Acute angiographic and clinical results of long balloon percutaneous transluminal coronary angioplasty and adjuvant stenting for long narrowings

Cutting balloons versus conventional long balloons for PCI of long coronary lesions

BACKGROUND

PCI for long coronary lesions remains a challenge because of high incidence of early complications and late restenosis. Cutting balloon angioplasty may result in reduced procedural complications and late restenosis than angioplasty with conventional long balloons (LBA) due to minimized injury to the culprit arteries.

OBJECTIVE

To compare the immediate and one-year outcomes of CBA and LBA for long coronary lesions.

METHODS

169 consecutive patients were retrospectively identified who underwent CBA or LBA for de novo lesions 20 mm in length and 2.5 mm in diameter. The primary endpoint was immediate procedural outcomes and angiographic restenosis at one year.

RESULTS

CBA was performed in 54 patients (56 lesions) and LBA in 115 patients (151 lesions). Baseline characteristics were similar in both groups with a mean lesion length of 34.89+/-11.19 mm, and vessel diameter of 3.03+/-0.54 mm. CBA resulted in reduced incidence of side branch loss (23.2% versus 41.7%, P=0.022) which was associated with less peri-procedural infarction (OR: 11.39 (95% CI: 1.34-96.53), P=0.026). It also caused less dissection (23.2% versus 38.4%, P=0.048) leading to a trend of less provisional focal stenting (32.1% versus 41.1%, P=0.264). The rate of angiographic restenosis and clinically driven target lesion revascularization at one year (follow-up 91.1%) was similar (25% versus 21.2%, and 20.4% versus 20%, for CBA versus LBA, both P=NS). The mean event-free survival was also similar (10.15+/-0.45 months for CBA versus 9.50+/-0.39 months for LBA, P=NS).

CONCLUSION

CBA demonstrated better immediate results and equivalent late results than LBA, and therefore, it may be considered a reasonable firstline approach for PCI of long coronary lesions.

Long balloon angioplasty with focal stenting for the treatment of diffuse coronary artery disease

The objective of this study was to evaluate the efficacy of treating long coronary lesions (> 30 mm) with either a 40 or a 60 mm long Scimed Cobra balloon followed by focal (contingency) stenting of areas with suboptimal results. Diffuse lesion length is a morphological characteristic associated with a poorer clinical outcome after balloon angioplasty with or without stenting. Patients were enrolled in a prospective randomized fashion to have initial PTCA with either a 40 or a 60 mm long balloon followed by focal stenting in areas with suboptimal results. The MACE rate at 6-month follow-up was collected from all patients and was the primary endpoint of the study. A total of 41 patients were enrolled into the study. The acute procedural success rate was 97.5% with a 6-month MACE rate of 9.8%. The use of long balloons with contingency stenting is a highly effective strategy for the treatment of diffuse coronary lesions.

A randomized comparison of the value of additional stenting after optimal balloon angioplasty for long coronary lesions: final results of the additional value of NIR stents for treatment of long coronary lesions (ADVANCE) study

OBJECTIVES

We sought to investigate the clinical benefit of additional stent implantation after achieving an optimal result of balloon angioplasty (BA) in long coronary lesions (>20 mm).

BACKGROUND

Long coronary lesions are associated with increased early complications and late restenosis after BA. Stenting improves the early outcome, but stent restenosis is also related to both lesion length and stent length.

METHODS

A total of 437 patients with a single native lesion 20 to 50 mm in length were included and underwent BA, using long balloons matched to lesion length and vessel diameter (balloon/artery ratio 1.1) to achieve a diameter stenosis (DS) <30% by on-line quantitative coronary angiography (QCA). "Bail-out stenting" was performed for flow-limiting dissections or >50% DS. Patients in whom an optimal BA result was achieved were randomized to additional stenting (using NIR stents) or no stenting. The primary end point was freedom from major adverse cardiac events (MACE) at nine months, and core laboratory QCA was performed on serial angiograms.

RESULTS

Bailout stenting was necessary in 149 patients (34%) and was associated with a significantly increased risk of peri-procedural infarction (p < 0.02). Among the 288 randomized patients, the mean lesion length was 27+/-9 mm, and the vessel diameter was 2.78+/-0.52 mm. The procedural success rate was 90% for the 143 patients assigned to BA alone (control group), as compared with 93% in the 145 patients assigned to additional stenting (stent group), which resulted in a superior early minimal lumen diameter (0.54 mm, p < 0.001) and led to reduced angiographic restenosis (27% vs. 42%, p = 0.022). Freedom from MACE at nine months was 77% in both groups.

CONCLUSIONS

A strategy of provisional stenting for long coronary lesions led to bailout stenting in one-third of patients, with a threefold increase in peri-procedural infarction. Additional stenting yielded a lower angiographic restenosis rate, but no reduction in MACE at nine months.

The relative influence of lesion length and other stenosis morphologies on procedural success of coronary intervention

As coronary interventional technology improves, the influence of lesion length (LL) on procedural success and device selection may vary. Thus, the authors prospectively analyzed 957 consecutive coronary interventions (CI) in 1,404 stenoses to ascertain the influence of lesion length on CI outcome. Stenosis morphology was prospectively classified by the AHA/ACC criteria. LL was analyzed both as dichotomous (S: < 10 mm, L: > 10 mm) variables and by the three-tiered AHA/ACC criteria (I: < 10 mm, II: 10-20 mm, III: > 20 mm). There was a significant univariate relationship between CI success and S stenosis (S: 95.8% vs L: 91.8%, p = 0.002 and I: 96.0%, II: 91.7%, III: 89.3%). Numerous interrelationships involving the morphologic characteristics were noted: lesion morphologies associated with S lesions were concentric (p = 0.0001) and had smooth contour (p = 0.0001), ostial location (p = 0.05) and little calcification (p = 0.0007), while irregular contour (p=0.0001), calcification (p=0.0076), eccentric (p=0.0001), thrombus (p = 0.0001), recent (p = 0.0001) or chronic (p = 0.001) total occlusion were associated with L lesions. When these relationships were taken into account by multiple logistic regression analysis, lesion length was not predictive of procedural outcome (p = 0.099). One morphologic type was associated with increased CI success: irregular contour (p = 0.022); recent (p < 0.0001) or chronic (< 0.0001) occlusions were associated with decreased CI success. Another factor considered was device selection: S lesions were associated with greater balloon angioplasty usage (p = 0.002), whereas more coronary stents (p = 0.024) and rotoblator (p = 0.018) devices were used in L lesions. More balloon angioplasty was performed in concentric (p < 0.0001) lesions; interventional devices were employed more often in eccentric (p < 0.0001) and irregular lesions (p < 0.0001). More complications were noted in lesions with thrombus (p = 0.0002), but lesion length was not predictive (p = NS). Lesion length is not a significant predictor of procedural success when adjusted for other lesion morphologies in the modern interventional era. The availability of new devices has improved the results in longer lesions since the AHA/ACC criteria were originally proposed.

Stenting of long coronary artery lesions: initial angiographic results and 6-month clinical outcome of the micro stent II-XL

To evaluate the results of long Micro Stent II (MS-XL) implantations, 119 MS-XLs were implanted in 102 patients (age, 62.83 years). Nineteen stents (16%) were implanted in saphenous vein grafts; 100 stents (84%) were implanted in native coronary arteries. Twenty-five patients (25%) were treated because of acute myocardial infarction (AMI); 30 patients (29%) because of unstable angina or angina class IV, and 47 patients (46%) because of stable angina. Eighty-six de novo lesions (84%) and 16 restenotic lesions (16%) were treated. Indications for stent implantation include elective, 61 patients (60%); suboptimal balloon angioplasty result, 22 patients (21%); and bailout after balloon angioplasty, 19 patients (19%). Because of residual thrombus after stenting, 27 patients (26%) received abciximab. All patients received ticlopidin for 28 days and acetylsalicylic acid. One hundred and seventeen MS-XLs (98%) were implanted successfully. Additional (shorter) MS-II were implanted in 40 patients (39%). The stented segment length was 45 +/- 20 mm. The minimum lumen diameter increased from 0.5 +/- 0.5 mm before to 2.7 +/- 0.5 mm after stent implantation. The acute gain was 2.2 +/- 0.4 mm. Early clinical events (<4 weeks) include death, 3 (3%); subacute stent thrombosis, 1 (1%); non-Q-wave infarction, 2 (2%); CABG, 1 (1%); vascular complications, 2 (2%). Late clinical events (<6 months) include acute myocardial infarction, 5 (5%); reintervention, 6 (6%); CABG, 1 (1%). The procedural success rate was 88%, and the event free survival at 6 months was 76%. Stenting of long lesions with the MS-XL was successful and associated with an acceptable complication rate. Cathet. Cardiovasc. Intervent. 48:105-112, 1999.

Comparison of immediate and follow-up results of the short and long NIR stent with the Palmaz-Schatz stent

The intrinsic characteristics of a stent including stent length may affect both procedural success and long-term outcome. The present study evaluated the immediate and follow-up results after implantation of the short and long NIR stent and compared these results with the Palmaz-Schatz stent. Between July 1995 and December 1996, stenting with a 16-mm NIR stent (NIR-16), a 32-mm NIR stent (NIR-32), or a Palmaz-Schatz stent (PS) was performed in 68, 57, and 155 lesions, respectively. There were no significant differences in the incidences of delivery failure (PS, 2.6%: NIR-16, 4.4%; NIR-32, 5.3%; p = NS) and procedural success (PS, 92%; NIR-16, 93%; NIR-32, 93%; p = NS) among the 3 groups. The reference vessel diameter was smaller in lesions with a 32-mm NIR stent than in those with a Palmaz-Schatz stent (PS, 3.14+/-0.58, NIR-16, 3.00+/-0.50; NIR-32, 2.90+/-0.47 mm; p <0.05). The lesion length was longer in lesions with a 32-mm NIR stent than in those with a Palmaz-Schatz or a 16-mm NIR stent (PS, 8.9+/-5.0; NIR-16, 11.0+/-4.1; NIR-32, 26.1+/-9.7 mm; p <0.01). After the procedure, the lesions with a 32-mm NIR stent had a smaller minimal lumen diameter than those with a Palmaz-Schatz stent (PS, 3.17+/-0.61; NIR-16, 2.99+/-0.51; NIR-32, 2.89+/-0.49 mm; p <0.01). At follow-up, a smaller minimal lumen diameter was observed in lesions with a 32-mm NIR stent than in those with a Palmaz-Schatz or a 16-mm NIR stent (PS, 2.32+/-0.98; NIR-16, 2.25+/-0.80; NIR-32, 1.68+/-0.79 mm; p <0.01). Restenosis rates were 16.5% in lesions with a Palmaz-Schatz stent, 13.3% in those with a 16-mm NIR stent, and 47.4% in those with a 32-mm NIR stent (p <0.01). Although stent delivery and procedural success of a long NIR stent were acceptable, the restenosis rate of a long NIR stent was high compared with a short NIR stent or a Palmaz-Schatz stent.

Long-term follow-up study of coronary reconstruction with multiple stents

BACKGROUND

Conventional balloon angioplasty of very long de novo coronary lesions or very long coronary dissection caused by angioplasty is associated with low success and high complication rates. Multiple intracoronary stents have been used to treat both conditions, although long-term efficacy has not been defined.

METHODS AND RESULTS

Between June 1993 and December 1995, 47 consecutive patients underwent native coronary angioplasty and stenting with 4 or more stents covering at least 2 consecutive diseased coronary segments. Preangioplasty and poststenting diameter stenoses were 81% +/- 13% and 21% +/- 12%, respectively. Reference vessel diameters were 3.53 +/- 0.55 mm proximal to the stents and 2. 95 +/- 0.62 mm distal to the stents. Average lesion length was 63 +/- 20 mm. The number of stents used was 4.5 +/- 1 per vessel (from 4 to 7). Gianturco Roubin I stents were used in all patients. Coronary Palmaz-Schatz stents were used as supplementary stents in 3 patients. Angiographic success was 100%. In-hospital outcomes include 1 death, 1 coronary bypass surgery, no Q-wave myocardial infarction, and 7 non-Q-wave myocardial infarctions. Long-term follow-up at 430 +/- 199 days was completed in all patients. Thirty-five (76%) patients were asymptomatic, 8 (17%) had class 1 or 2 angina, 1 had a myocardial infarction, 13 (28%) underwent repeat angioplasty, 2 patients had subsequent elective bypass surgery, and 3 died during follow-up.

CONCLUSIONS

Multiple intracoronary stents for very long lesions or dissection can be performed with acceptable immediate and long-term outcomes.

Acute directional coronary atherectomy prior to stenting in complex coronary lesions: ADAPTS Study

The purpose of this study was to determine the results of directional coronary atherectomy (DCA) combined with stenting in a high-risk patient population. The use of stenting or DCA alone for aorto-ostial lesions, total chronic occlusions, long lesions, and lesions containing thrombus is associated with lowered success and a relatively high restenosis rate. Between July 1993 and October 1996, we treated 89 lesions with the combined approach of DCA and stenting in 60 consecutive patients. Thirty-one (51.7%) patients were treated because of unstable angina, 11 (18.3%) for post-myocardial infarction (MI) angina, 3 (5.0%) for acute MI, and 15 (25.0%) patients for stable angina. A total of 43 (71.7%) patients had multivessel disease, 19 (31.7%) had undergone previous coronary artery bypass graft (CABG), and 17 (28.3%) patients had undergone multivessel revascularization. The procedure was successful in all patients; and no postprocedural deaths or emergent CABG occurred. Two patients (3.3%) had non-Q-wave MI after the procedure and 1 patient (1.7%) experienced Q-wave MI due to subacute stent closure 7 days after the procedure. During follow-up ranging from 6 months to 3 years, 2 (3.3%) patients died, 2 (3.3%) required CABG surgery, 1 (1.7%) patient had an MI, and 6 patients (10.0%) required target vessel revascularization. By the quantitative coronary angiography, the initial minimal luminal diameter (MLD) averaged 0.91+/-0.45 mm (74.7+/-11.8% stenosis) increasing to 3.80+/-0.44 mm (-6.7+/-12.1%) after the combined approach procedure. Thirty patients (50.0%) met criteria for late (> or =6 months) angiographic follow-up. Late MLD loss averaged 1.13+/-1.07 mm, for a mean net gain of 1.61+/-1.23 mm. Available angiographic follow-up evaluation showed a restenosis rate of 13.3%. A combined approach, defined as the use of both DCA and stenting, is safe and yields a low restenosis rate in high-risk patients who have lesions known to respond less favorably to stenting or DCA alone.

Procedural and follow up results with a new balloon expandable stent in unselected lesions

OBJECTIVE

To assess the clinical and angiographic results of the first clinical application of a new balloon expandable stent, the NIR stent, characterised by high longitudinal flexibility and low profile before expansion, and by high radial support and minimal recoil and shortening after expansion.

DESIGN

Single centre survey of unselected lesions in consecutive patients.

SETTING

Tertiary referral centre. PATIENTS AND LESIONS: 93 stents of various length (9, 16, and 32 mm) were implanted in 64 lesions in 41 patients. Twenty lesions (31%) were longer than 15 mm, and 17 lesions (27%) were located in vessels with a diameter smaller than 2.5 mm. Extreme tortuosity of the proximal vessel was present in 15 lesions (23%). All patients were treated with aspirin and ticlopidine. All lesions were evaluated before and after treatment by quantitative angiography, and in 47 lesions (75%) the stent expansion was also controlled by intracoronary ultrasound. Clinical follow up was available in all patients and angiographic follow up was performed in 53 lesions (84%), at a mean (SD) interval of 5.4 (1.7) months.

RESULTS

Deployment of the stent failed in two lesions (3%). Minimum lumen diameter increased from 1.01 (0.54) mm to 2.94 (0.49) mm, and diameter stenosis decreased from 66(15)% to 7(11)%. There was one in-hospital non-Q wave myocardial infarction, one sudden death after 40 days, and 17 target lesion revascularisations (27%). Angiographic restenosis (> or = 50% diameter stenosis) was documented in 19 lesions (36% of all lesions with angiographic follow up), with an average residual diameter stenosis of 43(21)% and minimum lumen diameter of 1.63 (0.74) mm. Restenosis was more common in vessels with a reference diameter < 2.5 mm (45%) and for lesions longer than 15 mm (46%).

CONCLUSIONS

The NIR stent could be used successfully in most lesions, achieving optimal angiographic results with very few in-hospital or subacute cardiac events. The angiographic restenosis rate and need for target lesion revascularisation remained high in this unfavourable lesion subset, especially in small vessels and long lesions.

Preliminary experience with stent-supported coronary angioplasty in long narrowings using the long Freedom Force stent: acute and six-month clinical and angiographic results in a series of 27 consecutive patients

This report describes our preliminary experience with coronary stent-supported angioplasty in long narrowings using a long stent with an innovative design. Twenty-seven consecutive patients with target lesions >20 mm in length had a stenting procedure using the Freedom Force long coronary stent (Global Therapeutics, Inc., Broomfield, CO). Target lesion length ranged from 20.7-57.5 mm (mean, 27.66+/-9.41 mm). A total of 35 stents was implanted with a mean stented length of 36.26+/-12.36 mm. The stenting procedure was successful in all patients. Single long stent implantation was performed in 19 patients, while 8 patients had double stent implantation. No major cardiac adverse events occurred during hospital stay. The restenosis rate at the 6-mo angiographic follow-up was 38% (follow-up rate, 96%). During follow-up, no major cardiac events such as death, myocardial infarction, or coronary artery surgery occurred, while 3 patients (11%), all with recurrent angina and angiographic restenosis, underwent repeat coronary angioplasty. Potential advantages of this innovative stent in long narrowings relate to its high flexibility in passing through long tortuous diseased segments, and in treating long lesions using only 1 or 2 stents.

Placement of multiple and different stent types for very long dissections during coronary angioplasty

We have been investigating the safety and efficacy of multiple and different stent types placed in the unfavorable situation of a very long dissection (> 20 mm) after coronary angioplasty. We report our preliminary experience in 20 patients who were treated by the following combinations: Palmaz-Schatz and Micro stent (14 patients). Wallstent and Micro stent (4 patients); Wiktor and Micro stent (1 patient); and Palmaz-Schatz, Micro and Wallstent (1 patient). Normal distal flow was restored in all except one (no reflow phenomenon) patient and complete covering of the dissection was obtained in all but two patients. Event-free survival at 30 days was 90% (18 of 20 patients). During follow-up (mean period: 8 +/- 3 months), two patients died. Of the 18 other patients, 16 remained asymptomatic and free of complications. Symptomatic restenosis was treated by standard angioplasty in the two remaining patients. In conclusion, placement of different stent types seems a feasible, safe, and efficient treatment for very long dissections caused by standard angioplasty.

Coronary artery stenting: indications and cost implications

The practice of coronary stenting is evolving rapidly, with new stent designs, deployment techniques, and adjunctive therapy. In many respects, clinical practice is changing in advance of the availability of supporting data. The consistent excellent angiographic result with stent deployment exceeds that achieved by any other previous interventional device, and the extent to which this accounts for the exponential increase in stent utilization cannot be accurately determined but is undoubtedly considerable. Controlled randomized trials have confirmed that stent deployment is superior to balloon angioplasty in certain lesion subsets or clinical scenarios. These include focal de novo native vessel lesions, lesions with late recoil after balloon angioplasty, acute closure after balloon angioplasty, and proximal left anterior descending coronary artery lesions. In addition, observational data is persuasive in focal coronary saphenous vein graft lesions and aorto-ostial lesions. On the other hand, the evidence supporting the use of stents strictly to improve on a suboptimal result, possibly the most frequent indication, is indirect and circumstantial. Stents are expensive, but it was anticipated that with the reduction in restenosis not only would they be cost-effective but also ultimately would reduce costs. This hope has not as yet been realized. However, there is little question that the introduction of intracoronary stents has been the most significant and exciting development since the introduction of percutaneous revascularization almost 20 years ago. It has revitalized the field.

In vivo validation of intravascular ultrasound length measurements using a motorized transducer pullback system

Using sonoreflective endovascular targets of known length (stainless steel tubular slotted stents), we have validated in vivo the accuracy and reproducibility of intravascular ultrasound length measurements using a system incorporating motorized transducer pullback through a stationary imaging sheath. The correlation was r = 0.936, with a measurement error of only +/- 5.2%, minimal intraobserver variability, and variability of sequential measurements of only +/- 4.8%.

Treatment of diffuse coronary artery and vein graft disease with a 60-mm-long balloon: early clinical experience

OBJECTIVE

To report our preliminary clinical experience with a new 60-mm-long angioplasty balloon.

DESIGN

We reviewed the results in patients who underwent this type of angioplasty between May and October 1993 at our institution.

MATERIAL AND METHODS

The study group consisted of 14 high-risk patients (57% with rest-related angina) and 19 treated coronary segments--52% in native coronary arteries and 48% in saphenous vein grafts (mean age, 9 years). Often, long balloon angioplasty was used in conjunction with laser or transluminal extraction atherectomy.

RESULTS

Angiographic success (40% or more visual reduction in diameter stenosis) was achieved in all patients. Intimal dissection occurred in 4 of the 19 treated segments (21%), but each was less than 50% obstructive. No patient required intracoronary stenting. Clinical success was achieved in 13 patients (93%). The one death that occurred was from vein graft distal embolization. At a mean follow-up of 9 months, three patients had required reinterventional procedures, and one patient had undergone a coronary artery bypass operation. No myocardial infarction or death occurred during this period.

CONCLUSION

Preliminary clinical experience with a 60-mm-long angioplasty balloon to treat complicated coronary lesions in high-risk patients suggests that, when used alone or in combination with other devices, this new balloon results in high initial success and low complication rates. A larger clinical experience is necessary for accurate assessment of the role of this new balloon catheter.

In-hospital outcome of percutaneous transluminal coronary angioplasty for long lesions and diffuse coronary artery disease

We performed coronary angioplasty on 151 long or diffuse lesions (120 long and 31 diffuse) in 141 patients (86% male, mean age 50 +/- 9 years). Long lesions were defined as lesions 11-20 mm in length and diffuse lesions as lesions longer than 20 mm, or three or more lesions in the same vessel. One or more adverse morphologic features were present in 131 (93%) lesions. Long balloons were used in 44%, significantly more often for diffuse disease (long lesions 39% and diffuse disease 64%; P = 0.004). Newer devices including the rotational atherectomy device (9 lesions), stents and perfusion balloons were employed in 18 (12%) lesions, more often for diffuse lesions (long lesions 8% vs. diffuse lesions 26%; P = 0.017). Lesion severity was comparable in the two groups (long lesions: 88 +/- 7%; diffuse lesions: 88 +/- 8%), but diffuse lesions were associated with significantly higher residual stenosis (long lesions: 6 +/- 8%; diffuse lesions: 12 +/- 13%, P = 0.01). Major complications occurred in five (3.5%) patients, including one death (0.7% mortality). The angiographic and clinical success rates for all patients were 99% and 96%, respectively, and were comparable for long and diffuse lesions. Judicious case selection and the use of long balloons and newer interventional devices permit coronary angioplasty for long lesions and diffuse disease with excellent success and a low risk of complications. Diffuse lesions are associated with more frequent use of long balloons and newer devices, especially rotational atherectomy and slightly higher residual stenosis as compared to long lesions.