Stent restenosis and the use of drug-eluting stents in patients with diabetes mellitus

Clinical impact of drug-eluting stents in an unselected population of diabetic patients

BACKGROUND

Drug-eluting stents (DES) have been shown in randomized trials to reduce clinical events in diabetic patients. Our aim was to determine whether these clinical results are applicable in an unselected population of patients with non-insulin-dependent diabetes mellitus (NIDDM) and insulin-dependent diabetes mellitus (IDDM).

METHODS

We studied 440 consecutive patients (271 NIDDM and 169 IDDM) who underwent percutaneous coronary intervention, divided into 2 cohorts: Group A (1998-2000): 220 patients with bare metal stents, and Group B (2002-2004): 220 patients with drug-eluting stents. We analyzed major coronary adverse events (death, nonfatal acute myocardial infarction, and target lesion revascularization) over a mean follow-up of 18+/-15 months.

RESULTS

Group B had more patients who were insulin-dependent (44.5 versus 32.3% p<0.001) or had hypertension (64.5 versus 54.1%; p=0.02), a lower left ventricular ejection fraction (53.89 versus 56.8%; p=0.04), more complex lesions (B2/C) (82.7 versus 62.3%; p<0.001), more treated lesions (1.40 versus 1.26; p<0.001), more stents implanted (1.69 versus 1.15; p<0.0001), and more patients treated with abciximab (76.8 versus 42.7%; p<0.0001). During the follow-up, Group B had fewer major adverse coronary events (11.7 versus 27.9%; p<0.001) and a reduction in target lesion revascularization (3.9 versus 17.2%; p<0.001), with no differences in death or myocardial infarction. Both groups experienced a significant reduction in events (NIDDM: 8.1 versus 26.7%; p<0.001 and IDDM: 16 versus 31.9%; p=0.016). Multivariate regression analysis showed the use of drug-eluting stents to be in direct relation with event-free survival (odds ratio [OR]: 3.37; 95% confidence interval [CI], 1.44-7.90; p=0.005).

CONCLUSION

Despite the worse angiographic characteristics, the use of DES reduced clinical events, particularly target lesion revascularization.

Percutaneous coronary revascularization in diabetics: from balloon angioplasty to drug-eluting stents

Diabetic patients may have aggressive coronary disease with an excessive rate of restenosis and accelerated atherosclerotic progression. This article reviews the different modalities of percutaneous treatment and their results in the diabetic population, from the early days of balloon angioplasty to the current implementation of drug-eluting stents. As restenosis may be virtually eradicated in the near future, plaque progression remains the cornerstone for interventional cardiologists and the medical community. In this regard, attempts to modify life habits, and a more accurate control of the components of the metabolic syndrome should be the main therapeutic objective.

Application, feasibility, and efficacy of a combined intravascular ultrasound and stent delivery system: results from a prospective multicenter trial

BACKGROUND

Intravascular ultrasound (IVUS) is the reference method for in vivo assessment of vessel dimensions and coronary plaque composition, which can influence device selection as well as stent sizing.

OBJECTIVES

The objective of this prospective multicenter-study was to test the application, safety, and feasibility of a new combined IVUS and stent delivery system.

METHODS

A total of 32 patients with planned direct stent implantation under IVUS guidance were included in the study. Procedural as well as angiographical and IVUS characteristics of the stent implantation with the combined IVUS and stent delivery system were assessed and compared to a historical control cohort where IVUS-guided stenting was performed with a separate IVUS catheter.

RESULTS

Direct stent placement was successfully performed in all patients and no malfunctions of the system were noted. A post-interventional IVUS assessment was possible in 27 (87%) of the 31 patients. The IVUS information led to a change in therapeutic strategy in 16 (50%) of the 32 patients. In the study group, both the procedural time and the amount of contrast dye were significantly lower than in the historical IVUS-guided stenting control group. A clinical 12-month follow-up revealed a 89% event-free survival and a target vessel revascularization rate of 7%.

CONCLUSION

The use of a combined IVUS and stent delivery device is safe, easy to handle, and can provide helpful additional information to guide a percutaneous coronary interventions procedure. Beyond angiography, these informations had significant impact on the interventional strategy in these patients, which resulted in a low rate of major adverse cardiac events. The concept of combining IVUS information and a stent delivery system may be increasingly attractive with evolving imaging modalities like virtual histology or a combination with drug-eluting stents.