Drug-Eluting Stents Versus Bare-Metal Stents in Saphenous Vein Graft Interventions

Percutaneous coronary intervention in saphenous vein grafts after coronary artery bypass grafting: a systematic review and meta-analysis

To investigate the results of percutaneous coronary intervention (PCI) in saphenous vein grafts after coronary artery bypass grafting (CABG). Design. MEDLINE, Embase, and the Cochrane library were searched for relevant articles published between 1 January 2000 and 29 February 2020. The PICO (population, intervention, comparison, outcome) model was applied in constructing the clinical question. Two independent researchers performed the literature search. Thirty-six articles were identified and subjected to a quality assessment. The primary outcomes of the meta-analysis were long-term in-stent restenosis and long-term major adverse cardiac events (MACE). Results. In-stent restenosis was 9.4% (95% CI: 4.2-14.7%) and MACE was 35.3% (95% CI: 27-43.7%) at mean time 2.7 ± 1.0 years. The secondary outcomes were the unsuccessful PCI rate (7.7%; 95% CI: 2.9-12.5%), 30-day MACE (4.3%; 95% CI: 2.5-6.1%), and 1-year MACE (15.5%; 95% CI: 11.7-19.3%). The use of drug-eluting stents resulted in better outcomes at least in term of in-stent restenosis, while the benefit of using embolic protection devices was questionable. Conclusions. PCI of a stenosed or occluded saphenous vein graft is a challenge for interventional cardiologists, and is still associated with relatively high rates of restenosis, MACE, and procedural failure. All efforts to enhance the results are warranted, including improved quality of the venous grafts used during CABG.

Drug-Eluting Stents Versus Bare-Metal Stents in Saphenous Vein Graft Intervention

Background Percutaneous coronary intervention with drug-eluting stents (DES) has been increasingly used for revascularization of saphenous vein graft stenosis without strong clinical evidence favoring their use. Randomized controlled trials comparing DES versus bare-metal stents (BMS) in saphenous vein graft-percutaneous coronary intervention have been inconclusive. Methods and Results We performed a comprehensive literature search through May 15, 2018, for all eligible studies comparing DES versus BMS in patients with saphenous vein graft stenosis in PubMed, EMBASE, SCOPUS, Google Scholar, and ClinicalTrials.gov. Clinical outcomes included all-cause mortality, cardiovascular mortality, major adverse cardiovascular events, myocardial infarction, stent thrombosis, and target vessel revascularization. Six randomized controlled trials were eligible and included 1582 patients, of whom 797 received DES and 785 received BMS. The follow-up period ranged from 18 months to 60 months. There was no statistically significant difference between DES and BMS for all-cause mortality (risk ratio [RR],1.11; 95% CI, 0.0.77-1.62; P=0.57), cardiovascular mortality (RR, 1.00; 95% CI, 0.64-1.57; P=0.99), major adverse cardiovascular events (RR, 0.83; 95% CI, 0.63-1.10; P=20), target vessel revascularization (RR, 0.73; 95% CI, 0.48-1.11; P=0.14), myocardial infarction (RR, 0.74; 95% CI, 0.48-1.16; P=0.19), or stent thrombosis (RR, 1.06; 95% CI, 0.42-2.65; P=0.90). Conclusions In patients undergoing percutaneous coronary intervention for saphenous vein graft lesions, our results showed that there was no significant difference between DES and BMS for mortality, major adverse cardiovascular events, target vessel revascularization, myocardial infarction, or stent thrombosis.

Drug-eluting Stents Versus Bare-metal Stents for Saphenous Vein Graft Interventions: A Systematic Review and Meta-analysis of Studies With Longer Follow-up

Randomized controlled trials comparing drug eluting stents (DES) with bare-metal stents (BMS) for saphenous vein graft (SVG) interventions have shown conflicting results. We conducted this meta-analysis to evaluate the cumulative evidence for long-term efficacy and safety of DES vs BMS in SVG lesions. A systematic search was conducted of Randomized controlled trials comparing DES vs BMS in patients undergoing percutaneous interventions for SVG lesions. End-points of interest were all-cause death, cardiac death, myocardial infarction, target lesion revascularization and target vessel revascularization at longest available follow-up. Random effects meta-analysis was conducted to estimate risk ratio with 95% confidence intervals for individual end-points. Seven studies with 1639 patients were included in the final analysis. Mean follow-up period was 32 months. Compared with BMS, DES was associated with similar risks of all-cause death (risk ratio 1.06; 95% confidence intervals 0.76-1.48) and cardiac death (0.95; 0.59-1.54). Similarly, there were no differences between DES and BMS in terms of myocardial infarction (0.81; 0.50-1.29), target vessel revascularization (0.73; 0.48-1.110 or target lesion revascularization (1.05; 0.76-1.43). Current analysis suggests no strong evidence for routine DES use in patients undergoing SVG intervention. Future studies should evaluate if SVG lesion characteristics could influence these results.

A comprehensive meta-analysis of randomized controlled trials comparing drug-eluting stents with bare-metal stents in saphenous vein graft interventions

BACKGROUND

Several large randomized controlled trials (RCTs) have proven the superiority of drug-eluting stents (DESs) over bare-metal stents (BMSs) for native coronary stenosis. However, RCTs comparing DESs with BMSs for SVG lesions have predominantly been small in size and have yielded conflicting results. Therefore, we conducted an updated comprehensive meta-analysis of RCTs comparing DESs versus BMSs for SVG interventions using the largest sample size to date.

METHODS

Scientific databases and websites were searched to find RCTs. Data from six RCTs involving 1,582 patients were included. Pooled risk ratios (RRs) were calculated using random-effects models. The primary outcome of this meta-analysis was target vessel revascularization (TVR). The secondary outcomes were major adverse cardiac events (MACEs), myocardial infarction (MI), stent thrombosis, all-cause mortality, and cardiac mortality.

RESULTS

Data from six RCTs involving 1,582 patients were included. Saphenous vein graft interventions with DESs reduced TVR (RR, 0.52; 95% CI, 0.30-0.88; P = 0.017) and MACE rate (RR, 0.60; 95% CI, 0.42-0.87; P = 0.007) compared to BMSs. No difference between the stents were found in rates of MI (RR, 0.69; 95% CI, 0.43-1.10; P = 0.123), stent thrombosis (RR, 0.61; 95% CI, 0.27-1.41; P = 0.255), all-cause mortality (RR, 1.13; 95% CI, 0.74-1.71; P = 0.554), or cardiac mortality.

CONCLUSION

For SVG intervention, the MACE rate was lower for DESs compared to BMSs, driven primarily by decreased non-MI-related TVR. Rates of MI, all-cause mortality, cardiac mortality, and stent thrombosis were not different between the stents.

Comparison between the STENTYS self-apposing bare metal and paclitaxel-eluting coronary stents for the treatment of saphenous vein grafts (ADEPT trial)

AIMS

To describe the safety and performance of STENTYS self-expandable bare metal stents (BMS) versus paclitaxel-eluting stents (PES) in saphenous vein grafts (SVGs).

METHODS AND RESULTS

A randomised controlled trial was performed in four hospitals in three European countries between December 2011 and December 2013. Patients with de novo lesions (>50% stenosis) in an SVG with a diameter between 2.5-6 mm were included. Primary endpoint was late lumen loss at 6 months. Secondary endpoints included procedural success and the occurrence of major adverse cardiac events (MACE) at 12 months. A total of 57 patients were randomised to STENTYS self-apposing BMS (n = 27) or PES (n = 30). Procedural success was obtained in 89.5%. No significant differences in late lumen loss were found between BMS and PES at 6 months (0.53 mm vs 0.47; p = 0.86). MACE rates at 12 months were comparable in both groups (BMS 22.2% vs. PES 26.7%; p = 0.70).

CONCLUSIONS

Treatment of SVGs with STENTYS self-expandable stents is safe and effective. No significant differences were found in late lumen loss and MACE between BMS and PES.

Should We Still Have Bare-Metal Stents Available in Our Catheterization Laboratory?

The introduction of bare-metal stents (BMS) has represented a major advancement over plain old balloon angioplasty in the management of coronary artery disease. However, the high rates of target lesion revascularization associated with use of BMS have led to the development of drug-eluting stents, which require prolonged dual antiplatelet therapy due to the increased risk of late and very late stent thrombosis. The improvements in newer-generation drug-eluting stents have translated into better safety and efficacy compared with earlier generation and BMS, thus allowing shorter dual antiplatelet therapy duration. Here, we aim to provide reasons as to why we still need BMS in our cardiac catheterization laboratory.

Current State of the Art in Approaches to Saphenous Vein Graft Interventions

Saphenous vein grafts (SVGs), used during coronary artery bypass graft surgery for severe coronary artery disease, are prone to degeneration and occlusion, leading to poor long-term patency compared with arterial grafts. Interventions used to treat SVG disease are susceptible to high rates of periprocedural MI and no-reflow. To minimise complications seen with these interventions, proper stents, embolic protection devices (EPDs) and pharmacological selection are crucial. Regarding stent selection, evidence has demonstrated superiority of drug-eluting stents over bare-metal stents in SVG intervention. The ACCF/AHA/SCA American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions guidelines recommend the use of EPDs during SVG intervention to decrease the risk of periprocedural MI, distal embolisation and no-reflow. The optimal pharmacological treatment for slow or no-reflow remains unclear, but various vasodilators show promise.

Open-Label Phase I Clinical Study to Assess the Safety and Efficacy of Cilostazol in Patients Undergoing Internal Carotid Artery Stent Placement

BACKGROUND

One-month dual antiplatelet treatment, with aspirin and clopidogrel, following internal carotid artery stent placement is the current standard of care to prevent in-stent thrombosis. Cilostazol, an antiplatelet drug, has been demonstrated to have a safety profile comparable to aspirin and clopidogrel.

OBJECTIVE

To evaluate the safety and clinical efficacy of cilostazol and aspirin therapy following internal carotid artery stent placement up to 1 month postprocedure.

METHODS

A phase I open-label, nonrandomized two-center prospective study was conducted. All subjects received aspirin (325 mg/day) and cilostazol (200 mg/day) 3 days before extracranial stent placement. Two antiplatelet agents were continued for 1 month postprocedure followed by aspirin daily monotherapy. The primary efficacy end point was the 30-day composite occurrence of death, cerebral infarction, transient ischemic attack, and in-stent thrombosis. The primary safety end point was bleeding.

RESULTS

Twelve subjects (mean age ± SD, 66 ± 12 years; 9 males) were enrolled and underwent internal carotid artery angioplasty and stent placement. None of the subjects who successfully followed the study protocol experienced any complications at the 1- and 3-month follow-ups. One patient had a protocol deviation due to concurrent use of enoxaparin (1 mg/kg twice daily) in addition to aspirin and cilostazol, resulting in a fatal symptomatic intracerebral hemorrhage following successful stent placement on postprocedure day 1. One patient discontinued cilostazol after the first dose secondary to dizziness.

CONCLUSION

The use of cilostazol and aspirin for internal carotid artery stent placement appears to be safe, but protocol compliance needs to be emphasized.

Drug-eluting versus bare metal stent in treatment of patients with saphenous vein graft disease: A meta-analysis of randomized controlled trials

Drug-eluting stent (DES) and bare metal stent (BMS) are effective treatments for preventing vascular disease, but whether using DES is associated with positive clinical outcomes compared with BMS in patients with saphenous vein graft disease (SVGD) has not been established. Three electronic databases including PubMed, EmBase, and the Cochrane Central Register of Controlled Trials were searched to identify potentially includible studies. We did a random-effects meta-analysis of randomized controlled trials (RCTs) to obtain summary effect estimates for the clinical outcomes with the use of relative risk calculated from the raw data of individual trial. Among 812 patients from 4 RCTs, DES was associated with lower risk of short-term major cardiovascular events (MACEs) when compared with BMS, whereas no significant effect on the risk of long-term MACEs. Furthermore, there was no significant difference between DES and BMS for short-term myocardial infarction (MI) and long-term MI. Similarly, DES was not associated with risk of short- and long-term mortality risk as compared with BMS. In addition, DES has no significant effect on the risk of cardiac death and stent thrombosis. Finally, DES therapy significantly reduced the risk of TLR, TVF, and TVR. SVGD patients received DES can minimize the risk of short-term MACEs, TLR, TVF, and TVR when compared with BMS. However, it does not effect on the incidence of long-term MACEs, MI, mortality, cardiac death, and stent thrombosis.

Second-generation versus first-generation drug-eluting stents in saphenous vein graftdisease: A meta-analysis of randomized controlled trials

BACKGROUND

Second-generation drug-eluting stents (DESs) have become increasingly popular devices for patients with saphenous vein graft (SVG) disease. Second-generation DESs were designed to have more safety and efficacy than first-generation DES, but clinical outcomes in SVG disease remain conflicting.

METHODS AND RESULTS

Randomized controlled trials (RCTs) were identified when comparing second- versus first-generation DESs in SVG disease. The main endpoint was all-cause death. The time of follow-up was at least 30days. The secondary endpoints were major adverse cardiovascular events (MACEs), target vessel revascularization (TVR), target lesion revascularization (TLR), myocardial infarction (MI), and stent thrombosis. These endpoints were assessed at 30days, 12months and 24months. Four RCTs with 1077 SVG patients undergoing the implantation of DES were collected in the current meta-analysis. As a result, second-generation DES-treated patients had the significantly lower MACE rates at 12months (P=0.03; OR: 0.69, 95% CI: 0.49,0.97). No differences in two groups were seen in all-cause death, MI, TVR, stent thrombosis and TLR.

CONCLUSIONS

Our limited evidence indicated that, second-generation DES in SVG patients, compared with first-generation DES, offered similar levels of safety, but were more effective than the former one.

Long term outcomes of saphaneous vein graft intervention in elderly patients with prior coronary artery bypass graft

OBJECTIVES

To investigate the procedure characteristics and long term follow-up of percutaneous coronary intervention (PCI) for saphaneous vein graft (SVG) lesions in the elderly patients.

METHODS

From December 2005 to December 2011, 84 graft lesions were treated percutaneously. Seventeen were located at proximal anastomosis, 48 were located at SVG body, 19 were located at distal anastomosis. Primary endpoint was defined as major adverse cardiovascular events (MACE, composite of cardiac death, target vessel revascularization, acute myocardial infarction).

RESULTS

The graft age was 6.7 ± 4.0 years. Most anastomosis lesions (80.0%) presented within one year post coronary artery bypass grafting (CABG). Proximal anastomosis lesion had the lowest successful rate for PCI compared with graft body and distal anastomosis lesions (70.6% vs. 91.7%, 79.0%, P < 0.05). The distal embolic protection device was used in 19.1% of patients, most frequently used in body graft PCI (29.2%, P < 0.01). The diameter of the stent was smallest in distal anastomosis group (2.9 ± 0.4 mm, P < 0.05). The highest post dilatation pressure was required in the proximal anastomosis (17.8 ± 2.7 atm, P < 0.05). The patients were followed up for 24.3 ± 16.9 months. MACE occurred in 18.57% of patients. Incidence of MACE was highest among proximal anastomosis PCI (47.1% vs. body graft PCI 16.7%, distal anastomosis PCI 21.1%; P < 0.05). Old myocardial infarction was the predictive factor for the poor clinical outcomes (P = 0.04).

CONCLUSIONS

PCI of SVG lesions is feasible with lower success rate. PCI of ostial graft anastomosis lesions had the lowest procedure success rate and highest MACE rate compared with graft body and distal anastomosis lesions. Old myocardial infarction was a predictive factor of poor outcomes.

Choosing the right coronary stent in the modern era

Research and development in the field of coronary stent design is a fast-evolving and fascinating journey. A device that was once introduced to salvage acute closure associated with balloon angioplasty is now the standard of care for many patients with coronary artery disease. Newer generation stents are the product of remarkable progress in technology and innovation, driven by the need to make the stents easier to deliver and to improve their safety and efficacy. As such, the design of these stents has become quite sophisticated and complex. The number of available stents has increased giving patients and physicians more choices on one hand, but also created confusion in selecting the optimal stent for a given patient. Although a 'one size fits all' approach may not be reasonable, several randomized trials have attested to the efficacy and safety of newer generation durable polymer drug eluting stents. This article discusses the evidence base to support various stent choices in contemporary practice.

Current application and bioavailability of drug-eluting stents

INTRODUCTION

Drug-eluting stents (DES) were developed to reduce the restenosis rate of bare metal stents (BMS) and comprises three main components: i) a metallic scaffold; ii) an antiproliferative drug to reduce or abolish the formation of the neointima; and iii) the polymer, which both enables and controls drug elution into the vessel wall. Over the years, growing evidence has been reported on the safety and efficacy for different indications of DES.

AREAS COVERED

Since the introduction of first-generation DES, the technology has been refined, including changes in the alloy, stent design, polymer, drug and drug dose. In 2014, we will usher in a third generation of DES, which will include biodegradable polymers, polymer-free DES and bioabsorbable scaffolds.

EXPERT OPINION

In recent years, considerable progress has been made in DES development. The BMS platform set the groundwork for the development of metal scaffolds with drug-eluting capability to prevent restenosis. Importantly, extensive research has shown long-term safety and efficacy of the newer generation DES. Available data suggest that DES can be safely and effectively used to treat a complex subset of patients and lesions, including patients presenting with acute myocardial infarction, lesions in saphenous vein grafts, chronic total occlusions, multivessel disease, small vessels, long lesions and bifurcations. One of the safety targets is to eliminate stent thrombosis.

An update on coronary bypass graft intervention

Coronary artery bypass grafting (CABG) remains one of the most common surgical procedures. In spite of great advancements like arterial grafts and off-pump bypass procedure, recurrent ischaemia may ensue with the lesions of the graft. Early postoperative ischaemia (<30 days) is due to graft occlusion or stenosis, and percutaneous coronary intervention (PCI) is frequently feasible. Late postoperative ischaemia (>3 years) is most often due to a saphenous vein graft (SVG) lesion. Multiple diseased grafts, reduced left ventricular function, and available arterial conduits favour repeat CABG, whereas, a patent left internal mammary artery to left anterior descending favours PCI. Embolic protection reduces atheroembolic myocardial infarction during PCI of SVG and should be routinely used in treatment of SVG lesions. A variety of vasodilators may reduce the risk of or mitigate the consequences of no-reflow. Drug-eluting stents reduce restenosis in SVG grafts, and have become the default strategy for many interventionalists.

Long-term follow-up of coronary venous bypass graft lesions treated with a new generation drug-eluting stent with bioabsorbable polymer

BACKGROUND

To date, no published data are available regarding long-term follow-up of new generation DES implanted in coronary artery bypass graft (CABG) lesions.

OBJECTIVES

To assess the long-term clinical outcome of patients receiving the new generation Biolimus A9-coated drug-eluting stent (DES) with biodegradable polymer in saphenous vein grafts (SVG).

METHODS

Three thousand sixty-seven patients were included in the NOBORI 2 registry: 71 patients with a total of 117 lesions received at least 1 biolimus A9 DES in SVG lesions and 2,959 patients received percutaneous coronary intervention in other lesions. Clinical follow-up was performed at 1, 6, and 12 months, and annually up to 3 years.

RESULTS

Compared to the non-CABG group, patients with CABG lesions were older (P < 0.001), had a higher Charlson Comorbidity Index (P = 0.004), and presented more often with acute coronary syndrome (P = 0.02). At 3-year follow-up, cardiac death occurred in 9.7% versus 2.1% (P < 0.001), myocardial infarction (MI) in 8.3% versus 3.0% (P = 0.02), target lesion failure in 13.9% versus 6.4% (P = 0.03), and major adverse cardiac event in 18.1% versus 8.6% (P = 0.01). No differences were observed in TV-MI and TLR, nor stent thrombosis (ST) which was generally low in both groups (1.4% vs 0.8%, P = NS).

CONCLUSION

Albeit 3-year outcomes were less favorable in the CABG group, the higher cardiac mortality was apparently not driven by ST, target vessel MI, or TLR, but is likely due to advanced disease and age as well as comorbidity. The low TLR rate as well as the absence of late and very late ST suggest that BES are safe and effective for the treatment of CABG lesions.

Comparison of first- and second-generation drug-eluting stents in saphenous vein grafts used as aorto-coronary conduits

Saphenous vein grafts (SVGs) are prone to an aggressive atherosclerotic process, and the efficacy of drug-eluting stents (DES) in treating this is still debated. In recent years, second-generation DES have been increasingly used in SVG intervention. The main objective of this study was to compare midterm clinical outcomes between first- and second-generation DES in SVGs because data regarding the use of second-generation DES in SVG are lacking. Patients treated with first-generation DES (127 patients with 143 lesions) and those treated with second-generation DES (84 patients with 100 lesions) were included in the study. Major adverse cardiac events, defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization, as well as target vessel revascularization and target lesion revascularization separately, were evaluated at 30-day, 12-month, and 18-month follow-up. Baseline characteristics were similar between the 2 groups. Older grafts were treated with second-generation DES (11.6 ± 5.3 vs 14.3 ± 6.0 years, p = 0.001). Stent length was longer in the first-generation group (34.1 ± 25.1 vs 30.5 ± 19.4 mm, p = 0.006), and maximum balloon diameter was smaller in the second-generation group (3.42 ± 0.42 vs 3.30 ± 0.41 mm, p = 0.003). Embolic protection device use was higher in the second-generation DES group (55.2% vs 72.0%, p = 0.012). At 18-month follow-up, rates of major adverse cardiac events, target vessel revascularization, and target lesion revascularization for the first- and second-generation groups were 24.4% versus 20.2% (p = 0.479), 18.1% versus 14.2% (p = 0.465), and 15.0% versus 10.7% (p = 0.373), respectively. In conclusion, second-generation DES are at least comparable with first-generation DES with regard to clinical outcomes at midterm follow-up.

Current percutaneous treatment strategies for saphenous vein graft disease

Coronary artery bypass graft surgery remains one of the most widely performed surgical procedures in North America and aortocoronary saphenous vein grafts (SVG) are the most frequently used surgical conduits. SVG disease (SVGD) remains the leading cause of symptomatic coronary artery disease postcoronary artery bypass graft. When optimal medical therapy is ineffective, repeat surgery is associated with higher mortality combined with less favorable clinical and angiographic results, thus percutaneous revascularization on SVG is currently the standard of care for the revascularization of SVGD. Balloon angioplasty, bare metal stents, polytetrafluoroethylene-covered stents, and drug-eluting stents have been extensively investigated for SVG interventions. Multiple recent randomized trials and meta-analyses have confirmed the pathophysiologic and clinical differences between SVGD and coronary artery disease. Decisions such as patient selection, premedication, stent, and protection device characteristics should be carefully considered to achieve optimal procedural and clinical results. Acute coronary syndromes due to SVG involvement, chronic total occlusions, retrograde approaches, and SVG perforation management are newer fields requesting additional research.

Saphenous vein graft failure after coronary artery bypass surgery: pathophysiology, management, and future directions

OBJECTIVE

To review our current understanding of the epidemiology and pathogenesis of vein graft failure (VGF), give an overview of current preventive and interventional measures, and explore strategies that may improve vein graft patency.

BACKGROUND

VGF and progression of native coronary artery disease limit the long-term efficacy of coronary artery bypass graft surgery.

METHODS

We reviewed the published literature on the pathophysiology, prevention, and/or treatment of VGF by searching the MEDLINE (January 1, 1966-January 1, 2012), EMBASE (January 1, 1980-January 1, 2012), and Cochrane (January 1, 1995-January 1, 2012) databases. In addition, we reviewed references from the selected articles for studies not identified in the initial search. Basic science and clinical studies were included; non-English language publications were excluded.

RESULTS

Acute thrombosis, neointimal hyperplasia, and accelerated atherosclerosis are the 3 mechanisms that lead to VGF. Preventive measures include matching and quality assessment of conduit and target vessel, lipid-lowering drugs, antithrombotic therapy, and cessation of smoking. Treatment of VGF includes medical therapy, percutaneous intervention, and redo coronary artery bypass graft surgery. In patients undergoing graft intervention, the use of drug-eluting stents, antiplatelet agents, and embolic protection devices may improve clinical outcomes.

CONCLUSIONS

Despite advances in management, VGF remains one of the leading causes of poor in-hospital and long-term outcomes after coronary artery bypass graft surgery. New developments in VGF prevention such as gene therapy, external graft support, fully tissue-engineered grafts, hybrid grafts, and synthetic conduits are promising but unproven. Future efforts to reduce VGF require a multidisciplinary approach with a primary focus on prevention.

Drug-Eluting Stents Versus Bare Metal Stents in Saphenous Vein Graft Intervention

Percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) is associated with higher adverse event rates, lower procedural success, and inferior longterm patency rates compared with native vessel PCI. The ability to comply with dual antiplatelet therapy, and whether the patient will need an interruption in dual antiplatelet therapy, should be considered when deciding whether to implant a drug-eluting stent (DES) or bare metal stent (BMS) in an SVG. DES should be used for SVG PCI because they seem to reduce target vessel revascularization. This article reviews the evolution and contemporary evidence regarding use of DES versus BMS in SVG PCI.

Degenerated Saphenous Vein Graft Intervention: Should We Target the Native Vessel instead?

Coronary interventions of degenerated saphenous vein grafts (SVGs) continue to present a management challenge. Although repeat coronary artery bypass grafting (CABG) remains a significant risk factor for operative mortality, percutaneous coronary intervention (PCI) is still associated with a high risk for periprocedural events. There is a lack of consensus on the optimal treatment strategy for patients with severe stenosis of SVGs. It is imperative to review the characteristics of native versus SVG disease, risk factors for complications after SVG intervention, procedural treatment strategies important to the decision on which therapeutic strategy to follow, and measures to mitigate the risks of periprocedural complications.

Addition of cilostazol to conventional dual antiplatelet therapy reduces the risk of cardiac events and restenosis after drug-eluting stent implantation: a meta-analysis

This meta-analysis was performed to compare the risk of cardiac events and restenosis between triple antiplatelet therapy (TAT, addition of cilostazol to aspirin and clopidogrel) and conventional dual antiplatelet therapy (DAT, aspirin and clopidogrel) in drug-eluting stents (DES) implantation patients. We performed PUBMED, MEDLINE, EMBASE, and Cochrane CENTRAL searches for randomized clinical trials of TAT versus DAT in patients after DES implantation. Five clinical trials were involved in the study. TAT was associated with a 36% reduction in major adverse cardiac events (MACE; odds ratio (OR) = 0.64; 95% confidence interval (CI) = 0.51-0.81, P < .01), a 40% reduction (OR = 0.60, 95% CI = 0.44-0.80; P < .01) in target vessel revascularization (TVR), a 44% reduction (OR = 0.56, 95% CI = 0.34-0.91; P = .02) in target lesion revascularization (TLR) and a 47%/44% reduction in in-segment/in-stent restenosis (P < .01) and lower in-segment/in-stent late loss (P < .01). As regards to the safety assessment, there was no significant difference about the risk of stent thrombosis and bleeding between TAT and DAT group, while the risk of gastrointestinal trouble was significantly higher in TAT group (OR = 2.46, 95% CI = 1.25-4.86; P < .01). Addition of cilostazol to DAT reduced the incidence of MACE, TVR, and TLR after DES implantation. TAT also reduced the risk of restenosis and late loss in patients after DES implantation.

[Update on interventional cardiology]

This article contains a review of the most important studies on interventional cardiology reported in either publications or presentations. In the area of coronary interventions, ST-elevation myocardial infarction continues to take center place: recent studies have confirmed the importance of timely intervention and the safety of drug-eluting stents. The numerous studies that have compared different generations of drug-eluting stents indicate that there has been a steady improvement in safety and efficacy. In addition, the use of stents in the left main coronary artery and in multivessel disease have also been investigated in major studies. Of the different intracoronary diagnostic techniques, optical coherence tomography is highlighted by this review, particularly for its use in the study of drug-eluting stents. There is increasing interest in the percutaneous treatment of structural heart disease, specifically percutaneous aortic valve implantation, especially following the publication of the first randomized trial, which produced encouraging results.

Optimal visualization of five different stent layers during and after percutaneous coronary intervention for recurrent in-stent restenosis using optical coherence tomography (OCT)

Optical coherence tomography (OCT) has gained increasing popularity in the recent years. In this case, we documented optimal visualization of four stent layers that were seen during percutaneous coronary intervention for recurrent in-stent restenosis. OCT was clearly able to penetrate all of the neointimal tissue layers extending through to the last stent, which was near the adventitia. Our case demonstrates the excellent utility of OCT for detail assessment of a lesion with multiple stents. To our knowledge, this case is the first case report that could demonstrate excellent visualization of 5 different stent layers using OCT, extending through the deepest stent layer near the adventitia.

Clinical outcomes of percutaneous interventions in saphenous vein grafts using drug-eluting stents compared to bare-metal stents: a comprehensive meta-analysisof all randomized clinical trials

BACKGROUND

Clinical outcomes of percutaneous coronary intervention (PCI) in patients with saphenous vein grafts (SVGs) remain poor despite the use of drug-eluting stents (DES). There is a disparity in clinical outcomes in SVG PCI based on various registries, and randomized clinical data remain scant. We conducted a meta-analysis of all existing randomized controlled trials (RCTS) comparing bare-metal stents (BMS) and DES in SVGPCIs.

HYPOTHESIS

PCI in patients with SVG disease using DES may reduce need for repeat revascularization without an excess mortality when compared to BMS.

METHODS

An aggregate data meta-analysis of clinical outcomes in RCTs comparing PCI with DES vs BMS for SVGs reporting at least 12 months of follow-up was performed. A literature search between Janurary 1, 2003 and September 30, 2011 identified 4 RCTs (812 patients; DES = 416, BMS = 396). Summary odds ratio (OR) and 95% confidence interval (CI) were calculated using the random-effects model. The primary endpoint was all-cause mortality. Secondary outcomes included nonfatal myocardial infarction (MI), repeat revascularization, and major adverse cardiac events (MACE). These outcomes were assessed in a cumulative fashion at 30 days, 18 months, and 36 months.

RESULTS

There were no intergroup differences in baseline clinical and sociodemographic characteristics. At a median follow-up of 25 months, patients in the DES and BMS group had similar rates of death (OR: 1.63, 95% CI: 0.45-5.92), MI (OR; 0.83, 95% CI: 0.27-2.60), and MACE (OR: 0.58, 95% CI: 0.25-1.32). Patients treated with DES had lower rates of repeat revascularization (OR: 0.40, 95% CI: 0.22-0.75).

CONCLUSIONS

In this comprehensive meta-analysis of all RCTs comparing clinical outcomes of PCI using DES vs BMS in patients with SVG disease, use of DES was associated with a reduction in rate of repeat revascularization and no difference in rates of all-cause death and MI. Clin. Cardiol. 2012 DOI: 10.1002/clc.21984 Dr. Virani is supported by a Department of Veterans Affairs Health Services Research and Development Service (HSR&D) Career Development Award (CDA-09-028), and has research support from Merck and National Football League Charities (all grants to the institution and not individual). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. The authors have no other funding, financial relationships, or conflicts of interest to disclose.

Saphenous vein graft intervention

Saphenous vein grafts are commonly used conduits for surgical revascularization of coronary arteries but are associated with poor long-term patency rates. Percutaneous revascularization of saphenous vein grafts is associated with worse clinical outcomes including higher rates of in-stent restenosis, target vessel revascularization, myocardial infarction, and death compared with percutaneous coronary intervention of native coronary arteries. Use of embolic protection devices is a Class I indication according to the American College of Cardiology/American Heart Association guidelines to decrease the risk of distal embolization, no-reflow, and periprocedural myocardial infarction. Nonetheless, these devices are underused in clinical practice. Various pharmacological agents are available that may also reduce the risk of or mitigate the consequences of no-reflow. Covered stents do not decrease the rates of periprocedural myocardial infarction and restenosis. Most available evidence supports treatment with drug-eluting stents in this high-risk lesion subset to reduce angiographic and clinical restenosis, although large, randomized trials comparing drug-eluting stents and bare-metal stents are needed.