Target Lesion Failure With Current Drug-Eluting Stents: Evidence From a Comprehensive Network Meta-Analysis

The association between stent type and developing angina pectoris following percutaneous coronary intervention

BACKGROUND

Angina pectoris can occur in up to 40% of patients following percutaneous coronary intervention (PCI). There is limited data assessing whether the type of stent implanted during revascularization can predict post-PCI angina symptoms.

METHODS

In this study, data regarding revascularization characteristics including the stent type in patients admitted for PCI was collected. Prospective data including occurrence of angina and the presenting class, new onset ST-segment elevation myocardial infarction (STEMI), and other clinical outcomes were collected at 1, 3, and 6-month follow-up intervals. Univariable and multivariable logistic regression models were used to assess the potential predictors of angina symptoms at 6-month follow-up.

RESULTS

A total of 787 patients (64.5% males) undergoing PCI with three stent types (Orsiro, Promus, and Xience) were included in the study. The occurrence of post PCI angina pectoris and new STEMI was similar among the stent types (p > 0.05). A linear association was found between the development of new STEMI (p = 0.018) and stroke (p = 0.003) and the worsening of angina class. The stent type was not a predictor of angina during the follow-up period. Other variables including dyslipidemia (odds ratio (OR) (95% CI), 1.51 (1.08; 2.10)), prior coronary artery disease (CAD) (OR (95% CI), 1.63 (1.02; 2.61)), and previous hospitalization (OR (95% CI), 2.10 (1.22; 3.63)) were independent predictors of angina.

CONCLUSIONS

Although the type of stent may not have an association with the post-PCI angina, other predictors such as dyslipidemia and previous CAD and hospitalization may predict recurrence of cardiac angina. The class of angina severity may have a linear association with new-onset STEMI and stroke.

Optimal Percutaneous Treatment Approach to Unprotected Ostial Left Anterior Descending Artery Disease: A Meta-Analysis and Systematic Review

BACKGROUND

The optimal management strategy for significant unprotected ostial left anterior descending artery (LAD) disease remains undefined. Merits of the two most common percutaneous approaches are considered in this quantitative synthesis.

METHOD

A meta-analysis was performed to compare ostial stenting (OS) and crossover stenting (CS) in the treatment of unprotected ostial LAD stenosis. The primary outcome is the disparity in target lesion revascularisation (TLR). The Mantel-Haenszel method was employed with random effect model, chosen a priori to account for heterogeneity among the included studies.

RESULTS

Seven studies comprising 1,181 patients were included in the analyses. Of these, 482 (40.8%) patients underwent CS. Overall, there was a statistically significant trend in favour of CS (odds ratio 0.51, 95% confidence interval 0.30-0.86, p=0.01) with respect to the rate of TLR at follow-up. This remained true when TLR involving the left circumflex artery (LCx) was considered, even when there was a greater need for unintended intervention to the LCx during the index procedure (odds ratio 6.68, 95% confidence interval: 1.69-26.49, p=0.007). Final kissing balloon inflation may reduce the need for acute LCx intervention. Imaging guidance appeared to improve clinical outcomes irrespective of approach chosen.

CONCLUSIONS

In the percutaneous management of unprotected ostial LAD disease, CS into the left main coronary artery (LMCA) appeared to reduce future TLR. Integration of intracoronary imaging was pivotal to procedural success. The higher incidence of unintended LCx intervention in the CS arm may be mitigated by routine final kissing balloon inflation, although the long-term implication of this remains unclear. In the absence of randomised trials, clinicians' discretion remains critical.

Real-World Clinical Performance of a Novolimus-Eluting Stent Versus a Sirolimus-Eluting Stent

INTRODUCTION

The DESyne novolimus-eluting coronary stent (NES) is a new-generation drug-eluting stent (DES) that is widely used, but clinical data are rarely reported for this stent. We compared the safety and effectiveness of the DESyne NES and the Orsiro bioresorbable polymer sirolimus-eluting stent (SES) in patients undergoing percutaneous coronary intervention (PCI).

METHODS

This was a retrospective, single-center, observational study. Between July 2017 and December 2022, patients who presented with chronic or acute coronary syndrome undergoing PCI with DESyne NES or Orsiro SES were consecutively enrolled in the present study. The primary endpoint, major adverse cardiovascular event (MACE), was a composite of cardiovascular death, target-vessel myocardial infarction, or clinically driven target-lesion revascularization.

RESULTS

A total of 776 patients (age 68.8 ± 12.2; 75.9% male) undergoing PCI were included. Overall, 231 patients with 313 lesions received NES and 545 patients with 846 lesions received SES. During a follow-up duration of 784 ± 522 days, the primary endpoint occurred in 10 patients (4.3%) in the NES group and in 36 patients (6.6%) in the SES group. After multivariate adjustment, the risk of MACE did not significantly differ between groups (NES vs. SES, hazard ratio 0.74, 95% CI, 0.35-1.55, p = 0.425). The event rate of individual components of the primary endpoint was comparable between the two groups.

CONCLUSIONS

Favorable and similar clinical outcomes were observed in patients undergoing PCI with either NES or SES in a medium-term follow-up duration. Future studies with adequately powered clinical endpoints are required for further evaluation.

Comparison Among Ultra-Thin Coronary Stents: A Network Meta-Analysis

Ultrathin-strut drug-eluting stents (DES) have been related to potential improvement in stent-related outcomes compared with thicker-struts DES. However, comparisons among different ultrathin devices are lacking. All randomized controlled trials comparing ultrathin (struts thickness <70 µm) and thicker-struts DESs in an all-comers population were included. Target lesion failure (TLF), as defined by included trials, at 1-year follow-up was the primary end point. Overall mortality, myocardial infarction, target lesion revascularization (TLR), and stent thrombosis were the secondary end points. Arms of included trials were compared using network meta-analysis. Nine studies encompassing 20,081 patients were included, of which 9,509 patients had an ultrathin DES: Orsiro (evaluated in 7 arms with 8,086 patients), MiStent (1 arm with 703 patients), or Supraflex (1 arm with 720 patients). At 1-year follow-up, no significant differences were noted for TLF among these ultrathin DES. In particular, Orsiro was associated with a similar risk of TLF compared with Supraflex (risk rate 1.07, 95% confidence interval 0.59 to 1.78) and showed the highest probability of performing best in terms of TLF, myocardial infarction, and TLR. Ultrathin DES are all associated with a comparable risk of TLF compared with thicker-strut DES. In terms of TLR and TLF risk, Orsiro was the one with the highest probability of best performances, either compared with other ultrathin DES or to devices with thicker struts.

One-Year Outcome of Drug-Coated Balloon vs. Drug-Eluting Stent in Patients Undergoing Initial Percutaneous Coronary Intervention (PCI) for De Novo Lesion

BACKGROUND

Drug-eluting stents (DES) are the major treatment option in percutaneous coronary intervention (PCI). Recently, drug-coated balloon (DCB) utilization has been increasing globally, leading to the expected new strategy of "stent-less PCI." This study aimed to evaluate the one-year outcome of DCB compared to DES.

METHODS

Patients who underwent initial PCI for de novo lesions in our institution from January 2018 to December 2021 (n=337) were subjected to retrospective analysis. Among them, 75 patients were treated with DCB, while 262 patients were treated with DES. Target lesion failure (TLF) was evaluated during the follow-up period.

RESULTS

The proportion of PCIs for ACS was significantly lower in the DCB group (DCB, n=23, 30.7% vs. DES, n=143, 54.6%; p=0.001). The median device diameter and length in the DES group were larger than those in the DCB group (DCB, 2.60 mm vs. DES, 2.98 mm; p<0.001; DCB, 19.1 mm vs. DES, 25.2 mm; p<0.001). There was no significant difference between the DCB and DES groups in lesion calcification. The proportion of ostial lesions was significantly higher in the DCB group (DCB, n=13, 17.3% vs. DES, n=21, 8.0%; p=0.018). The cumulative rate of TLF (DCB, n=5, 6.7% vs. DES, n=18, 6.9%; p=0.951) did not significantly differ between the DCB and DES groups.

CONCLUSION

DCB may be as effective a strategy as DES in the patient who underwent initial PCI for a de novo lesion.

Very long-term outlook of acute coronary syndromes after percutaneous coronary intervention with implantation of polymer-free versus durable-polymer new-generation drug-eluting stents

BACKGROUND

Detailed long-term follow-up data on patients with acute coronary syndromes (ACS) in general, and those with ST-elevation myocardial infarction (STEMI) in particular, are limited. We aimed to appraise the long-term outlook of patients undergoing percutaneous coronary intervention (PCI) with state-of-the-art coronary stents for STEMI, other types of ACS and stable coronary artery disease (CAD), and also explore the potential beneficial impact of new-generation polymer-free drug-eluting stents (DES) in this setting.

METHODS

Baseline, procedural and very long-term outcome data on patients undergoing PCI and randomized to implantation of new-generation polymer-free vs. durable polymer DES were systematically collected, explicitly distinguishing subjects with admission diagnosis of STEMI, non-ST-elevation ACS (NSTEACS), and stable CAD. Outcomes of interest included death, myocardial infarction, revascularization (i.e. patient-oriented composite endpoints [POCE]), major adverse cardiac events (MACE), and device-oriented composite endpoints (DOCE).

RESULTS

A total of 3002 patients were included, 1770 (59.0%) with stable CAD, 921 (30.7%) with NSTEACS, and 311 (10.4%) with STEMI. At long-term follow-up (7.5±3.1 years), all clinical events were significantly more common in the NSTEACS group and, to a lesser extent, in the stable CAD group (e.g. POCE occurred in, respectively, 637 [44.7%] vs. 964 [37.9%] vs. 133 [31.5%], P<0.001). While these differences were largely attributable to adverse coexisting features in patients with NSTEACS (e.g. advanced age, insulin-dependent diabetes, and extent of CAD), the unfavorable outlook of patients presenting with NSTEACS persisted even after multivariable adjustment including several prognostically relevant factors (hazard ratio [HR] of NSTEACS vs. stable CAD 1.19 [95% confidence interval 1.03-1.38], P=0.016). Notably, even after encompassing all prognostically impactful features, no difference between polymer-free and permanent polymer drug-eluting stents appeared (HR=0.96 [0.84-1.10], P=0.560).

CONCLUSIONS

Unstable coronary artery disease, especially when presenting without ST-elevation, represents an informative marker of adverse long-term prognosis in current state-of-the-art invasive cardiology practice. Even considering admission diagnosis, and despite of using no polymer, polymer-free DES showed similar results with regards to safety and efficacy when compared with DES with permanent polymer.

Ultrathin bioresorbable polymer sirolimus-eluting stents in US patients undergoing coronary revascularization: 1-Year outcomes from the BIOFLOW VII trial

BACKGROUND

Ultrathin strut coronary drug-eluting stents (DES) have demonstrated improved safety and efficacy in large contemporary trials. The evaluation of an ultrathin strut DES in a post-market United States (US) patient population was undertaken.

OBJECTIVE

The purpose of this post-approval study is to confirm that the clinical performance of an ultrathin strut bioresorbable polymer sirolimus-eluting stent (BP SES) in clinical practice is similar to that observed with BP SES in the BIOFLOW V pivotal trial.

METHODS

BIOFLOW VII is a prospective, multicenter, single-arm US post-market approval study to confirm the clinical performance of BP SES in a real-world setting. The primary endpoint of 1-year target lesion failure (TLF) was compared with a performance goal of 6.9% based on an adapted BIOFLOW V trial BP SES TLF rate and TLF rates from other US market-released DES utilizing the Society for Cardiovascular Angiography and Interventions definition for peri-procedural myocardial infarction (MI). Subjects undergoing percutaneous coronary intervention with BP SES were consented within 24 h post-index procedure with planned follow-up through 5 years.

RESULTS

Among 556 enrolled patients, clinical demographics included: 34.7% female, 35.6% with diabetes mellitus, and 56.8% with acute coronary syndromes. The average stent length (mean ± standard deviation) was 20.2 ± 11.8 mm, and the mean number of stents per patient was 1.3 ± 0.6. Procedure success was 99.1% (551/556), and device success was 99.9% (689/690). Among 531 subjects included in the primary endpoint analysis, the 1-year rate of TLF rate was 1.7% (9/531), and the primary endpoint was met compared with the performance goal (p < 0.0001, 95% confidence interval: 0.69%, 3.43%). Rates of target vessel MI and clinically driven target lesion revascularization were 1.3% (7/531) and 0.9% (5/531), with no occurrence of cardiac death. Definite stent thrombosis was observed for two cases (0.4%; 2/556) with one acute (≤24 h) and one late (>30 days and ≤1 year) event.

CONCLUSION

In a post-approval study, 1-year clinical outcomes with BP SES were consistent with prior trials supporting the safety and effectiveness of ultrathin BP SES.

Safety and Efficacy of Everolimus-Eluting Bioresorbable Vascular Scaffold Versus Second-Generation Drug-Eluting Stents in Real-World Practice

BACKGROUND

The risk of device thrombosis and device-oriented clinical outcomes with bioresorbable vascular scaffold (BVS) was reported to be significantly higher than with contemporary drug-eluting stents (DESs). However, optimal device implantation may improve clinical outcomes in patients receiving BVS. The current study evaluated mid-term safety and efficacy of Absorb BVS with meticulous device optimization under intravascular imaging guidance.

METHODS

The SMART-REWARD and PERSPECTIVE-PCI registries in Korea prospectively enrolled 390 patients with BVS and 675 patients with DES, respectively. The primary endpoint was target vessel failure (TVF) at 2 years and the secondary major endpoint was patient-oriented composite outcome (POCO) at 2 years.

RESULTS

Patient-level pooled analysis evaluated 1,003 patients (377 patients with BVS and 626 patients with DES). Mean scaffold diameter per lesion was 3.24 ± 0.30 mm in BVS group. Most BVSs were implanted with pre-dilatation (90.9%), intravascular imaging guidance (74.9%), and post-dilatation (73.1%) at proximal to mid segment (81.9%) in target vessel. Patients treated with BVS showed comparable risks of 2-year TVF (2.9% vs. 3.7%, adjusted hazard ratio [HR], 1.283, 95% confidence interval [CI], 0.487-3.378, P = 0.615) and 2-year POCO (4.5% vs. 5.9%, adjusted HR, 1.413, 95% CI, 0.663-3.012, P = 0.370) than those with DES. The rate of 2-year definite or probable device thrombosis (0.3% vs. 0.5%, P = 0.424) was also similar. The sensitivity analyses consistently showed comparable risk of TVF and POCO between the 2 groups.

CONCLUSION

With meticulous device optimization under imaging guidance and avoidance of implantation in small vessels, BVS showed comparable risks of 2-year TVF and device thrombosis with DES.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02601404, NCT04265443.

Stent Thrombosis and Restenosis with Contemporary Drug-Eluting Stents: Predictors and Current Evidence

Iterations in stent technologies, advances in pharmacotherapy, and awareness of the implications of implantation techniques have markedly reduced the risk of stent failure, both in the form of stent thrombosis (ST) and in-stent restenosis (ISR). However, given the number of percutaneous coronary interventions (PCI) performed worldwide every year, ST and ISR, albeit occurring at a fairly low rate, represent a public health problem even with contemporary DES platforms. The understanding of mechanisms and risk factors for these two PCI complications has been of fundamental importance for the parallel evolution of stent technologies. Risk factors associated with ST and ISR are usually divided into patient-, lesion-, device- and procedure-related. A number of studies have shown how certain risk factors are related to early (1 month) versus late/very late ST (between 1 month and 1 year and >1 year, respectively). However, more research is required to conclusively show the role of time-dependence of risk factors also in the incidence of ISR (early [1 year] or late [>1 year]). A thorough risk assessment is required due to the complex etiology of ST and ISR. The most effective strategy to treat ST and ISR is still to prevent them; hence, it is crucial to identify patient-, lesion-, device- and procedure-related predictors.

Five-Year Clinical Outcome of the Biodegradable Polymer Ultrathin Strut Sirolimus-Eluting Stent Compared to the Biodegradable Polymer Biolimus-Eluting Stent in Patients Treated With Percutaneous Coronary Intervention: From the SORT OUT VII Trial

BACKGROUND

Biodegradable polymer drug-eluting stents were developed to improve safety and efficacy outcomes for patients undergoing percutaneous coronary intervention. However, few long-term follow-up efficacy studies are available. The study sought to investigate 5-year results from the SORT OUT VII trial (Scandinavian Organization for Randomized Trials With Clinical Outcome) comparing the biodegradable polymer ultrathin-strut sirolimus-eluting Orsiro stent (O-SES) versus the biodegradable polymer biolimus-eluting Nobori stent (N-BES).

METHODS

This registry-based, randomized, multicenter, single-blinded, noninferiority trial compared O-SES and N-BES in an all-comer population. The composite primary end point, target lesion failure, consisted of cardiac death, myocardial infarction related to the target lesion, or target lesion revascularization within 1 year. Follow-up was extended to 5 years.

RESULTS

Five-year follow-up was completed for 2521 patients (99.8%). Five-year target lesion failure did not differ between O-SES (12.4%) and N-BES (13.1%; rate ratio [RR], 0.94 [95% CI, 0.75-1.18]). Cardiac death (RR, 0.95 [95% CI, 0.67-1.34]), target myocardial infarction (RR, 1.14 [95% CI, 0.76-1.71]), target lesion revascularization (RR, 0.90 [95% CI, 0.67-1.21]), and definite stent thrombosis rates (RR, 0.73 [95% CI, 0.41-1.33]) did not differ significantly between the 2 stents. Within the first year, definite ST was significantly lower for O-SES (0.4%) compared to N-BES (1.2%; RR, 0.33 [95% CI, 0.12-0.92]), but no difference was from 1 through 5 years: O-SES 1.2% and N-BES 0.9% (RR, 1.28 [95% CI, 0.58-2.82]).

CONCLUSIONS

Five years after treatment with biodegradable polymer stents, target lesion failure did not differ among O-SES and N-BES. Definite stent thrombosis was less often seen within the first year in the O-SES but the difference was not maintained after 5 years.

REGISTRATION

URL: https://clinicaltrials.gov; Unique identifier: NCT01879358.

Ultrathin Bioresorbable Polymer Sirolimus-Eluting Stents Versus Durable Polymer Everolimus-Eluting Stents: BIOFLOW V Final 5-Year Outcomes

BACKGROUND

Randomized trials have demonstrated the superiority of ultrathin strut drug-eluting stents compared with alternative stent designs. Whether these differences persist over late-term follow-up is uncertain.

OBJECTIVES

This study sought to compare late-term (5-year) clinical outcomes among patients treated with ultrathin strut (60 µm) bioresorbable polymer sirolimus-eluting stents (BP SES) and thin strut (81 µm) durable polymer everolimus-eluting stents (DP EES).

METHODS

BIOFLOW V (Biotronik Prospective Randomized Multicenter Study to Assess the Safety and Effectiveness of the Orsiro Sirolimus Eluting Coronary Stent System in the Treatment of Subjects with Up to Three De Novo or Restenotic Coronary Artery Lesions V) was an international, 2:1 randomized trial comparing percutaneous coronary intervention with ultrathin strut BP SES versus thin strut DP EES regarding the primary endpoint of 12-month target lesion failure (TLF). Prespecified outcomes through 5 years were assessed.

RESULTS

Among 1,334 patients randomized to treatment with BP SES (n = 884) or DP EES (n = 450), the 5-year rates of TLF were 12.3% for BP SES and 15.3% for DP EES (P = 0.108). Revascularization with BP SES was associated with a significantly lower target vessel-related myocardial infarction (6.6% vs 10.3%, P = 0.015) and late/very late definite/probable stent thrombosis (0.3% vs 1.6%, P = 0.021). Ischemia-driven target lesion revascularization was numerically but not significantly lower with BP SES (5.9% vs 7.7%, P = 0.202). Cardiac death rates were 2.6% versus 1.9% (P = 0.495) for BP SES and DP EES, respectively.

CONCLUSIONS

In a large, randomized trial, TLF and the individual outcomes of cardiac death and target lesion revascularization at 5 years were similar among patients treated with BP SES versus DP EES. Both target vessel-related myocardial infarction and late/very late definite/probable stent thrombosis were significantly lower with BP SES. These results confirm the durability of safety and the effectiveness of percutaneous coronary intervention with ultrathin BP SES.

Combined Analysis of Two Parallel Randomized Trials of Sirolimus-Coated and Paclitaxel-Coated Balloons in Coronary In-Stent Restenosis Lesions

BACKGROUND

Paclitaxel-coated balloons (PCBs) are a preferred treatment option for coronary in-stent restenosis. To date, data from randomized trials of alternative drug coatings are lacking. The aim of the randomized Malaysian and German-Swiss randomized trials was to investigate a novel sirolimus-coated balloon (SCB) compared with a PCB in in-stent restenosis.

METHODS

One hundred one patients with drug-eluting stent in-stent restenosis were enrolled in 2 identical randomized trials comparing the novel SCB (SeQuent SCB, 4 μg/mm²) with the clinically proven PCB (SeQuent Please, 3 μg/mm²). Primary end point was angiographic late lumen loss at 6 months. Secondary end points included procedural success, major adverse cardiac events, and individual clinical end points such as stent thrombosis, cardiac death, target lesion myocardial infarction, clinically driven target lesion revascularization, and binary restenosis.

RESULTS

Quantitative coronary angiography revealed no differences in baseline parameters. After 6 months, in-segment late lumen loss was 0.25±0.57 mm in the PCB group versus 0.26±0.60 mm in the SCB group. Mean difference between SCB and PCB was 0.01 (95% CI, -0.23 to 0.24). Noninferiority at a predefined margin of 0.35 was shown. Clinical events up to 12 months did not differ between the groups.

CONCLUSIONS

This first-in man comparison of a novel SCB with a crystalline coating showed similar angiographic and clinical outcomes in the treatment of coronary drug-eluting stent in-stent restenosis compared with PCB.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02996318, NCT03242096.

Drug-Coated Balloon for Small Coronary Artery Disease in Patients With and Without High-Bleeding Risk in the BASKET-SMALL 2 Trial

BACKGROUND

Patients at high-bleeding risk (HBR) undergoing percutaneous coronary intervention represent a challenging patient population. The use of drug-coated balloon (DCB) allows shorter duration of dual antiplatelet therapy compared with drug-eluting stents (DES) and reduces thrombotic risk due to the absence of a permanent implant. The present analysis aimed to investigate if the effect of DCB versus DES differed between patients with and without HBR treated with percutaneous coronary intervention in small coronary arteries.

METHODS

This prespecified subgroup analysis of a multicenter, randomized, noninferiority trial included 758 patients with de novo lesions in coronary vessels <3 mm and an indication for percutaneous coronary intervention, randomized to DCB (n=382) or second-generation DES (n=376). Patients were followed over 3 years for major adverse cardiac events.

RESULTS

Of the 758 patients randomized, 155 (20%) had HBR; these patients had higher mortality at 3 years (hazard ratio [95% CI], 3.09 [1.78-5.36]; P<0.001). Rates of major bleeding events were overall low but tended to be lower after DCB versus DES (1.6% versus 3.7%; P=0.064), were similar in patients with HBR (4.5% versus 3.4%) but less frequent in DCB-versus DES-treated patients without HBR (0.9% versus 3.8%). There was no difference in major adverse cardiac events between DCB and DES regardless of bleeding risk (HBR, hazard ratio: 1.16 [0.51-2.62]; P=0.719 versus non-HBR, 0.96 [0.62-1.49]; P=0.863).

CONCLUSIONS

DCBs were similarly safe and effective as current-generation DES in the treatment of coronary arteries <3 mm, regardless of bleeding risk. In patients treated with DCB, there was a trend towards a reduction of severe bleeding events at 3 years.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT01574534.

ST-segment elevation myocardial infarction with plaque erosion, to stent or not to stent: utility of intracoronary optical coherence tomography (OCT) imaging-a case report

BACKGROUND

Treating acute myocardial infarction in the setting of insignificant coronary obstruction is an emerging challenge especially with the application of intracoronary imaging like intravascular ultrasound and optical coherence tomography (OCT). The cardiologists dealing with such patients may consider not to stent if there is intracoronary imaging evidence of minimal thrombus without plaque rupture and the vessel appears patent with settling of chest pain and electrocardiogram (ECG) changes.

CASE SUMMARY

A 47-year-old gentleman presented direct to the emergency department after experiencing retrosternal chest pain with an ECG showing hyperacute anterior T waves. He had ongoing chest pain and was therefore brought to the cardiac cath lab on the primary percutaneous coronary intervention (PCI) pathway. The first picture showed that the proximal left anterior descending (LAD) was occluded (TIMI 0 flow) with evidence of large thrombus burden. Pre-dilating with a 2.5 × 15 mm balloon did not change flow. Aspiration with an Export catheter was carried out for several runs. Most of the thrombus was successfully removed; however, some of it did go into the distal LAD but was successfully retrieved with aspiration catheter. The diagonal branch was occluded with thrombus which was wired followed by thrombus aspiration establishing TIMI II flow. The procedure was covered with Eptifibatide boluses and heparin. After thrombectomy, angiographically there was no obvious lesion present within the LAD. Optical coherence tomography confirmed only mild atheroma with a small amount of plaque and minimal thrombus. There was OCT evidence of plaque erosion without any plaque rupture. The area was above 9 mm² and we decided not to treat that with a stent. The right coronary artery had an anterior take-off and was unobstructed. In conclusion, the patient had successful primary PCI to LAD with thrombus aspiration and balloon angioplasty only. He was placed on 12 months of dual antiplatelets therapy with Aspirin and Prasugrel.

DISCUSSION

This case highlights the rare presentation of patients with acute myocardial infarction with plaque erosion and the usefulness of OCT in formulating a management plan.

Functional Angioplasty: Definitions, Historical Overview, and Future Perspectives

Percutaneous coronary intervention (PCI) is used to treat obstructive coronary artery disease (CAD). The role of PCI is well defined in acute coronary syndrome, but that for stable CAD remains debatable. Although PCI generally relieves angina in patients with stable CAD, it may not change its prognosis. The extent and severity of CAD are major determinants of prognosis, and complete revascularization (CR) of all ischemia-causing lesions might improve outcomes. Several studies have shown better outcomes with CR than with incomplete revascularization, emphasizing the importance of functional angioplasty. However, different definitions of inducible myocardial ischemia have been used across studies, making their comparison difficult. Various diagnostic tools have been used to estimate the presence, extent, and severity of inducible myocardial ischemia. However, to date, there are no agreed reference standards of inducible myocardial ischemia. The hallmarks of inducible myocardial ischemia such as electrocardiographic changes and regional wall motion abnormalities may be more clinically relevant as the reference standard to define ischemia-causing lesions. In this review, we summarize studies regarding myocardial ischemia, PCI guidance, and possible explanations for similar findings across studies. Also, we provide some insights into the ideal definition of inducible myocardial ischemia and highlight the appropriate PCI strategy.