 of these patients diameter stenosis was > or =70%. Total occlusions occurred in an additional 10 patients (11%). There was a trend toward an increased recurrent restenosis rate in patients with diabetes mellitus and long lesions or total occlusions (p = 0.059). Forty-eight patients (50%) received medical treatment after six months. Reinterventions were necessary in 30 patients (31%), and coronary artery bypass surgery was performed in 17 patients (18%). Event-free survival was 50%. CONCLUSIONS Excimer laser angioplasty for in-stent restenosis was associated with a high incidence of recurrent restenosis in this group of patients, suggesting that this technique is unlikely to reduce recurrent in-stent restenosis and that other approaches are necessary.
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Affiliation(s)
- R Köster
- University Hospital Eppendorf, Medical Clinic, Department of Cardiology, Hamburg, Germany
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31
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Weaver WD, Reisman MA, Griffin JJ, Buller CE, Leimgruber PP, Henry T, D'Haem C, Clark VL, Martin JS, Cohen DJ, Neil N, Every NR. Optimum percutaneous transluminal coronary angioplasty compared with routine stent strategy trial (OPUS-1): a randomised trial. Lancet 2000; 355:2199-203. [PMID: 10881893 DOI: 10.1016/s0140-6736(00)02403-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Whether routine implantation of coronary stents is the best strategy to treat flow-limiting coronary stenoses is unclear. An alternative approach is to do balloon angioplasty and provisionally use stents only to treat suboptimum results. We did a multicentre trial to compare the outcomes of patients treated with these strategies. METHODS We randomly assigned 479 patients undergoing single-vessel coronary angioplasty routine stent implantation or initial balloon angioplasty and provisional stenting. We followed up patients for 6 months to determine the composite rate of death, myocardial infarction, cardiac surgery, and target-vessel revascularisation. RESULTS Stents were implanted in 227 (98.7%) of the patients assigned routine stenting. 93 (37%) patients assigned balloon angioplasty had at least one stent placed because of suboptimum angioplasty results. At 6 months the composite endpoint was significantly lower in the routine stent strategy (14 events, 6.1%) than with the strategy of balloon angioplasty with provisional stenting (37 events, 14.9%, p=0.003). The cost of the initial revascularisation procedure was higher than when a routine stent strategy was used (US$389 vs $339, p<0.001) but at 6 months, average per-patient hospital costs did not differ ($10,206 vs $10,490). Bootstrap replication of 6-month cost data showed continued economic benefit of the routine stent strategy. INTERPRETATION Routine stent implantation leads to better acute and long-term clinical outcomes at a cost similar to that of initial balloon angioplasty with provisional stenting.
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Affiliation(s)
- W D Weaver
- Henry Ford Health System Heart and Vascular Institute, Detroit, MI 48202, USA.
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32
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BALDUS STEPHAN, REIMERS JACOBUS, KÖSTER RALF, KÄHLER JAN, SCHAPS KLAUSPETER, BOLTE JOHANN, HAMM CHRISTIANW. Recurrent Coronary In-Stent Restenosis: Potential of Membrane-Covered Stents. J Interv Cardiol 2000. [DOI: 10.1111/j.1540-8183.2000.tb00284.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Bossi I, Klersy C, Black AJ, Cortina R, Choussat R, Cassagneau B, Jordan C, Laborde JC, Laurent JP, Bernies M, Fajadet J, Marco J. In-stent restenosis: long-term outcome and predictors of subsequent target lesion revascularization after repeat balloon angioplasty. J Am Coll Cardiol 2000; 35:1569-76. [PMID: 10807462 DOI: 10.1016/s0735-1097(00)00584-2] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We sought to evaluate the long-term clinical outcome of patients undergoing successful balloon angioplasty for in-stent restenosis, and to determine correlates of the need for subsequent target lesion revascularization (TLR). BACKGROUND In-stent restenosis can be safely treated by repeat percutaneous intervention. Reported subsequent TLR rates have varied from 20% to 80% and seem related to the type of restenotic lesion. METHODS The study population comprised 234 patients with follow-up data who were successfully treated with repeat balloon angioplasty for in-stent restenosis in 257 lesions between May 1995 and January 1998 at our institution. RESULTS Clinical follow-up was available at 459 (286 to 693) days after the repeat procedure. Event-free survival was 78.5% and 74.6% at 12 and 24 months, respectively. Recurrent events occurred in 58 patients (24.8%), including 6 deaths (2.6%), 4 myocardial infarction (1.7%) and repeat target vessel revascularization in 50 patients (21.4%). Independent predictors of repeat TLR were time to in-stent restenosis <90 days (Hazard ratio 4.67, p < 0.001), minimal luminal diameter after repeat procedure (Hazard ratio 0.38, p = 0.034) and the angiographic pattern of in-stent restenosis (Hazard ratio 1.65, p = 0.036). CONCLUSIONS Balloon angioplasty is an effective means of treating in-stent restenosis. The long-term results are acceptable particularly for focal restenotic lesions. Further restenosis is more common in patients with early initial recurrence, more proliferative lesions and a poorer angiographic result from repeat angioplasty.
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Affiliation(s)
- I Bossi
- Unité de Cardiologie Interventionelle, Clinique Pasteur, Toulouse, France.
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HABERBOSCH WERNER, WAAS WOLFGANG, WALDECKER BERND, HEIZMANN HEINRICH, HÖLSCHERMANN HANS, RAU MATTHIAS, TILLMANNS HARALD. Directional Coronary Atherectomy of In-stent Restenosis: A Two-Center Experience. J Interv Cardiol 2000. [DOI: 10.1111/j.1540-8183.2000.tb00271.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Alfonso F, Cequier A, Zueco J, Morís C, Suárez CP, Colman T, Esplugas E, Pérez-Vizcayno MJ, Fernández C, Macaya C. Stenting the stent: initial results and long-term clinical and angiographic outcome of coronary stenting for patients with in-stent restenosis. Am J Cardiol 2000; 85:327-32. [PMID: 11078301 DOI: 10.1016/s0002-9149(99)00741-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Stent restenosis constitutes a therapeutic challenge affecting an increasing number of patients. Conventional angioplasty and debulking techniques are currently used in these patients. However, the potential role of a second stent implantation in this setting (stenting the stent) remains unknown. Therefore, 65 consecutive patients (12 women, aged 62 +/- 11 years) undergoing stent implantation (42 elective and 23 unplanned) for the treatment of in-stent restenosis (diffuse [> 10 mm] in 39 [60%]) were studied. Angiographic success was obtained in all patients. Three patients developed hospital complications: 1 died from refractory heart failure and 2 suffered non-Q-wave myocardial infarctions. During follow-up (mean 17 +/- 11 months) 1 patient died (noncardiac cause) and only 9 (14%) required target vessel revascularization. Kaplan-Meier event-free survival (freedom from death, myocardial infarction, and target vessel revascularization) at 1 year was 84%. Using Cox analysis, patients with unstable symptoms, a short time to stent restenosis, nonelective stenting, and B2-C lesions tended to have poorer prognosis. After adjustment, nonelective stenting was associated (adjusted RR 2.9, 95% confidence interval [CI] 0.82 to 10.3, p = 0.09) with an adverse clinical outcome. On quantitative angiography (core lab) restenosis was found in 13 of 43 patients (30%) (75% of those eligible). Logistic regression analysis identify restenosis length (adjusted RR 1.43, 95% CI 1.04 to 2.14, p = 0.04), and time to restenosis (adjusted RR 0.67, 95% CI 0.47 to 0.94, p = 0.01) as the only independent predictors of recurrent restenosis. Thus, repeat coronary stenting is a safe and efficacious strategy for the treatment of patients with in-stent restenosis. Both elective and nonelective stenting provide excellent initial results. The long-term clinical and angiographic outcome of these patients is also favorable.
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Affiliation(s)
- F Alfonso
- Interventional Cardiology Units, San Carlos University Hospital, Madrid, Spain
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Elezi S, Kastrati A, Hadamitzky M, Dirschinger J, Neumann FJ, Schömig A. Clinical and angiographic follow-up after balloon angioplasty with provisional stenting for coronary in-stent restenosis. Catheter Cardiovasc Interv 1999; 48:151-6. [PMID: 10506769 DOI: 10.1002/(sici)1522-726x(199910)48:2<151::aid-ccd6>3.0.co;2-c] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The objective of this study was to assess the angiographic and clinical outcome of patients with coronary in-stent restenosis treated with balloon angioplasty with provisional stenting. The study included 375 consecutive patients with in-stent restenosis managed with balloon angioplasty alone or combined with stenting. Clinical events were recorded during a 1-year follow-up period and quantitative analysis was performed on 6-month angiographic data. Of the 373 patients (451 lesions) with a successful procedure, 273 were treated with angioplasty alone and 100 with additional stenting. Target lesion revascularization was required in 23.7% of the patients: 20.7% in patients with angioplasty and 31.0% in patients with stenting. Angiographic restenosis rate was 38.9%: 35.8% in the angioplasty group and 47.7% in the stent group. Stenting in small vessels was associated with a much higher restenosis rate than in larger vessels (65.6% vs. 37.5%, respectively; P = 0.01). Thus, repeat balloon angioplasty with provisional stenting for in-stent restenosis is a safe treatment strategy associated with a relatively favorable long-term outcome. However, the long-term results might be improved if additional stenting is avoided especially in small vessels. Cathet. Cardiovasc. Intervent. 48:151-156, 1999.
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Affiliation(s)
- S Elezi
- Deutsches Herzzentrum and 1, Medizinische Klinik rechts der Isar, Technische Universität München, Munich, Germany
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37
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Tsuchikane E, Sumitsuji S, Awata N, Nakamura T, Kobayashi T, Izumi M, Otsuji S, Tateyama H, Sakurai M, Kobayashi T. Final results of the STent versus directional coronary Atherectomy Randomized Trial (START). J Am Coll Cardiol 1999; 34:1050-7. [PMID: 10520789 DOI: 10.1016/s0735-1097(99)00324-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study was designed to compare primary stenting with optimal directional coronary atherectomy (DCA). BACKGROUND No previous prospective randomized trial comparing stenting and DCA has been performed. METHODS One hundred and twenty-two lesions suitable for both Palmaz-Schatz stenting and DCA were randomly assigned to stent (62 lesions) or DCA (60 lesions) arm. Single or multiple stents were implanted with high-pressure dilation in the stent arm. Aggressive debulking using intravascular ultrasound (IVUS) was performed in the DCA arm. Serial quantitative angiography and IVUS were performed preprocedure, postprocedure and at six months. The primary end point was restenosis, defined as > or =50% diameter stenosis at six months. Clinical event rates at one year were also assessed. RESULTS Baseline characteristics were similar. Procedural success was achieved in all lesions. Although the postprocedural lumen diameter was similar (2.79 vs. 2.90 mm, stent vs. DCA), the follow-up lumen diameter was significantly smaller (1.89 vs. 2.18 mm; p = 0.023) in the stent arm. The IVUS revealed that intimal proliferation was significantly larger in the stent arm than in the DCA arm (3.1 vs. 1.1 mm ; p < 0.0001), which accounted for the significantly smaller follow-up lumen area of the stent arm (5.3 vs. 7.0 mm2; p = 0.030). Restenosis was significantly lower (32.8% vs. 15.8%; p = 0.032), and target vessel failure at one year tended to be lower in the DCA arm (33.9% vs. 18.3%; p = 0.056). CONCLUSIONS These results suggest that aggressive DCA may provide superior angiographic and clinical outcomes to primary stenting.
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Affiliation(s)
- E Tsuchikane
- Department of Cardiology, Osaka Medical Center, Higashinari, Japan.
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KIPSHIDZE NICHOLAS, CHAWLA PARAMJITHS. Role of Autoperfusion Balloon in Endovascular Interventions. J Interv Cardiol 1999. [DOI: 10.1111/j.1540-8183.1999.tb00256.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Elsner M, Auch-Schwelk W, Britten M, Walter DH, Schächinger V, Zeiher AM. Coronary stent grafts covered by a polytetrafluoroethylene membrane. Am J Cardiol 1999; 84:335-8, A8. [PMID: 10496448 DOI: 10.1016/s0002-9149(99)00289-1] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In a prospective observational study, 40 patients were treated with coronary stent grafts covered by a polytetrafluoroethylene membrane. These devices may be regarded as therapy of choice for acute coronary rupture; treatment of conventional in-stent restenosis was not associated with a favorable outcome, whereas the promising results in degenerated vein grafts warrant a randomized, controlled trial.
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Affiliation(s)
- M Elsner
- Medizinische Klinik IV (Department of Cardiology), J.W. Goethe University, Frankfurt, Germany.
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40
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Köster R, Hamm CW, Seabra-Gomes R, Herrmann G, Sievert H, Macaya C, Fleck E, Fischer K, Bonnier JJ, Fajadet J, Waigand J, Kuck KH, Henry M, Morice MC, Pizzulli L, Webb-Peploe MM, Buchwald AB, Ekström L, Grube E, Al Kasab S, Colombo A, Sanati A, Ernst SM, Haude M, Serruys PW. Laser angioplasty of restenosed coronary stents: results of a multicenter surveillance trial. The Laser Angioplasty of Restenosed Stents (LARS) Investigators. J Am Coll Cardiol 1999; 34:25-32. [PMID: 10399988 DOI: 10.1016/s0735-1097(99)00167-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study evaluated safety and efficacy of excimer laser angioplasty for treatment of restenosed or occluded coronary stents. BACKGROUND Balloon angioplasty of in-stent restenosis is limited by a high recurrence rate. Debulking by laser angioplasty is a novel concept to treat in-stent restenosis. METHODS A total of 440 patients with restenoses or occlusions in 527 stents were enrolled for treatment with concentric or eccentric laser catheters and adjunctive balloon angioplasty. RESULTS Laser angioplasty success (< or =50% diameter stenosis after laser treatment or successful passage with a 2.0-mm or 1.7-mm eccentric laser catheter) was achieved in 92% of patients. Adjunctive balloon angioplasty was performed in 99%. Procedural success (laser angioplasty success followed by < or =30% stenosis with or without balloon angioplasty) was 91%. There was neither a significant difference in success with respect to lesion length, nor were there differences between small and large vessels or native vessels and vein grafts. Success was higher and residual stenosis lower using large or eccentric catheters. Serious adverse events included death (1.6%, not directly laser catheter related), Q-wave myocardial infarction (0.5%), non-Q-wave infarction (2.7%), cardiac tamponade (0.5%) and stent damage (0.5%). Perforations after laser treatment occurred in 0.9% of patients and after balloon angioplasty in 0.2%. Dissections were visible in 4.8% of patients after laser treatment and in 9.3% after balloon angioplasty. Reinterventions during hospitalization were necessary in 0.9% of patients; bypass surgery was performed in 0.2%. CONCLUSIONS Excimer laser angioplasty with adjunctive balloon angioplasty is a safe and efficient technology to treat in-stent restenoses. These data justify a randomized comparison with balloon angioplasty.
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Affiliation(s)
- R Köster
- Medical Clinic, Department of Cardiology, University Hospital Eppendorf, Hamburg, Germany
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Alfonso F, Pérez-Vizcayno MJ, Hernández R, Goicolea J, Fernández-Ortíz A, Escaned J, Bañuelos C, Fernández C, Macaya C. Long-term outcome and determinants of event-free survival in patients treated with balloon angioplasty for in-stent restenosis. Am J Cardiol 1999; 83:1268-70, A9. [PMID: 10215297 DOI: 10.1016/s0002-9149(99)00071-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Long-term prognosis and predictors of event-free survival were studied in 56 consecutive patients with in-stent restenosis successfully treated with balloon angioplasty. Most patients sustained prolonged clinical benefit, but during follow-up, those with diabetes or with a short time interval (<4 months) from stenting to repeat angioplasty experienced adverse cardiac events more often.
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Affiliation(s)
- F Alfonso
- Interventional Cardiology Unit, San Carlos University Hospital, Madrid, Spain
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vom Dahl J, Radke PW, Haager PK, Koch KC, Kastrau F, Reffelmann T, Janssens U, Hanrath P, Klues HG. Clinical and angiographic predictors of recurrent restenosis after percutaneous transluminal rotational atherectomy for treatment of diffuse in-stent restenosis. Am J Cardiol 1999; 83:862-7. [PMID: 10190400 DOI: 10.1016/s0002-9149(98)01074-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Due to the widespread use of stents in complex coronary lesions, stent restenosis represents an increasing problem, for which optimal treatment is under debate. "Debulking" of in-stent neointimal tissue using percutaneous transluminal rotational atherectomy (PTRA) offers an alternative approach to tissue compression and extrusion achieved by balloon angioplasty. One hundred patients (70 men, aged 58 +/- 11 years) with a first in-stent restenosis underwent PTRA using an incremental burr size approach followed by adjunctive angioplasty. The average lesion length by quantitative angiography was 21 +/- 8 mm (range 5 to 68) including 22 patients with a length > or = 40 mm. Twenty-nine patients had complete stent occlusions with a lesion length of 44 +/- 23 mm. Baseline diameter stenosis measured 78 +/- 17%, was reduced to 32 +/- 9% after PTRA, and further reduced to 21 +/- 10% after adjunctive angioplasty. Primary PTRA was successful in 97 of 100 patients. Clinical success was 97%, whereas 2 patients developed non-Q-wave infarctions without clinical sequelae. Clinical follow-up was available for all patients at 5 +/- 4 months without any cardiac event. Angiography in 72 patients revealed restenosis in 49%, with necessary target lesion reintervention in 35%. The incidence of rerestenosis correlated with the length of the primarily stented segment and the length of a first in-stent restenosis. Thus, PTRA offers an alternative approach to treat diffuse in-stent restenosis. Neointimal debulking of stenosed stents can be achieved effectively and safely. PTRA resulted in an acceptable recurrent restenosis rate in short and modestly diffuse lesion, whereas the restenosis rate in very long lesions remains high despite debulking.
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Affiliation(s)
- J vom Dahl
- Department of Cardiology, University Hospital, University of Technology, Aachen, Germany.
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Schiele F, Vuillemenot A, Meneveau N, Pales-Espinosa D, Gupta S, Bassand JP. Effects of increasing balloon pressure on mechanism and results of balloon angioplasty for treatment of restenosis after Palmaz-Schatz stent implantation: an angiographic and intravascular ultrasound study. Catheter Cardiovasc Interv 1999; 46:314-21. [PMID: 10348129 DOI: 10.1002/(sici)1522-726x(199903)46:3<314::aid-ccd11>3.0.co;2-i] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Repeat balloon angioplasty is a widely used therapeutic option for in-stent restenosis, but the optimal balloon inflation pressure has not yet been determined. We used angiography and intravascular ultrasound imaging to assess the mechanism and results of lumen enlargement at various inflation pressures. Thirteen consecutive patients with restenosis post-Palmaz-Schatz stent implantation were submitted to a four-step balloon angioplasty using increasing balloon pressure of 2, 4, 8, and >12 atm. As a global result, the lumen size was only 80% of that observed at stent implantation. Significant changes in angiographic minimal lumen diameter, minimal lumen cross-sectional area, and lumen volume were observed after each step except after the highest-pressure inflation. At low inflation pressure (<8 atm), the decrease in neointimal tissue and the stent over expansion explained the lumen enlargement, whereas after further high inflation pressure (>8 atm), only additional stent over expansion was observed. These results suggest that only moderate balloon inflation pressure (up to 12 atm) is needed for angioplasty of post-Palmaz-Schatz stent restenotic lesions.
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Affiliation(s)
- F Schiele
- Hôpital Saint-Jacques, Besançon, France.
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Javier Goicolea Ruigómez F, Macaya Miguel C. Angioplastia coronaria: ¿stents siempre en arterias de más de 2,5 mm? Argumentos en contra. Rev Esp Cardiol 1999. [DOI: 10.1016/s0300-8932(99)74874-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mahdi NA, Pathan AZ, Harrell L, Leon MN, Lopez J, Butte A, Ferrell M, Gold HK, Palacios IF. Directional coronary atherectomy for the treatment of Palmaz-Schatz in-stent restenosis. Am J Cardiol 1998; 82:1345-51. [PMID: 9856917 DOI: 10.1016/s0002-9149(98)00639-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Management of in-stent restenosis has become a significant challenge in interventional cardiology. The results of balloon angioplasty have been disappointing due to the high recurrence of restenosis at follow-up. Debulking of the restenotic tissue within the stents using directional coronary atherectomy (DCA) may offer a therapeutic advantage. We report the immediate clinical and angiographic outcomes and long-term clinical follow-up results of 45 patients (46 lesions), mean age 63+/-12 years, 73% men, with a mean reference diameter of 2.9+/-0.6 mm, treated with DCA for symptomatic Palmaz-Schatz in-stent restenosis. DCA was performed successfully in all 46 lesions and resulted in a postprocedural minimal luminal diameter of 2.7+/-0.7 mm and a residual diameter stenosis of 17+/-10%. There were no in-hospital deaths, Q-wave myocardial infarctions, or emergency coronary artery bypass surgeries. Four patients (9%) suffered a non-Q-wave myocardial infarction. Target lesion revascularization was 28.3% at a mean follow-up of 10+/-4.6 months. Kaplan-Meier event-free survival (freedom from death, myocardial infarction, and repeat target lesion revascularization) was 71.2% and 64.7% at 6 and 12 months after DCA, respectively. Thus, DCA is safe and efficacious for the treatment of Palmaz-Schatz in-stent restenosis. It results in a large postprocedural minimal luminal diameter and a low rate of both target lesion revascularization and combined major clinical events at follow-up.
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Affiliation(s)
- N A Mahdi
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
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Holmes DR, Hirshfeld J, Faxon D, Vlietstra RE, Jacobs A, King SB. ACC Expert Consensus document on coronary artery stents. Document of the American College of Cardiology. J Am Coll Cardiol 1998; 32:1471-82. [PMID: 9809967 DOI: 10.1016/s0735-1097(98)00427-6] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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48
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Eltchaninoff H, Koning R, Tron C, Gupta V, Cribier A. Balloon angioplasty for the treatment of coronary in-stent restenosis: immediate results and 6-month angiographic recurrent restenosis rate. J Am Coll Cardiol 1998; 32:980-4. [PMID: 9768721 DOI: 10.1016/s0735-1097(98)00333-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The purpose of this prospective study was to evaluate the immediate results and the 6-month angiographic recurrent restenosis rate after balloon angioplasty for in-stent restenosis. BACKGROUND Despite excellent immediate and mid-term results, 20% to 30% of patients with coronary stent implantation will present an angiographic restenosis and may require additional treatment. The optimal treatment for in-stent restenosis is still unclear. METHODS Quantitative coronary angiography (QCA) analyses were performed before and after stent implantation, before and after balloon angioplasty for in-stent restenosis and on a 6-month systematic coronary angiogram to assess the recurrent angiographic restenosis rate. RESULTS Balloon angioplasty was performed in 52 patients presenting in-stent restenosis. In-stent restenosis was either diffuse (> or =10 mm) inside the stent (71%) or focal (29%). Mean stent length was 16+/-7 mm. Balloon diameter of 2.98+/-0.37 mm and maximal inflation pressure of 10+/-3 atm were used for balloon angioplasty. Angiographic success rate was 100% without any complication. Acute gain was lower after balloon angioplasty for in-stent restenosis than after stent implantation: 1.19+/-0.60 mm vs. 1.75+/-0.68 mm (p=0.0002). At 6-month follow-up, 60% of patients were asymptomatic and no patient died. Eighteen patients (35%) had repeat target vessel revascularization. Angiographic restenosis rate was 54%. Recurrent restenosis rate was higher when in-stent restenosis was diffuse: 63% vs. 31% when focal, p=0.046. CONCLUSIONS Although balloon angioplasty for in-stent restenosis can be safely and successfully performed, it leads to less immediate stenosis improvement than at time of stent implantation and carries a high recurrent angiographic restenosis rate at 6 months, in particular in diffuse in-stent restenosis lesions.
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Affiliation(s)
- H Eltchaninoff
- Department of Cardiology, Hôpital Charles Nicolle, University of Rouen, France
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Lee SG, Lee CW, Cheong SS, Hong MK, Kim JJ, Park SW, Park SJ. Immediate and long-term outcomes of rotational atherectomy versus balloon angioplasty alone for treatment of diffuse in-stent restenosis. Am J Cardiol 1998; 82:140-3. [PMID: 9678281 DOI: 10.1016/s0002-9149(98)00292-6] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This study was performed to compare the effects of rotational atherectomy (RA) plus balloon angioplasty (BA) with those of BA alone for treatment of diffuse in-stent restenosis. RA+BA or BA alone was performed in a consecutive, prospective (not randomized) manner in 81 patients with 81 diffuse in-stent restenotic lesions (lesion length > 10 mm): 36 patients underwent RA+BA, and 45 patients BA. Clinical recurrence was the primary end point of this study, and was defined as angina associated with objective evidence of myocardial ischemia on stress testing. Mean follow-up duration was 277 +/- 109 days. In the BA group, acute lumen gain after repeat intervention was significantly lower than that of the original stenting procedure (1.94 +/- 0.63 vs 2.37 +/- 0.51 mm, p <0.05). In the RA + BA group, however, acute lumen gain of repeat intervention was similar to that of the original stenting procedure (2.16 +/- 0.52 vs 2.26 +/- 0.66 mm). Clinical recurrence rate at 6 months follow-up was significantly lower in the RA+BA group than in the BA group (25% vs 47%, p <0.05). Clinical events (death, myocardial infarction, repeat intervention) occurred in 6.7% (3 of 45) of patients in the BA group, but in no patient in the RA+BA group during the follow-up period. The long-term angina-free survival rate was significantly higher in the RA+BA group than in the BA group (72% vs 49%, p = 0.02). In conclusion, RA+BA seems to be a more effective therapeutic modality than BA alone for treatment of diffuse in-stent restenosis.
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Affiliation(s)
- S G Lee
- Department of Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea
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Affiliation(s)
- C R Narins
- Department of Cardiology and Joseph J. Jacobs Center for Vascular Biology, The Cleveland Clinic Foundation, Ohio 44195, USA
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