Midterm angiographic outcome of single-vessel intracoronary stent placement in diabetic versus nondiabetic patients: a matched comparative study

SGLT2 inhibitor improves the prognosis of patients with coronary heart disease and prevents in-stent restenosis

Coronary heart disease is a narrowing or obstruction of the vascular cavity caused by atherosclerosis of the coronary arteries, which leads to myocardial ischemia and hypoxia. At present, percutaneous coronary intervention (PCI) is an effective treatment for coronary atherosclerotic heart disease. Restenosis is the main limiting factor of the long-term success of PCI, and it is also a difficult problem in the field of intervention. Sodium-glucose cotransporter 2 (SGLT2) inhibitor is a new oral glucose-lowering agent used in the treatment of diabetes in recent years. Recent studies have shown that SGLT2 inhibitors can effectively improve the prognosis of patients after PCI and reduce the occurrence of restenosis. This review provides an overview of the clinical studies and mechanisms of SGLT2 inhibitors in the prevention of restenosis, providing a new option for improving the clinical prognosis of patients after PCI.

Efficacy and safety of low-dose pioglitazone after primary coronary angioplasty with the use of bare metal stent in patients with acute myocardial infarction and with type 2 diabetes mellitus or impaired glucose tolerance

Thiazolidinediones (TZDs) have beneficial effects on markers of cardiovascular risk in patients with type 2 diabetes mellitus (DM). This study aimed to investigate the efficacy and safety of low-dose pioglitazone (15 mg per day) in patients with acute myocardial infarction (AMI) and type 2 DM or impaired glucose tolerance (IGT) treated with coronary angioplasty using bare metal stent (BMS). In 56 patients, pioglitazone was orally administered for 6 months after stenting (pioglitazone group). The incidence of in-stent restenosis (ISR) and left ventricular end-diastolic volume index (LVEDVI) at acute phase and 6 months after stenting in these patients were retrospectively compared with those in the other 37 patients (control group) treated without pioglitazone. No adverse events including death, emergency bypass surgery, and reinfarction, occurred in any patients in the hospital. There was no congestive heart failure (CHF) during a follow-up period in the pioglitazone group. At 6 months after stenting, the overall angiographic ISR rate was significantly lower in the pioglitazone group than in the control group (28.6% vs 48.6%, P = 0.049). In patients with hemoglobin A1c (HbA1c) <7.0% at follow-up, the ISR rate was also significantly lower in the pioglitazone group than in controls (21.3% vs 44.8%, P = 0.03). Delta-LVEDVI (defined as follow-up LVEDVI minus acute LVEDVI) was similar between the pioglitazone group and control group (0.13 vs 5.16 ml/m(2), P = 0.482). Low-dose pioglitazone seems to have a potential to reduce ISR and does not adversely affect LV remodeling after AMI treated with coronary angioplasty using BMS in patients with type 2 DM or IGT.

[Percutaneous coronary intervention in diabetes mellitus: an updated analysis of medical practice]

Patients with diabetes and coronary artery disease are frequently considered for myocardial revascularization procedures, aiming at cardiovascular events risk reduction and a better quality of life. In clinical practice, decisions concerning surgery or percutaneous coronary intervention are frequently difficult, because of cases' severity, disease extension and co-morbidities association. Beyond that, the bulk of literature information was generated by subgroup analysis of randomized clinical trials, which were designed for the general population, not for diabetics. The aim of this study was to review literature on coronary percutaneous intervention in diabetic patients, and also to show recent data from the experience in this procedure at the Catheterization Laboratory of the Cardiology Institute of RS.

How to revascularize patients with diabetes mellitus: bypass or stents and drugs?

The diabetic patient is at high risk for coronary artery disease. Incidence as well as severity of the disease is highly increased in comparison to non-diabetic patients. The revascularization of the diabetic patient is a great challenge, since the longterm results are disappointing when compared to non-diabetic patients. The success of coronary artery bypass grafting is limited by increased perioperative mortality and a faster occlusion of especially venous bypass grafts. In percutaneous interventions the excessive high restenosis rates worsen longterm results. Several clinical trials investigated the outcome of the two revascularization strategies and could demonstrate at least a tendency towards better results when the operative approach was chosen. Particularly, the BARI trial showed reduced mortality for surgery when compared to percutaneous coronary interventions. However, in this trial, in 87% of patients undergoing bypass surgery all stenoses were successfully treated, whereas in patients undergoing percutaneous coronary intervention only 76% of all stenoses were primarily successfully treated. In addition, no stents were used in this trial.Furthermore, the enrollment of the previous trials dates one decade ago. These trials do therefore not necessarily represent the current standard therapy, especially for percutaneous coronary interventions. The restenosis rate could be decreased in recent years by means of drug-eluting stents and an aggressive antiplatelet therapy from more than 50% to less than 10% leading to considerably improved long-term results. Therefore, percutaneous coronary interventions have developed to be a reasonable alternative to bypass surgery. Different clinical trials are currently underway (BARI 2D, CarDIA, FREEDOM) comparing the outcome of the two approaches.

Diabetes e implante de stents coronarianos: experiência de um centro de referência em cardiologia intervencionista

Nosso objetivo foi avaliar a influência do diabetes mellitus (DM) na evolução clínica de pacientes com doença arterial coronariana tratada com implante de stents. Foram implantados 934 stents em 893 pacientes em nossa instituição de 1996 a 2000; 23% destes apresentavam DM. Características clínicas, angiográficas e desfechos clínicos dos pacientes com e sem DM foram prospectivamente incluídos em banco de dados computadorizado. O grupo DM tinha maior idade (61,5 ± 10 vs. 59,8 ± 11 anos; p= 0,04) e prevalência de hipertensão arterial (69% vs. 62%; p= 0,09). A taxa de sucesso clínico do procedimento (estenose residual < 30%, fluxo TIMI 3, ausência de eventos clínicos adversos na internação) foi menor nos pacientes com DM (88% vs. 92%; p= 0,05). Em 1 ano, os pacientes com DM apresentaram maiores taxas de revascularização do vaso-alvo (12,3% vs. 8%; p= 0,06), óbitos (5,4% vs. 2,5%; p= 0,03) e eventos cardiovasculares maiores (ECVM; nova angioplastia, cirurgia, infarto agudo do miocárdio ou óbito: 16,3% vs. 9,3%; p= 0,003). A presença de DM foi independentemente associada a ECVM na análise multivariada (OR: 2,00; IC: 1,253,24; p= 0,004). Concluímos que o DM associa-se a aumento do risco de complicações intra-hospitalares, re-estenose e eventos cardiovasculares maiores em pacientes submetidos ao implante de stents coronarianos.

Randomized blinded clinical trial of intracoronary brachytherapy with 90Sr/Y beta-radiation for the prevention of restenosis after stent implantation in native coronary arteries in diabetic patients

BACKGROUND

We report a double-blind, randomized clinical trial of intracoronary beta-radiation for prevention of restenosis after stent implantation in native coronary de novo lesions in diabetic patients.

METHODS

After successful stent implantation in native coronary de novo lesions, 106 lesions in 89 diabetic patients were randomly allocated to treatment with beta-radiation with 18 Gy at 1 mm vessel depth (n = 53) or placebo treatment (n = 53).

RESULTS

Angiographic analysis at 9 month follow-up revealed a late lumen loss of 0.7+/-0.9 mm in the radiotherapy group versus 1.2+/-0.8 mm in the control group at the injured segment (P = 0.006), 0.9+/-1.0 versus 1.3+/-0.7 mm at the radiated segment (P = 0.02), and 0.9+/-1.0 versus 1.3+/-0.7 mm at the target segment (P = 0.04) (defined as active source length plus 5mm on proximal and distal sites). Binary restenosis rates were significantly lower in the radiation group in all subsegments (injured segment: 10.9 versus 37.3%, P = 0.003; radiated segment: 21.7 versus 49.0%, P = 0.005; target segment: 23.9 versus 49.0%, P = 0.01). Target lesion revascularization for restenosis was required in nine lesions (17.6%) in the radiotherapy group versus 18 (34.0%) in the placebo group (P = 0.05). Late thrombosis occurred in four radiated patients (after premature discontinuation of antiplatelet therapy in all), resulting in a major adverse clinical event rate of 37.2% in the brachytherapy group versus 38.6% in the placebo group (P = ns).

CONCLUSIONS

In diabetic patients with de novo coronary lesions, intracoronary radiation after stent implantation significantly reduced restenosis. However, this clinical benefit was reduced by the frequent occurrence of late thrombosis.

Insulin resistance as a predictor for restenosis after coronary stenting

PURPOSE

The rationale of this study was to determine whether insulin resistance is an independent risk factor for restenosis after coronary stenting.

BACKGROUND

Previous studies suggested that hyperinsulinemia may be an important risk factor for ischemic heart disease. Restenosis after coronary stenting is neointimal tissue proliferation and de-novo stenosis is atherosclerosis from the point of view of histology. However, it has not been determined whether insulin resistance is independently related to restenosis after coronary stenting.

METHODS

Clinical variables of unselected population of 110 patients were analyzed in multivariate logistic regression analyses for both restenosis and de-novo stenosis. Clinical, lesion-related, and procedural variables were analyzed by chi-square analysis, and relative risk.

RESULTS

Multivariate logistic regression analysis showed that homeostasis model assessment insulin resistance (HOMA-IR) and HbA1c were associated with restenosis after coronary stenting (HOMA-IR; P=0.0447, HbA1c; P=0.0462), and HbA1c and low-density lipoprotein cholesterol (LDL-C) were associated with de-novo stenosis (HbA1c; P=0.0201, LDL-C; P=0.0204). Restenosis was influenced by insulin resistance [Relative Risk (RR) 2.06; 95 percent confidence interval (95%CI) 1.20 to 3.56], diabetes mellitus (DM: RR 1.92; 95%CI 1.25 to 2.95), and final minimal lumen diameter (RR 2.83; 95%CI 1.32 to 6.06).

CONCLUSIONS

HOMA-IR and DM are the predictors of restenosis after coronary stenting, and HbA1c and LDL-C are the predictors of de-novo stenosis. These results may be reflected in histological differences between neointimal tissue proliferation as restenosis and atherosclerosis as de-novo stenosis.

Sex-associated differences in clinical outcomes after coronary stenting in patients with diabetes mellitus

PURPOSE

It has been suggested that the influence of diabetes on cardiovascular mortality is sex dependent. We undertook this study to determine whether there were sex-related differences in 1-year clinical outcomes following coronary artery stenting in diabetic patients.

METHODS

The study included 4460 consecutive patients (1084 women) who underwent coronary artery stenting for stable or unstable angina, of whom 970 (22%) had diabetes. Six-month follow-up angiography was performed in 3452 patients (77.4%). The primary endpoint was the combined incidence of major adverse cardiac events (death, myocardial infarction, and target vessel revascularization).

RESULTS

Diabetes was associated with a significant increase in the combined incidence of death, myocardial infarction, and target vessel revascularization at 1 year in women; this incidence was greater in diabetic women than in nondiabetic women (26.9% [84/312] vs. 18.9% [146/772]; odds ratio [OR] = 1.5; 95% confidence interval [CI]: 1.2 to 2.0; P = 0.002). The primary endpoint appeared to be similar in men regardless of diabetes status (24.6% [162/658] with diabetes vs. 23.3% [634/2718] without diabetes; OR = 1.07; 95% CI: 0.90 to 1.27; P = 0.43). There was a significant interaction between diabetes and sex in both unadjusted (P = 0.03) and adjusted (P = 0.04) analyses, with diabetes having a greater negative effect in women than in men for major adverse cardiac events after coronary stenting.

CONCLUSION

In patients who underwent coronary artery stenting, the increased risk of adverse cardiac events associated with diabetes was more pronounced in women than in men.

Comparison of frequency of insulin resistance after coronary stenting in patients with type 2 diabetes mellitus with versus without coronary restenosis

The large incidence of restenosis after coronary angioplasty in diabetic patients renders this procedure less effective than in nondiabetics, and insulin resistance could be a relevant cause of restenosis in such patients. This study assessed insulin resistance and biologic markers of metabolic control in type 2 diabetic patients treated with stented angioplasty. Seventy-four patients were studied prospectively. Biochemical determinations, insulin tolerance test results, and the rate constant for plasma glucose disappearance (K(itt)%) were obtained. The angiographic outcome of angioplasty was assessed by quantitative coronary analysis at baseline and at 6 months in 64 patients (86%). Patients with restenosis had smaller minimum luminal diameters after stenting (2.8 +/- 0.5 vs 3.04 +/- 0.5 mm, p = 0.05), were more often hypertensive (97% vs 79%, p = 0.02) and treated with angiotensin-converting enzyme inhibitors (53% vs 23%, p = 0.02), and had smaller K(itt)% (2.9 +/- 1.6%/min vs 3.7 +/- 1.4%/min, p = 0.04) and larger titers of growth hormone (1.36 +/- 1.5 vs 0.68 +/- 0.6 ng/ml, p = 0.02).

Drug-eluting stents: new era and new concerns

At present there is much excitement about drug-eluting stents, which hold promise for the treatment of coronary artery disease. This ingenious therapy involves coating the outside of a standard coronary stent with a thin polymer containing medication that can prevent scarring at the site of coronary intervention. Early trials with sirolimus coated stents showed that they might prevent coronary artery restenosis, but later studies, involving more complex coronary lesions, did not show a complete absence of restenosis. Recent studies have demonstrated the long term cost effectiveness of drug-eluting stents as they have reduced the need for revascularisation procedures. At present there are few data on the safety and effectiveness of stents over follow up periods exceeding two years, and data obtained from animal models of stenting might not be completely applicable to humans. There are concerns that drug-eluting stents might delay, rather than inhibit, restenosis. Also there is concern regarding the inflammation caused by the polymer substrate. This article reviews the present data on drug-eluting stents and their benefits, shortcomings, and concerns.

Pioglitazone reduces neointimal tissue proliferation after coronary stent implantation in patients with type 2 diabetes mellitus: an intravascular ultrasound scanning study

BACKGROUND

It has been reported that pioglitazone reduces neointimal hyperplasia after balloon-induced vascular injury in an experimental model.

METHODS

To determine whether pioglitazone reduces neointimal tissue proliferation after coronary stent implantation in patients with type 2 diabetes mellitus, we studied 44 stented lesions in 44 patients with diabetes mellitus who underwent successful coronary stent implantation. Study patients were randomized into 2 groups: the pioglitazone group (23 patients with 23 lesions) and the control group (21 patients with 21 lesions). All patients underwent serial quantitative coronary angiography and serial intravascular ultrasound scanning studies. With a motorized pullback system, multiple image slices within the stent were obtained at every 1 mm. The stent area and lumen area were measured, and the neointimal area was calculated. Measurements were averaged over the number of selected image slices. The neointimal index was calculated as the averaged neointimal area divided by the averaged stent area multiplied by 100 (%).

RESULTS

After 6 months of treatment, angiographic in-stent restenosis (17% vs 43%, respectively, P =.0994) and target lesion revascularization (13% vs 38%, respectively, P =.0835) were less frequent in the pioglitazone group than the control group; however, these differences did not reach significance. The intravascular ultrasound scanning study demonstrated that the neointimal index in the pioglitazone group was significantly smaller than that in the control group (28% +/- 9% vs 48% +/- 15%, respectively, P <.0001).

CONCLUSION

A serial intravascular ultrasound scanning assessment demonstrated that pioglitazone reduces neointimal tissue proliferation after coronary stent implantation in patients with type 2 diabetes mellitus.

Endovascular therapy for stenosis of the petrous or cavernous portion of the internal carotid artery: percutaneous transluminal angioplasty compared with stent placement

OBJECT

The effects of percutaneous transluminal angioplasty (PTA) and stent placement for stenosis of the petrous or cavernous portion of the internal carotid artery (ICA) were compared.

METHODS

Twenty-four patients with symptomatic, greater than 60% stenosis of the petrous or cavernous portion of the ICA were treated using PTA or stent placement; 15 were treated with PTA and nine with stent insertion. Initial and follow-up results (> 3 months posttreatment) were compared in each group. Stenotic portions of the ICA were successfully opened in 13 of 15 patients in the PTA group, and in all nine patients in the stent-treated group. In one case in the PTA group stent delivery was attempted; however, the device could not pass through the vessel's tortuous curve, and PTA alone was performed in this case. Postoperatively, the mean stenotic ratio decreased from 72.1 to 29.6% in the PTA group, and from 75.6 to 2.2% in the stent-treated group. In four patients in the PTA group, stenoses greater than 50% were demonstrated on follow-up angiography performed at 3 to 6 months after PTA. In the stent-treated group, no restenosis was encountered, although in one case acute occlusion of the stent occurred; the device was recanalized with PTA and infusion of tissue plasminogen activator. This case was the only one of the 24 in which any neurological deficits related to the endovascular procedure occurred. Stent placement brought a greater gain in diameter than did PTA at the initial and late follow-up period; this gain was statistically significant.

CONCLUSIONS

Stent placement is more effective than PTA for stenosis of the petrous or cavernous portion of the ICA from the viewpoint of initial and late gain in diameter.

Role of vessel size as a predictor for the occurrence of in-stent restenosis in patients with diabetes mellitus

Intracoronary stents have been shown to reduce the rate of restenosis when compared with balloon angioplasty, but in-stent restenosis continues to be an important clinical problem. It was therefore the aim of this registry to identify procedural and angiographic predictors for the occurrence of in-stent restenosis. We analyzed 368 patients with 421 lesions who underwent coronary stent implantation between January 1998 and February 2000. Indications for the placement of a coronary stent were severe dissections (37%), suboptimal angiographic results (38%), restenotic lesions (20%), and graft lesions (4%). Angiographic follow-up was obtained in 270 patients (73%) with 293 lesions after 6 months. Clinical and angiographic variables were analyzed by univariate and multivariate models for the ability to predict the occurrence of in-stent restenosis, defined as a diameter stenosis >50%. In-stent restenosis was angiographically documented in 67 patients and 68 lesions (23%). Under all tested variables the reference luminal diameter before stent implantation (p = 0.006) and diabetes mellitus (p = 0.023) were identified as independent predictors for the occurrence of in-stent restenosis. The comparison of diabetic and nondiabetic patients according to vessel size revealed a 2 times higher rate of in-stent restenosis in small vessels (44% vs 23%, p = 0.002), whereas in vessels >3.0 mm the rate of in-stent restenosis was not significantly different between the 2 groups. In this registry, the clinical variable diabetes and the procedural variable reference vessel size were independent predictors for the occurrence of in-stent restenosis. In these patients, the rate of in-stent restenosis was as high as 45%.

Early and mid-term angiographic and clinical results after intracoronary duet stent placement

The Duet stent (Guidant/Advanced Cardiovascular Systems) is a new stent with a corrugated ring design and very limited data on its short- and mid-term performance. Accordingly, in this study we sought to determine the early and mid-term clinical and angiographic outcomes in a moderate-sized series of 86 consecutive patients who underwent placement of 108 premounted Duet stents in 98 coronary lesions. Procedural success, accomplished in all patients, was accompanied by a significant reduction in lesion severity from 89% +/- 11% before to 5% +/- 3% diameter stenosis after the procedure (P = 0.0001) and a 0.9% incidence of subacute stent thrombosis. Angiographic restudy at 5.7 months in 89% of eligible patients revealed a binary in-stent restenosis rate of 26%. Coronary stenting with the new Duet stent confers a low risk of stent thrombosis and a favorable mid-term clinical and angiographic outcome despite the presence of a large proportion of patients at high risk of in-stent restenosis.

Localized intracoronary gamma-radiation therapy to inhibit the recurrence of restenosis after stenting

BACKGROUND

Although the frequency of restenosis after coronary angioplasty is reduced by stenting, when restenosis develops within a stent, the risk of subsequent restenosis is greater than 50 percent. We report on a multicenter, double-blind, randomized trial of intracoronary radiation therapy for the treatment of in-stent restenosis.

METHODS

Of 252 eligible patients in whom in-stent restenosis had developed, 131 were randomly assigned to receive an indwelling intracoronary ribbon containing a sealed source of iridium-192, and 121 were assigned to receive a similar-appearing nonradioactive ribbon (placebo).

RESULTS

The primary end point, a composite of death, myocardial infarction, and the need for repeated revascularization of the target lesion during nine months of follow-up, occurred in 53 patients assigned to placebo (43.8 percent) and 37 patients assigned to iridium-192 (28.2 percent, P=0.02). However, the reduction in the incidence of major adverse cardiac events was determined solely by a diminished need for revascularization of the target lesion, not by reductions in the incidence of death or myocardial infarction. Late thrombosis occurred in 5.3 percent of the iridium-192 group, as compared with 0.8 percent of the placebo group (P=0.07), resulting in more late myocardial infarctions in the iridium-192 group (9.9 percent vs. 4.1 percent, P=0.09). Late thrombosis occurred in irradiated patients only after the discontinuation of oral antiplatelet therapy (with ticlopidine or clopidogrel) and only in patients who had received new stents at the time of radiation treatment.

CONCLUSIONS

Intracoronary irradiation with iridium-192 resulted in lower rates of clinical and angiographic restenosis, although it was also associated with a higher rate of late thrombosis, resulting in an increased risk of myocardial infarction. If the problem of late thrombosis within the stent can be overcome, intracoronary irradiation with iridium-192 may become a useful approach to the treatment of in-stent restenosis.

Clopidogrel for prevention of major cardiac events after coronary stent implantation: 30-day and 6-month results in patients with smaller stents

OBJECTIVES

We developed this study to assess the procedural outcome, complications, and clinical follow-up in patients treated with different antiplatelet regimens after intracoronary stent implantation with small stents. Three hundred sixty-one consecutive patients, in whom at least one 3.0-mm intracoronary stent was implanted, were studied.

METHODS

The study was a prospective, observational registry of unselected consecutive patients treated in our institution. Patients who underwent stent implantation between December 1997 and July 1998 were treated with aspirin and ticlopidine; those who received stents between August 1998 and February 1999 were treated with aspirin and clopidogrel.

RESULTS

In the group treated with ticlopidine, there were 190 patients who had 253 lesions treated with 274 stents. Mean age was 59.1 years, 72% were male, 31% had unstable angina, 64% had 1 stent, 36% had >1 stent, and 23% had multivessel intervention. In the group treated with clopidogrel, there were 171 patients who had 226 lesions treated with 245 stents. Mean age was 60.4 years, 79% were male, 26% had unstable angina, 70% had 1 stent, 30% had >1 stent, and 26% had multivessel intervention. Complications at 30 days in the ticlopidine group were death in 1 (0.5%), stent occlusion in 3 (1. 6%; all reopened with repeat angioplasty), non-Q-wave myocardial infarction in 2 (1%), and urgent revascularization in 4 (2%). Complications at 30 days in the clopidogrel group were noncardiac death in 1 (1.2%), cardiac death in 1 (1.2%), stent occlusion in 0, non-Q-wave myocardial infarction in 3 (1.8%), and urgent revascularization in 0. Follow-up was available in 100% of patients in both groups (mean 253 +/- 75 days in the ticlopidine group, 198 +/- 53 days in the clopidogrel group). Complications at >30 days in the ticlopidine group were death in 1 and clinical restenosis in 11 (5.8%); 1 additional patient had an admission with unstable angina to the local hospital. Hence, recurrent angina as a consequence of target lesion restenosis occurred in 5.8%. Complications at >30 days in the clopidogrel group were death in 0 and clinical restenosis in 8 (4.7%); 2 additional patients were admitted with unstable angina to the local hospital, and 1 patient had a myocardial infarction 164 days after stent implantation. Hence, recurrent angina as a consequence of target lesion restenosis occurred in 4.7%. There were no significant differences in complications between the 2 groups.

CONCLUSIONS

Our observations suggest that clopidogrel can be used instead of ticlopidine in patients treated with stents with a diameter of </=3.0 mm, without any increase in major adverse cardiac events, both within the first 30 days and at medium-term follow-up. Clopidogrel has significant cost advantages over ticlopidine, and carries a superior side-effect profile. We suggest that, in combination with aspirin, clopidogrel should replace ticlopidine as standard antiplatelet therapy after intracoronary stent implantation.

Nine-year follow-up of balloon-expandable Palmaz-Schatz stent in patients with single-vessel disease

The long-term effects of intracoronary stents in human are unknown. This is the first 9-year follow-up report of single-vessel-disease patients treated with the Palmaz-Schatz stent. Between March and December 1989, out of the 107 patients undergoing Palmaz-Schatz stent implantation, 71 (66%) had single-vessel disease. The average age of these patients was 58+/-9 years and 79% were men. At 9 years, follow-up was obtained for 90.1% and major adverse clinical events consisted of 4 deaths giving a global survival rate of 95.8%, 7 myocardial infarction, 3 bypass surgeries, and 16 repeat percutaneous revascularization procedures. The 9-year event-free survival rate was 60%, and 81.7% of the patients were free from death, myocardial infarction, and bypass surgery. Multivariate analysis showed that the only predictive factor of major adverse clinical events was the presence of diabetes mellitus (P<0.004). Cathet. Cardiovasc. Intervent. 50:170-174, 2000.

Current perspectives on interventional treatment strategies in diabetic patients with coronary artery disease

Diabetes mellitus has a negative impact on mortality and morbidity following catheter-based coronary procedures as well as coronary artery bypass surgery. Increased restenosis remains the main limitation of catheter-based coronary intervention among diabetes mellitus in addition to accelerated atherosclerosis lesion progression in other untreated coronary sites. Determinants such as excess restenosis, high atherosclerosis burden, lesion complexity, small target vessel size, and accelerated coronary atherosclerosis in remote sites may favor the surgical strategy in most cases of diabetic multivessel disease. The importance of periprocedural adjunctive pharmacotherapy, specifically with the use of antiplatelet and long-term antilipidemic treatment, was shown to improve outcomes in diabetics undergoing percutaneous coronary interventions. The purpose of the review is to examine potential mechanisms causing more restenosis in diabetics, the clinical outcomes of patients with diabetes after coronary interventions including stenting, the treatment alternatives of diabetic patients with diffuse coronary artery disease, including coronary bypass surgery, and current understanding of the benefit of adjunctive pharmacology on clinical outcomes after coronary interventions among diabetics.

Influence of treatment modality on angiographic outcome after coronary stenting in diabetic patients: a controlled study

OBJECTIVES

This retrospective study was designed to determine the six-month angiographic outcome after stenting of native coronary arteries in insulin-treated (ITDM) and non-ITDM patients with diabetes mellitus (DM) and compare the results with those in non-DM patients.

BACKGROUND

The influence of the treatment modality for DM on restenosis in patients undergoing coronary artery stenting has not been elucidated sufficiently.

METHODS

A total of 1,439 (70%) of 2,061 patients underwent repeated angiography within six months of coronary stenting. The ITDM and non-ITDM (oral hypoglycemic drugs or diet) were documented in 48 (3.3%) and 177 patients (12.3%), respectively, leaving 1,214 non-DM patients.

RESULTS

Baseline reference vessel diameter tended to be smaller in ITDM patients (mean, 2.73 mm) than in non-DM and non-ITDM patients (2.88 mm and 2.85 mm, respectively). However, percent diameter stenosis was not different. The median number of stents deployed was 1; median stent length was 15 mm. Statistically significant differences were present after stenting for the means of minimal lumen diameter (MLD) and acute gain between ITDM patients (MLD: 2.67 mm, acute gain: 1.98 mm) and non-DM patients (MLD: 2.81 mm, acute gain: 2.16 mm). At follow-up, percent diameter stenosis, late lumen loss and loss index were significantly higher in both non-ITDM lesions (42%, 1.14 mm and 0.56, respectively) and ITDM lesions (48%, 1.26 mm and 0.65, respectively) than in non-DM lesions (35%, 0.96 mm and 0.45, respectively). The corresponding differences between non-ITDM and ITDM lesions did not reach statistical significance. Restenosis rates in non-DM, non-ITDM and ITDM lesions were 23.8%, 32.8% (p = 0.013 vs. non-DM) and 39.6% (p = 0.02 vs. non-DM, p = 0.477 vs. non-ITDM), respectively.

CONCLUSIONS

This study showed that compared with stenting in non-DM patients, stenting of native coronary arteries in DM patients is associated with significantly increased lumen renarrowing, regardless of the treatment modality for DM.

Clinical and angiographic outcome after angiography-guided stent placement in small coronary vessels

BACKGROUND

Although it is widely accepted that stenting confers favorable angiographic and clinical results in coronary arteries >/=3.0 mm in diameter, the outcome of stent placement in smaller vessels remains largely unclear.

METHODS AND RESULTS

We sought to specifically determine the early and long-term clinical outcomes in a large series of 197 consecutive patients who underwent stent placement in 207 vessels <3.0 mm in diameter. Procedural success, accomplished in 97.3%, was accompanied by a significant reduction in lesion severity from 85% +/- 9% before to 3% +/- 7% diameter stenosis after the procedure (P =.0001) and a 0.5% incidence of subacute stent thrombosis. At 1 and 2 years of follow-up, survival rate without major target lesion-driven events was observed in 77.3% and 73.9% of patients, respectively. Repeat revascularization procedures accounted for most of these events; cardiac deaths (including those related to subacute stent thrombosis) and late (>30 days) myocardial infarctions were infrequent (2.4% and 1.0%, respectively). The 6-month angiographic binary instent restenosis rate was 30.1%. On multivariate analysis, diabetes mellitus (P =. 0275), small baseline reference vessel size (P =.0300), and stent size </=2.7 mm (P =.0111) were independently associated with an increased instent restenosis rate.

CONCLUSIONS

Optimal angiography-guided coronary stenting of vessels <3.0 mm in diameter in association with the stringent use of a poststent combined aspirin-ticlopidine antiplatelet regimen confers a low risk of stent thrombosis, an acceptable incidence of angiographic instent restenosis, and a favorable long-term clinical outcome.

Mid-term clinical and angiographic follow-up outcome after placement of a new balloon expandable stent in native coronary arteries

The widely disparate characteristics that exist among the different stent designs currently available for clinical use may impact on their acute and late angiographic and clinical results. The BeStent (Medtronic Instent, MN) is a relatively new stainless steel, laser-cut, serpentine stent design with only very limited data regarding its performance. In this report, we examined the results of 74 consecutive patients (54 men, 20 women; mean age, 58 years) treated with 76 BeStents in 75 native coronary arteries with a mean reference size of 2.8 mm. Successful stenting without 30-day major adverse cardiac complications was achieved in 97.3% of procedures, resulting in a significant improvement in diameter stenosis from 85% to 2% (P = 0.0001). Six-month angiographic restudy in 88% of patients revealed a per-lesion in-stent restenosis rate of 27%. At a mean follow-up period of 9.3 months, there were no deaths or myocardial infarctions. In summary, the present study demonstrates that the BeStent has an excellent performance profile, is associated with a low risk of stent thrombosis, and yields an acceptable restenosis rate despite the inclusion of a high proportion of patients with diabetes (41%) and small vessels (< 3.0 mm in diameter; 77%).