Clinical and angiographic follow-up in patients with Cypher or Taxus stents in populations with high percentage of trial-excluded lesions

The IMPact on Revascularization Outcomes of intraVascular ultrasound-guided treatment of complex lesions and Economic impact (IMPROVE) trial: Study design and rationale

Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) has been shown in clinical trials, registries, and meta-analyses to reduce recurrent major adverse cardiovascular events after PCI. However, IVUS utilization remains low. An increasing number of high-risk or complex coronary artery lesions are treated with PCI, and we hypothesize that the impact of IVUS in guiding treatment of these complex lesions will be of increased importance in reducing major adverse cardiovascular events while remaining cost-effective. The "IMPact on Revascularization Outcomes of intraVascular ultrasound-guided treatment of complex lesions and Economic impact" trial (registered on clinicaltrials.gov: NCT04221815) is a multicenter, international, clinical trial randomizing subjects to IVUS-guided versus angiography-guided PCI in a 1:1 ratio. Patients undergoing PCI involving a complex lesion are eligible for enrollment. Complex lesion is defined as involving at least 1 of the following characteristics: chronic total occlusion, in-stent restenosis, severe coronary artery calcification, long lesion (≥28 mm), or bifurcation lesion. The clinical investigation will be conducted at approximately 120 centers in North America and Europe, enrolling approximately 2,500 to 3,100 randomized subjects with an adaptive design. The primary clinical end point is the rate of target vessel failure at 12 months, defined as the composite of cardiac death, target vessel-related myocardial infarction, and ischemia-driven target vessel revascularization. The co-primary imaging end point is the final post-PCI minimum stent area assessed by IVUS. The primary objective of this study is to assess the impact of IVUS guidance on the PCI treatment of complex lesions.

Impact of Intravascular Ultrasound on Outcomes Following PErcutaneous Coronary InterventioN in Complex Lesions (iOPEN Complex)

BACKGROUND

Clinical data support the use of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) as being associated with improved outcomes. Nonetheless, global utilization of IVUS remains low. We hypothesize that, in the revascularization of complex lesions, IVUS use is associated with improved outcomes.

METHODS

All patients with complex lesions treated with PCI at a single center from 2003 to 2016 were stratified by use of IVUS. Complex lesions were defined as follows: American College of Cardiology/American Heart Association type C lesions, in-stent restenosis, long lesions, bifurcations, severe calcification, left main lesions, and chronic total occlusions. The primary end point was the rate of major adverse cardiac events (MACE) at 1-year follow-up, defined as the composite of all-cause mortality, Q-wave myocardial infarction, and target vessel revascularization. Inverse probability weighting was used in the adjusted analysis.

RESULTS

A total of 6,855 patients were included in the final analysis, of whom 67.3% had IVUS and 32.7% had angiography alone. The primary end point occurred in 13.4% of patients treated with IVUS and 18.3% of patients treated with angiography alone (P < .001). Inverse probability weighting-adjusted 1-year MACE rates demonstrated significant reduction with IVUS for each complex lesion type.

CONCLUSIONS

Among patients with complex lesions, the use of IVUS was associated with lower MACE 1 year after PCI than angiography alone was. Because of the increased procedural risk in complex lesions, routine utilization of IVUS-guided PCI should be considered in this subset of patients.

Overview of the 2007 Food and Drug Administration Circulatory System Devices Panel meeting on the Xience V Everolimus-Eluting Coronary Stent

The Xience V Everolimus-Eluting Coronary Stent System (Abbott Vascular, Santa Clara, California) drug-eluting stent (DES) is the most recent stent to undergo an extensive evaluation based on the initial requirements for DES approval. Safety and efficacy data were presented in a public meeting of the Food and Drug Administration (FDA) Circulatory System Devices Panel in November 2007. The sponsor presented data from their pre-clinical program demonstrating polymeric biocompatibility and a pharmacokenitic profile with complete drug elution by 4 months. Both the sponsor and FDA presented clinical efficacy and safety data from the SPIRIT trials. The EES demonstrated consistent late loss across the SPIRIT trials both in-stent and in-segment, including among subgroups of patients and lesions. Within this trial series, the primary endpoints were met in all studies with the establishment of superiority to both bare metal stents (BMS) and paclitaxel-eluting stents (PES) with respect to late loss and non-inferiority to PES with respect to target vessel failure through 9 months. The safety profile was reviewed by both presenters, demonstrating no evidence of an abnormal DES class-effect increase in stent thrombosis up to and between 1 and 2 years for the available data. The sponsor outlined an extensive integrated pre- and post-approval clinical program to further monitor potential safety concerns surrounding this class of stents. The Panel voted in favor of approval with conditions similar to those posed to the other DES; with FDA subsequently approving the stent for US commercial sale on July 2, 2008.

Abciximab offers greater benefits to insulin-dependent diabetic patients undergoing coronary stent implantation

INTRODUCTION AND OBJECTIVES

Abciximab use does not exceed 25% in most of the studies on diabetic patients undergoing stent implantation. The aim of this study was to evaluate whether abciximab could be more beneficial in different subgroups such as insulin-dependent (ID) patients and whether its use could provide additional benefits to those afforded by drug-eluting stents in these patients.

PATIENTS AND METHODS

A total of 373 consecutive diabetics [223 non-insulin-dependent (NID) and 150 ID patients] who had undergone stent implantation were examined with a follow-up of 25.6+/-16.2 months. Abciximab was used in 21.7%.

RESULTS

The abciximab-treated group had a lower rate of revascularization (26.8% vs. 15.8%. P=.02). The results by subgroups were as follows: NID nonabciximab, 23.5%; NID abciximab, 19% (P=NS); ID nonabciximab, 32.7%; ID abciximab, 12.2% (P=.05). In multivariate analysis, the restenosis predictors were insulin dependency (OR, 2.7), abciximab use (OR, 0.18), stent diameter (OR, 0.18).

CONCLUSIONS

Abciximab use in diabetics with stent implantation has a favorable effect by reducing the need for new revascularization. This benefit is more evident in ID patients; the negative prognosis effect of being insulin-dependent is eliminated, and the percentage of events in this population over a long follow-up period is equal to those in NID patients.