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El-Andari R, Bozso SJ, Fialka NM, Kang JJH, MacArthur RGG, Meyer SR, Freed DH, Nagendran J. Coronary Artery Revascularization in Heart Transplant Patients: A Systematic Review and Meta-analysis. Cardiology 2022; 147:348-363. [PMID: 35500568 DOI: 10.1159/000524781] [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] [Received: 11/27/2021] [Accepted: 02/02/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is the primary cause of late mortality after heart transplantation (HTx). We look to provide a comprehensive review of contemporary revascularization strategies in CAV. METHODS PubMed and Web of Science were systematically searched by 3 authors. 1,870 articles were initially screened and 24 were included in this review. RESULTS PCI is the main revascularization technique utilized in CAV. The pooled estimates for restenosis significantly favored DES over BMS (OR 4.26; 95% CI, 2.54-7.13; p< 0.00001; I2=4%). There was insufficient data to quantitatively compare mortality following DES versus BMS. There was no difference in short-term mortality between CABG and PCI. In-hospital mortality was 0.0% for CABG and ranged from 0.0-8.34% for PCI. 1-year mortality was 8.0% for CABG and 5.0-25.0% for PCI. CABG had a potential advantage at 5 years. 5-year mortality was 17.0% for CABG and ranged from 14-40.4% following PCI. Select measures of postoperative morbidity trended towards superior outcomes for CABG. CONCLUSIONS In CAV, PCI is the primary revascularization strategy utilized, with DES exhibiting superiority to BMS regarding postoperative morbidity. Further investigation into outcomes following CABG in CAV is required to conclusively elucidate the superior management strategy in CAV.
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Affiliation(s)
- Ryaan El-Andari
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sabin J Bozso
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Nicholas M Fialka
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jimmy J H Kang
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Roderick G G MacArthur
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Steven R Meyer
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jeevan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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“Cardiac allograft vasculopathy: Pathogenesis, diagnosis and therapy”. Transplant Rev (Orlando) 2020; 34:100569. [DOI: 10.1016/j.trre.2020.100569] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/19/2020] [Indexed: 01/06/2023]
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Pyka Ł, Hawranek M, Szyguła-Jurkiewicz B, Desperak P, Szczurek W, Lekston A, Gąsior M, Zembala MO, Pawlak S, Zembala M, Przybyłowski P. Everolimus-Eluting Second-Generation Stents for Treatment of De Novo Lesions in Patients with Cardiac Allograft Vasculopathy. Ann Transplant 2020; 25:e921266. [PMID: 32253369 PMCID: PMC7163333 DOI: 10.12659/aot.921266] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Cardiac allograft vasculopathy is a major cause of cardiac allograft rejection. Percutaneous coronary intervention has become the main form of treatment of significant focal lesions. Despite the significance of the problem, data remain scarce. With a large population of transplant recipients undergoing coronary angiography at our center, we decided to analyze the implications of the use of everolimus-eluting second-generation stents by performing 6-month clinical and angiographic follow-up. Material/Methods From December 2012 and August 2019, 319 patients after heart transplantation undergoing coronary angiography at our institution were analyzed. Subsequently, 22 patients underwent de novo angioplasty with second-generation everolimus-eluting stents. The primary study endpoint was angiographic restenosis as evaluated by quantitative coronary angiography. Secondary outcomes included binary restenosis, target lesion revascularization, and cardiac death during the follow-up period (6 months). Results Patient comorbidities included hypertension (77.3%), type 2 diabetes mellitus (68.2%), dyslipidemia (68.2%), and obesity (31.8%). Primary success was obtained in all of the treated lesions. The analysis of quantitative coronary angiography after 6-month follow-up revealed low late lumen loss (0.22±0.40). Significant restenosis was observed in 1 of the cases. There were no deaths in the 6-month observation period. Conclusions In the analyzed population, invasive strategy with second-generation everolimus-eluting stents for de novo lesions in cardiac allograft vasculopathy resulted in a low rate of binary restenosis, low late lumen loss, and no deaths during the 6-month follow-up.
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Affiliation(s)
- Łukasz Pyka
- Third Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Michał Hawranek
- Third Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Bożena Szyguła-Jurkiewicz
- Third Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Piotr Desperak
- Third Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Wioletta Szczurek
- Third Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Andrzej Lekston
- Third Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Mariusz Gąsior
- Third Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Michał O Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Szymon Pawlak
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Marian Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Piotr Przybyłowski
- Silesian Center for Heart Diseases, Zabrze, Poland.,First Department of General Surgery, Jagiellonian University, Medical College, Cracow, Poland
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Nikolova AP, Kobashigawa JA. Cardiac Allograft Vasculopathy: The Enduring Enemy of Cardiac Transplantation. Transplantation 2019; 103:1338-1348. [PMID: 31241553 DOI: 10.1097/tp.0000000000002704] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Cardiac allograft vasculopathy remains a major limiting factor in the long-term survival of the heart transplant recipient. Our understanding of its pathogenesis is continuously evolving as advances in imaging modalities have allowed a direct window into the natural history of the disease. Innovation in diagnostic modalities has spurred the proliferation of prognostic tools and biomarkers. And in parallel, pharmacological advances have emerged that have helped ameliorate the disease's progressive course.
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Affiliation(s)
- Andriana P Nikolova
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jon A Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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Cheng R, Vanichsarn C, Patel JK, Currier J, Chang DH, Kittleson MM, Makkar R, Kobashigawa JA, Azarbal B. Long-term clinical and angiographic outcomes of percutanenous coronary intervention with everolimus-eluting stents for the treatment of cardiac allograft vasculopathy. Catheter Cardiovasc Interv 2016; 90:48-55. [DOI: 10.1002/ccd.26830] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 09/21/2016] [Accepted: 10/08/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Richard Cheng
- Cedars-Sinai Heart Institute; Los Angeles California
| | | | | | - Jesse Currier
- Division of Cardiology; VA Greater Los Angeles Healthcare System; Los Angeles California
| | | | | | - Raj Makkar
- Cedars-Sinai Heart Institute; Los Angeles California
| | | | - Babak Azarbal
- Cedars-Sinai Heart Institute; Los Angeles California
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Gómez-Monterrosas O, Fernández D, Brugaletta S, Scalone G, Regueiro A, Otsuki S, Farrero M, Sabaté M. Acute myocardial infarction, primary percutaneous coronary intervention and stent thrombosis in heart transplanted patient: Potential role of elevated coagulation factor VIII. COR ET VASA 2014. [DOI: 10.1016/j.crvasa.2014.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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PARK KIE, HUO TIANYAO, MULLER KEITHE, ARANDA JUANM, HILL JAMESA, ANDERSON RDAVID. Drug-Eluting Stents May Not Reduce Target Lesion Revascularization in Cardiac Allograft Vasculopathy. J Interv Cardiol 2014; 27:80-5. [DOI: 10.1111/joic.12088] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- KI E. PARK
- Division of Cardiovascular Medicine, Department of Medicine; University of Florida College of Medicine; Gainesville Florida
| | - TIANYAO HUO
- Division of Cardiovascular Medicine, Department of Medicine; University of Florida College of Medicine; Gainesville Florida
| | - KEITH E. MULLER
- Department of Health Outcomes and Policy; University of Florida College of Medicine; Gainesville Florida
| | - JUAN M. ARANDA
- Division of Cardiovascular Medicine, Department of Medicine; University of Florida College of Medicine; Gainesville Florida
| | - JAMES A. HILL
- Division of Cardiovascular Medicine, Department of Medicine; University of Florida College of Medicine; Gainesville Florida
| | - R. DAVID ANDERSON
- Division of Cardiovascular Medicine, Department of Medicine; University of Florida College of Medicine; Gainesville Florida
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Benatti RD, Taylor DO. Evolving concepts and treatment strategies for cardiac allograft vasculopathy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 16:278. [PMID: 24346852 DOI: 10.1007/s11936-013-0278-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT The central event in the development of allograft vasculopathy is the inflammatory response to immune-mediated and nonimmune-mediated endothelial damage. This response is characterized by the release of inflammatory cytokines, upregulation of cell-surface adhesion molecules, and subsequent binding of leukocytes. Growth factors stimulate smooth muscle cell proliferation and circulating progenitor cells are recruited to sites of arterial injury leading to neointima formation. Because of its diffuse nature, intravascular ultrasound is more sensitive than angiography for early diagnosis. Proliferation signal inhibitors (PSIs) have the capacity to slow vasculopathy progression by inhibiting smooth muscle cell proliferation, but its side effects profile makes its use as a first line agent difficult. Retransplantation is still the only definitive therapy but is available only in selected cases. The current hope is that immunomodulation at the time of transplant could induce long-term tolerance and graft accommodation, leading to less vasculopathy.
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Affiliation(s)
- Rodolfo Denadai Benatti
- Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J3-4 desk, Cleveland, OH, 44195, USA
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Azarbal B, Arbit B, Ramaraj R, Kittleson M, Young A, Czer L, Rafiei M, Currier J, Makkar R, Kobashigawa J. Clinical and angiographic outcomes with everolimus eluting stents for the treatment of cardiac allograft vasculopathy. J Interv Cardiol 2013; 27:73-9. [PMID: 24118198 DOI: 10.1111/joic.12071] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES This study aimed to examine clinical efficacy, safety, and intermediate clinical outcomes with everolimus-eluting stents (EESs) in patients with transplant coronary artery disease (TCAD). BACKGROUND TCAD is a major cause of mortality in patients following orthotopic heart transplantation (OHT). Systemic everolimus in OHT patients has been shown to reduce TCAD. The safety and efficacy of an EES, the Xience V, have not been evaluated in this population. METHODS Patients post-OHT with hemodynamically significant CAD who underwent percutaneous coronary intervention (PCI) with EES were included. Participants were maintained on dual antiplatelet therapy for 1-year post-PCI. We examined procedural success, in-hospital and 1-year mortality, stent thrombosis, angiographic restenosis, and myocardial infarction rates. All patients had follow-up angiography 1-year after PCI. Target vessel revascularization (TVR), target lesion revascularization (TLR), in-segment restenosis, target vessel failure (TVF), and lumen late loss were noted. RESULTS PCI was performed in 34 de novo lesions in 21 patients, and 40 EES were placed. Procedural success rate was 100%. Average stent was 16.5 ± 5.1 mm long and 3.0 ± 0.6 mm in diameter. All patients had angiographic follow-up (409 ± 201 days). There was no stent thrombosis, deaths, or myocardial infarctions during follow-up. Two patients had focal in-stent restenosis. TLR rate was 5.9% (2/34), and TVR rate was 11.1% (3/27). Quantitative coronary angiography (QCA) showed stenosis diameter to be 19.98 ± 17.57%. CONCLUSIONS Use of an EES is associated with a low incidence of TVR and TLR in patients with TCAD. Further studies are needed to determine whether PCI with EES changes long-term outcomes.
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Affiliation(s)
- Babak Azarbal
- Cedars-Sinai Medical Center, Heart Institute, Los Angeles, California
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Lee MS, Yang T. Rebuttal: Reply to letter to the editor written by Fernandez-Pereira et al. Catheter Cardiovasc Interv 2013; 82:238-9. [PMID: 22972699 DOI: 10.1002/ccd.24660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 09/08/2012] [Indexed: 11/08/2022]
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Kapur NK, Imbrie GA. Cardiac allograft vasculopathy: vulnerable patients, not vulnerable plaques. Catheter Cardiovasc Interv 2013; 81:436-7. [PMID: 23404864 DOI: 10.1002/ccd.24822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 01/10/2013] [Indexed: 11/06/2022]
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Lee MS, Yang T, Kandzari D, Mahmud E, Liao H, Kirtane A. Long-term clinical outcomes in patients treated with drug-eluting compared to bare-metal stents for the treatment of transplant coronary artery disease. Catheter Cardiovasc Interv 2012; 80:533-8. [PMID: 21953766 DOI: 10.1002/ccd.23379] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 09/08/2011] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We aimed to compare the long-term clinical outcomes of first-vessel percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and bare metal stents (BMS) for the treatment of transplant coronary artery disease (TCAD). BACKGROUND TCAD is the leading cause of late death in orthotopic heart transplantation (OHT) recipients. PCI is associated with worse clinical outcomes compared with non-OHT patients. Our institution previously reported superior angiographic outcomes with DES compared with BMS in OHT patients. However, long-term clinical outcomes comparing PCI with DES versus BMS are lacking. METHODS The data on 105 OHT recipients who underwent first-vessel PCI with DES (n = 58) or BMS (n = 47) at UCLA Medical Center between 1995 and 2009 were retrospectively analyzed. RESULTS Five-year clinical outcomes were not significantly different with DES and BMS in terms of the composite of death, myocardial infarction (MI), or target vessel revascularization (TVR) [(40.8 ± 7.2)% vs. (59.6 ± 7.2)%, log-rank P = 0.33], death [(31.8 ± 7.8)% vs. (40.4 ± 7.2)%, log-rank P = 0.46], MI [(12.2 ± 6.2)% vs. (11.3 ± 5.4)%, log rank P = 0.98], TVR [(25.5 ± 6.9)% vs. (26.5 ± 7.3)%, log rank P = 0.76], and time to repeat OHT [(2.27 ± 1.79) vs. (3.22 ± 3.34), P = 0.98]. CONCLUSIONS At long-term follow-up, PCI with DES and BMS provided similar clinical outcomes in OHT. Long-term mortality remains high in OHT recipients after PCI with either DES or BMS. Randomized clinical trials are required to determine the optimal treatment strategy for OHT recipients with TCAD.
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Affiliation(s)
- Michael S Lee
- University of California Los Angeles Medical Center, Los Angeles, California, USA.
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Tremmel JA, Ng MK, Ikeno F, Hunt SA, Lee DP, Yeung AC, Fearon WF. Comparison of drug-eluting versus bare metal stents in cardiac allograft vasculopathy. Am J Cardiol 2011; 108:665-8. [PMID: 21684511 DOI: 10.1016/j.amjcard.2011.04.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 04/07/2011] [Accepted: 04/12/2011] [Indexed: 10/18/2022]
Abstract
Although not a definitive treatment, percutaneous coronary intervention offers a palliative benefit to patients with cardiac allograft vasculopathy. Given the superior outcomes with drug-eluting stents (DESs) over bare metal stents (BMSs) in native coronary artery disease, similar improvements might be expected in transplant patients; however, the results have been mixed. Consecutive cardiac transplantation recipients at a single center receiving a stent for de novo cardiac allograft vasculopathy from 1997 to 2009 were retrospectively analyzed according to receipt of a DES versus a BMS. The angiographic and clinical outcomes were subsequently evaluated at 1 year. The baseline clinical and procedural characteristics were similar among those receiving DESs (n = 18) and BMSs (n = 16). Quantitative coronary angiography revealed no difference in the reference diameter, lesion length, or pre-/postprocedural minimal luminal diameter. At the 12-month angiographic follow-up visit, the mean lumen loss was significantly lower in the DES group than in the BMS group (0.19 ± 0.73 mm vs 0.76 ± 0.97 mm, p = 0.02). The DES group also had a lower rate of in-stent restenosis (12.5% vs 33%, p = 0.18), as well as a significantly lower rate of target lesion revascularization (0% vs 19%, p = 0.03). At 1 year, DESs were associated with a lower composite rate of cardiac death and nonfatal myocardial infarction (12% vs 38%, p = 0.04). In conclusion, DESs are safe and effective in the suppression of neointimal hyperplasia after percutaneous coronary intervention for cardiac allograft vasculopathy, resulting in significantly lower rates of late lumen loss and target lesion revascularization, as well as a reduced combined rate of cardiac death and nonfatal myocardial infarction.
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Dasari TW, Hennebry TA, Hanna EB, Saucedo JF. Drug eluting versus bare metal stents in cardiac allograft vasculopathy: a systematic review of literature. Catheter Cardiovasc Interv 2011; 77:962-9. [PMID: 21413135 DOI: 10.1002/ccd.22975] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2010] [Accepted: 01/06/2011] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is a distinct pathological condition characterized by diffuse and progressive arteriopathy and it is an important determinant of long-term graft survival. Definitive CAV treatment is retransplantation but palliation with stenting might temporarily alleviate it. The benefit of drug eluting stents (DES) over bare metal stents (BMS) in the treatment of such lesions is debatable. We therefore sought to do a literature search to review the available evidence comparing DES to BMS. METHODS We conducted Pub Med, EMBASE, Cochrane database review, Web of Science search of studies comparing DES with BMS in CAV. Available studies were retrospective in nature with either direct comparison groups (n = 5) or historical controls (n = 1). The main outcomes analyzed were in stent restenosis (ISR) during follow-up and clinical outcomes. RESULTS A total of 312 patients from six studies were included in the review (1995-2007). Most commonly used DES were sirolimus eluting stent. DES appeared to reduce the long-term risk of ISR compared with BMS. Three of the five studies showed a statistically significant reduction in ISR at 12 months while the one study assessing ISR at 6 months showed no significant difference. Clinical endpoints such as death and major adverse cardiac events were not statistically different. CONCLUSION DES appear to reduce the incidence of ISR in CAV as compared with BMS. Prospective randomized clinical trials are needed to determine the clinical benefit of DES beyond a reduction in ISR.
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Affiliation(s)
- Tarun W Dasari
- Department of Internal Medicine, Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
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