Angiographic patterns of restenosis after percutaneous intervention of chronic total occlusive lesions with drug-eluting stents

Self-Apposing Stents in Coronary Chronic Total Occlusions: A Pilot Study

OBJECTIVES

This pilot study assessed the 12-month angiographic and clinical outcomes of self-apposing (SA) stents in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

BACKGROUND

Self-apposing (SA) stents may decrease incomplete strut apposition and stent strut coverage that are common after CTO PCI.

METHODS

We compared 20 patients who underwent CTO PCI using SA drug-eluting stents (DESs) with 20 matched control patients who underwent CTO PCI using balloon-expandable (BE)-DESs. All patients were followed up clinically for 12 months and had coronary angiography with optical coherence tomography at the end of the follow-up period. The primary end points were stent strut malapposition and strut coverage. The secondary end point was composite major adverse cardiovascular events (MACEs) at 12 months.

RESULTS

Both groups had high prevalence of diabetes mellitus, and most of the treated lesions were complex, with 62% having a J-CTO score of ≥3. All CTO PCI techniques were allowed for recanalisation, and 75% of the procedures were guided by intravascular ultrasound. At 12 months, the SA-DES group had fewer malapposed struts (0% [interquartile range (IQR) 0%-0%] vs 4.5% [IQR 0%-20%]; p<0.001) and uncovered struts (0.08% [IQR 0%-1.6%] vs 8.2% [IQR 0%-16%]; p<0.001). However, they showed significantly higher rates of MACEs due to clinically-driven target lesion revascularisation (45% vs 15%; p=0.038).

CONCLUSIONS

In this pilot study, compared with conventional BE-DESs, SA-DESs used in CTO PCI were associated with fewer malapposed and uncovered stent struts but also with significantly higher rates of in-stent restenosis and MACEs, mainly caused by clinically driven target lesion revascularisation.

Impact of Elevated Serum Uric Acid Level on Target Lesion Revascularization After Percutaneous Coronary Intervention for Chronic Total Occlusion

Elevated serum uric acid (SUA) level is reportedly associated with subsequent cardiovascular events including revascularization in patients with coronary artery disease. However, the impact of SUA level on revascularization in patients with chronic total occlusion (CTO), one of the highest risk subsets in coronary artery disease, is unclear. The aim of this study was to evaluate the impact of SUA level on target lesion revascularization (TLR) in contemporary percutaneous coronary intervention (PCI) for CTO. A total of 165 patients who underwent successful PCI with new-generation drug-eluting stent for CTO under intravascular ultrasound guidance were included. Patients were classified into 3 groups according to the tertiles of SUA level at baseline. Coronary angiography was qualitatively and quantitatively assessed, and gray-scale intravascular ultrasound was also analyzed. The primary end point was TLR. The tertiles of SUA level were as follows: low tertile, ≤5.2 mg/dl; intermediate tertile, 5.3 to 6.4 mg/dl; and high tertile, ≥6.5 mg/dl. During a median follow-up of 34 months, TLR was observed in 5 patients (8.8%) in the low tertile, in 5 (9.4%) in the intermediate tertile, and in 14 (25.5%) in the high tertile (p = 0.02). Kaplan-Meier analysis demonstrated a significantly higher incidence of TLR in patients with high tertile than the low and intermediate groups. Multivariable analysis showed SUA ≥6.5 mg/dl, diabetes mellitus, and longer CTO length as independent predictors of TLR. In conclusion, in patients who underwent PCI with drug-eluting stent, elevated SUA level was associated with TLR after successful recanalization of CTO.

Evaluation of Preprocedural Laboratory Parameters as Predictors of Drug-Eluting Stent Restenosis in Coronary Chronic Total Occlusion Lesions

This retrospective, single-center study assessed the prognostic value of several emerging inflammatory markers as predictors of in-stent restenosis (ISR) after drug-eluting stent implantation for coronary chronic total occlusion (CTO) lesions. Consecutive patients (n = 416) who underwent successful percutaneous coronary intervention (PCI) for documented CTO lesions and with follow-up angiography were enrolled. Preprocedural high-sensitivity C-reactive protein (hsCRP), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and red cell distribution width (RDW) were analyzed. At mean follow-up of 14.4 ± 3.3 months, ISR occurred in 72 patients. Compared with the non-ISR group, preprocedural hsCRP level, PLR, NLR, and RDW were significantly higher in the ISR group. The ISR group also had significantly greater proportions of patients with diabetes and smoking history, lower estimated glomerular filtration rate, higher low-density lipoprotein cholesterol (LDL-C) level and neutrophil count, longer stent length, and higher rate of severe dissection. In multivariate analysis, NLR (odds ratio [OR]: 3.110; 95% confidence interval [CI], 2.102-4.063; P < .001) and PLR (OR: 1.029; 95% CI, 1.016-1.143; P < .001) were independent predictors of ISR, along with LDL-C level and stent length. In conclusion, higher preprocedural NLR and PLR levels were independent risk factors for the development of ISR in patients who underwent PCI for CTO lesions.

Treatment of chronic total occlusions in native coronary arteries by drug-coated balloons without stenting - A feasibility and safety study

BACKGROUND

Chronic total occlusions remain one of the biggest challenges for interventional cardiologists and the high risk of restenosis and stent thrombosis is still a major problem. Drug-coated balloons showed favorable results for the treatment of in-stent restenosis and other lesion types. The aim of this study was to evaluate the feasibility and outcome of a drug-coated balloon only approach for chronic total occlusion.

METHODS

We included 34 patients with a native chronic total occlusion treated only by drug-coated balloons. A visual residual stenosis of 30% or less without major dissection was considered a satisfactory percutaneous intervention result according to the German Consensus Group recommendations for drug-coated balloon use. We collected clinical and procedural data. Angiograms were conducted during the procedure and at follow-up. Quantitative coronary analysis was performed and mean and minimal lumen diameter and late luminal changes were assessed.

RESULTS

The recanalization was considered satisfactory in 79.4% (n=27). Restenosis occurred in 11.8% (n=4) and reocclusion in 5.9% (n=2). Out of the 27 patients with a satisfactory initial result, 3.7% (n=1) had reocclusion and 3.7% (n=1) had restenosis. In the subgroup without satisfactory result (n=7), restenosis occurred in 3 patients (42.9%) and reocclusion in 1 patient (14.3%). A luminal increase was found in 67.6% (n=23) and mean late luminal gain was 0.11±0.49mm. Angina class improved significantly (p<0.001). There was no death or myocardial infarction.

CONCLUSIONS

Drug-coated balloon angioplasty without stenting is a feasible and well-tolerated treatment method for chronic total occlusions if the predilatation result is good.

Impact of Neutrophil to Lymphocyte Ratio (NLR) Index and Its Periprocedural Change (NLRΔ) for Percutaneous Coronary Intervention in Patients With Chronic Total Occlusion

We assessed the association between neutrophil to lymphocyte ratio (NLR) and chronic coronary total occlusion (CTO), as well as clinical prognosis of percutaneous coronary intervention (PCI). Patients referred for elective coronary angiography for stable angina pectoris were enrolled, including a CTO (n = 160) and a non-CTO group (n = 160). Neutrophil to lymphocyte ratio on admission and post-PCI was measured, and NLR_Δ was defined as the change between the 2 values. Subgroup analysis was performed based on the value of NLR_Δ (≥0.5 vs <0.5). Clinical characteristics, angiographic data, and follow-up data were recorded. Compared with the non-CTO group, the total white blood cell count, neutrophil counts, and NLR were significantly higher in the CTO group. In the NLR_Δ ≥ 0.5 subgroup, the incidence of severe dissection, slow coronary flow, in-stent restenosis (ISR), and major adverse cardiac events (MACEs) was obviously higher. In multivariate analysis, NLR_Δ was independently and positively associated with higher risks of ISR and MACE. The NLR could be a potential predictor of CTO, and NLR_Δ is independently associated with the adverse clinical outcomes in patients who underwent PCI.

Intravascular Ultrasound and Angiographic Predictors of In-Stent Restenosis of Chronic Total Occlusion Lesions

Despite the benefits of successful percutaneous coronary interventions (PCIs) for chronic total occlusion (CTO) lesions, PCIs of CTO lesions still carry a high rate of adverse events, including in-stent restenosis (ISR). Because previous reports have not specifically investigated the intravascular ultrasound (IVUS) predictors of ISR in CTO lesions, we focused on these predictors. We included 126 patients who underwent successful PCIs, using drug-eluting stents, and post-PCI IVUS of CTO lesions. Patient and lesion characteristics were analyzed to elucidate the ISR predictors. In each lesion, an average of 1.7 ± 0.7 (mean length, 46.4 ± 20.3 mm) stents were used. At 9 months follow-up, 14 (11%) patients demonstrated ISR, and 8 (6.3%) underwent target lesion revascularization. Multivariate logistic regression analysis showed that the independent predictors of ISR were the post-PCI minimal luminal diameter (MLD) and the stent expansion ratio (SER; minimal stent cross-sectional area (CSA) over the nominal CSA of the implanted stent), measured using quantitative coronary angiography (QCA) and IVUS, respectively. A receiver operating characteristic analysis indicated that the best post-PCI MLD and SER cut-off values for predicting ISR were 2.4 mm (area under the curve [AUC], 0.762; 95% confidence interval (CI), 0.639–0.885) and 70% (AUC, 0.714; 95% CI, 0.577–0.852), respectively. Lesions with post-PCI MLD and SER values less than these threshold values were at a higher risk of ISR, with an odds ratio of 23.3 (95% CI, 2.74–198.08), compared with lesions having larger MLD and SER values. Thus, the potential predictors of ISR, after PCI of CTO lesions, are the post-PCI MLD and SER values. The ISR rate was highest in lesions with a post-PCI MLD ≤2.4 mm and an SER ≤70%.

Comparison between diabetic and non-diabetic patients after successful percutaneous coronary intervention for chronic total occlusions in the drug-eluting stent era

OBJECTIVE

Diabetes mellitus and chronic total occlusions are associated with unfavorable outcome after percutaneous coronary intervention. We sought to assess the clinical and angiographic outcomes of diabetic and non-diabetic patients who underwent successful percutaneous revascularization of chronic total occlusions with drug-eluting stents.

METHODS

Baseline clinical and angiographic characteristics, procedural details, nine-month angiographic follow-up and clinical events at 12 months were compared between 75 diabetic and 132 non-diabetic patients included in a clinical trial that randomized successful recanalization of chronic total occlusions to receive sirolimus- or everolimus-eluting stents.

RESULTS

In both diabetic and non-diabetic groups there was a favorable non-significantly different angiographic result at nine months, with low in-stent late loss (0.14±0.60 mm vs. 0.25±0.68 mm, p=0.305) and rates of binary restenosis (4.0% vs. 10.6%, p=0.180) and reocclusion (0.0% vs. 2.3%, p=0.334). During follow-up similar survival from death (97.3±1.9% vs. 99.2±0.8%, log-rank p=0.273), acute myocardial infarction (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192), target vessel revascularization (88.7±3.8% vs. 88.2±2.9%, log-rank p=0.899) and stent thrombosis (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192) was observed. Furthermore, the presence of more diffuse peripheral and coronary artery disease and higher frequency of calcified lesions in diabetic patients did not lead to significant differences in the approach (20.0% vs. 25.0% radial approach, p=0.413), strategy (6.7% vs. 3.8% retrograde strategy, p=0.353), total stent length (48.1±24.6 mm vs. 49.2±23.9 mm, p=0758) or contrast volume (261.3±116.4 ml vs. 297.4±135.9 ml, p=0.109) required for revascularization.

CONCLUSIONS

In the drug-eluting stent era, diabetic and non-diabetic patients have comparable favorable clinical and angiographic outcomes after successful percutaneous revascularization of chronic total occlusions.

Coronary stenting approaches in the treatment of chronic total occlusion: contemporary registry-based experience

AIMS

This 'real-world' investigation attempted to determine the long-term prognoses of patients who have undergone successful revascularization of chronic total occlusion (CTO) lesions.

METHODS

All consecutive unselected patients from January 2006 to June 2011, undergoing stenting for CTO (n = 272), were retrospectively identified through an institutional registry. Procedural failure was defined as final diameter stenosis greater than 30% or postdilatation thrombolysis in myocardial infarction flow less than 3. Outcomes were assessed based on stenting type [bare metal stent (BMS), drug-eluting stent (DES), or mixed] in the successful procedural cohort. Multiple logistic regression analyses were used to account for known baseline cardiovascular risk imbalances. The primary endpoint was 2-year target vessel revascularization.

RESULTS

Overall procedural failure occurred in 55 (20.2%) patients presenting with CTO lesions. Failed revascularization was independently associated with multivessel disease, lesion lengths greater than 15 mm, tortuous segments, and presence of calcifications. Major complications included coronary dissection (10%) and perforation (2%). Of the successful procedures, 141 (64%) underwent pure DES, 46 (21%) pure BMS, and 34 (15%) mixed stenting. At 2-year follow-up, fewer patients in the DES group required repeat revascularization compared to the mixed stenting group (6 vs. 26%; P = 0.002). Mixed stenting was an independent predictor of long-term target vessel revascularization (adjusted odds ratio 2.1, 95% confidence interval 1.1-4.1, P = 0.02) compared to DES.

CONCLUSIONS

Failed revascularization of CTO lesions occurs in a fifth of patients and appears to be associated with complex vessel anatomy. Our data suggest that DES use in this setting are associated with improved 2-year clinical endpoints compared with pure BMS or mixed stenting approaches.