Randomized comparison of success and adverse event rates and cost effectiveness of one long versus two short stents for treatment of long coronary narrowings

Comparison of outcomes between single long stent and overlapping stents: a meta-analysis of the literature

OBJECTIVES

There is no consensus on whether to treat diffuse coronary artery lesions with a single long stent (SLS) or by overlapping two or more stents (OLS). The goal of this review was to compare the outcomes of these two approaches through a meta-analysis of the literature.

METHODS

We searched for relevant studies in MEDLINE, Scopus, EMBASE, Google Scholar, and the Cochrane Library. Our meta-analysis included 12 studies (n = 6414) that reported outcomes during the follow-up period.

RESULTS

Individuals who received OLS had a greater risk of cardiac mortality and target lesion revascularization (TLR) than those who received SLS (RR: 1.51, CI: 1.03-2.21, p = 0.03, I2 = 0% and RR: 1.64, CI: 1.02-2.65, p = 0.04, I2 = 38%, respectively). The fluoroscopy period in the OLS group was longer than in the SLS group (SMD: 0.35, CI: 0.25-0.46, p < 0.01, I2 = 0%). more contrast volume was sued for the OLS group; however, there was substantial variability in the pooled analysis (I2 = 95%). In terms of all outcomes, there were no differences between stent generation types.

CONCLUSION

In the first meta-analysis of mainly observational data comparing OLS vs. SLS for long coronary lesions, OLS had higher rates of cardiac mortality and TLR as well as longer fluoroscopy times compared to SLS.

Ultrathin Strut Biodegradable Polymer-Coated Sirolimus-Eluting Coronary Stents: Patient-Level Pooled Analysis From Two Indian Registries

Background Despite significant evolution in stent technology, female gender, and patients with diabetes mellitus, multivessel disease, total occlusions, long lesions, and small vessels represent the "Achilles' heel" of contemporary percutaneous coronary intervention (PCI). We performed a pooled analysis of high-risk subgroup on patient-level data from the T-Flex registry (1,203 patients) and a real-world Indian registry (1,269 patients), with the aim of assessing one-year safety and clinical performance of ultrathin strut biodegradable polymer-coated Supra family of sirolimus-eluting stents (SES) (Sahajanand Medical Technologies Limited, Surat, India) in the real-world, all-comer population. Method We pooled the following high-risk subgroups data from two all-comer registries: female gender (n=678), diabetes mellitus (n=852), multivessel disease (n=406), total occlusions (n=420), long lesions (≥28 mm) (n=1241), and small vessels (≤2.5 mm) (n=726). Both the registries included patients with coronary artery disease who underwent implantation of at least one SES belonging to the Supra family of stents from May 2016 until March 2018, irrespective of lesion complexity and comorbidities. The primary endpoint was the inci-dence of target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction, and clinically indicated target lesion revas-cularization by percutaneous or surgical methods up to one year. The safety endpoint was stent thrombosis.  Results According to prespecified high-risk subgroups, one-year rates of TLF and overall stent thrombosis, respectively, were as follows: female gender (4.9% and 0.6%), diabetes mellitus (6.9% and 1.0%), multivessel disease (6.4% and 0.8%), total occlusions (5.2% and 0.5%), long lesions (≥28 mm) (6.6% and 0.8%), and small vessels (≤2.5 mm) (6.1% and 1.3%). Conclusion This present pooled analysis demonstrated the one-year safety and clinical performance of ultrathin strut biodegradable polymer-coated Supra family of SES in a real-world, all-comer population, with considerably low rates of TLF and stent thrombosis.

One-year Outcomes of XIENCE Skypoint 48-mm Drug-Eluting Stents in Long Coronary Lesions: The SPIRIT 48 Trial

Background

Diffuse coronary artery disease may need multiple overlapping stents, associated with less favorable outcomes than those of a single stent. The availability of longer stents can circumvent the need for overlapping stents in long lesions. This prospective, single-arm, SPIRIT 48 trial evaluated the safety and effectiveness of Abbott's next-generation drug-eluting stent, XIENCE Skypoint 48, in patients with coronary artery disease with long de novo native coronary lesions.

Methods

SPIRIT 48 enrolled 107 patients at 25 sites in 3 countries. Patients were required to have 1 target lesion treated with XIENCE Skypoint 48 (lesion length of >32.0 mm and ≤44.0 mm). The primary end point was target lesion failure (TLF; composite of cardiac death, target vessel-related myocardial infarction, or clinically indicated target lesion revascularization) at the 1-year compared with a prespecified performance goal of 20%, established through historical control data. This study recently completed its 1-year follow-up.

Results

XIENCE Skypoint 48 was implanted in 105 patients with a device success rate of 97.2%. SPIRIT 48 met its primary end point, with a TLF rate of 5.7%, and the upper bound of 95% CI at 9.5% (

Conclusions

Primary end point data obtained at the 1-year follow-up from the SPIRIT 48 trial present strong evidence supporting the deliverability, safety, and effectiveness of XIENCE Skypoint 48 mm drug-eluting stent in treating long de novo coronary lesions.

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Key Words

• coronary disease
• drug-eluting stents
• percutaneous coronary intervention

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Affiliation(s)

Ki E. Park Division of Cardiovascular Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, Florida
Chiung-Jen Wu Department of Cardiology, Chung-Gung Memorial Hospital, Kaohsiung, Taiwan
Bassem Chehab Department of Medicine, Ascension Via Christi Hospital, University of Kansas, Wichita, Kansas
Aziz Maksoud Department of Medicine, Cardiovascular Research Institute of Kansas, University of Kansas, Wichita, Kansas
Barry Bertolet Cardiac Catheterization Laboratory, North Mississippi Medical Center, Tupelo, Mississippi
Shih-Wa Ying Abbott Vascular, Santa Clara, California
Tiessa Simoes Abbott Vascular, Santa Clara, California
Sandeep C. Pingle Abbott Vascular, Santa Clara, California
Chi-Jen Chang Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Tapei, Taiwan

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Impact of the ultra-long 48 mm drug-eluting stent on procedural and clinical outcomes in patients with diffuse long coronary artery disease

BACKGROUND

Diffuse coronary artery disease (CAD) is a prognostic factor after percutaneous coronary intervention (PCI) and requires multiple overlapping stent implantations.

HYPOTHESIS

We investigated the impact of ultra-long 48 mm drug-eluting stent (DES) on procedural and clinical outcomes in real-world practice.

METHODS

Patients who underwent DES implantation for a lesion length of >40 mm were selected from a prospective registry between 2019 and 2021. Patients treated with one or more ultra-long 48 mm DES were in the ultra-long DES group (n = 221). The others comprised the conventional DES group (n = 428). Procedural and clinical outcomes were compared after propensity score matching (PSM). The primary endpoint was a device-oriented composite outcome (DOCO) consisting of cardiac death, target vessel-related myocardial infarction, and target lesion revascularization at 1-year follow-up.

RESULTS

After PSM, 158 matched pairs of patients showed no differences in the baseline clinical and angiographic characteristics. The stent delivery failure rate, the use of guide-extension catheter or anchor balloon technique, and the procedural success rate were similar for both groups. Approximately two-thirds of lesions could be treated with one DES in the ultra-long DES group. At 1-year follow-up, the DOCO was similar for both groups (2.5% vs. 0.6%, p = .168).

CONCLUSIONS

In daily clinical practice, ultra-long DES implantation is as safe and effective as multiple overlapping conventional DES implants in treating diffuse long CAD. However, ultra-long DES can reduce the number of stents. (Trial Registration: ClinicalTrials.gov Identifier: NCT02038127).

Safety and efficacy of Everolimus-Eluting bioabsorbable Polymer-Coated stent in patients with long coronary lesions: The EVOLVE 48 study

Objectives

The EVOLVE 48 study evaluated the safety and effectiveness of the SYNERGY 48 mm stent for the treatment of long lesions.

Background

Clinical evidence supporting the use of very long stents during percutaneous coronary intervention (PCI) is limited. The bioabsorbable polymer SYNERGY stent has shown good long‐term data in a broad population of patients undergoing PCI.

Methods

Patients with lesion length >34‐ ≤44 mm and reference vessel diameter (RVD) ≥2.5‐ ≤ 4.0 mm were enrolled in this prospective, multicenter, single‐arm study. The primary endpoint was 12‐month target lesion failure (TLF; composite of target lesion revascularization [TLR], target‐vessel myocardial infarction [TV‐MI], or cardiac death) compared to a prespecified performance goal (PG).

Results

A total of 100 patients with mean lesion length of 35.34 ± 7.15 mm (26 patients with lesion length > 40 mm) and mean RVD 2.72 ± 0.44 mm were enrolled. Moderate to severe calcification was present in 30% of the patients and 89% had pre‐TIMI flow grade 3. The rates of technical and clinical procedural success were 100%. One‐year TLF was observed in 4.1% patients compared to a prespecified PG of 19.5% (95% upper confidence bound = 9.1%; p < 0.0001). Cardiac death and TLR were each observed in one patient, and TV‐MI in two patients treated with SYNERGY 48 mm stent. Between the 1‐2‐year timeframe, TV‐MI occurred in one additional patient. None of the patients experienced a definite or probable stent thrombosis through 2 years.

Conclusions

PCI of long coronary lesions with the 48 mm SYNERGY stent demonstrated good procedural and clinical outcomes through 2 years, supporting its clinical safety and efficacy.

Impact of ultra-long sirolimus-eluting stents on coronary artery lesions: one-year results of real-world FLEX-LONG Study

BACKGROUND

The FLEX-LONG study assessed the safety and clinical outcomes of ultra-long (44 mm/48 mm) biodegradable polymer-coated Supraflex (Sahajanand Medical Technology Pvt. Ltd., Surat, India) sirolimus-eluting stents (SES) in real-world patients with complex, long coronary artery lesions.

METHODS

It was an investigator-initiated, retrospective, non-randomized, observational and single-center study, which evaluated one-year results of 141 patients who had undergone implantation of at least one ultra-long (44 mm/48 mm) Supraflex SES. The incidence of major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction (MI) and target lesion revascularization (TLR), at one-year follow-up was considered as primary outcome. Stent thrombosis was analyzed as a safety outcome.

RESULTS

The mean age of the study population was 56.2±9.6 years and 78.0% (110/141) patients were male. The study analyzed high risk patients, including 62 (44.0%) hypertensive and 60 (42.6%) diabetic patients. Total 147 target lesions were treated, including 25 (17.0%) total occlusions. Total 51 (34.7%) and 96 (65.3%) Supraflex SES of 44 mm and 48 mm were implanted, respectively. Average stent length and diameter were 46.6±1.9 mm and 3.4±0.2 mm, respectively. One-year follow-up was obtained in 100% of patients. There was one probable stent thrombosis after three weeks. At one-year follow-up, 99.3% of patients remained event free.

CONCLUSIONS

The results of the FLEX-LONG study support the use of ultra-long (44 mm/48 mm) Supraflex SES, in the treatment of high-risk real-world patients. The stent appeared to be safe and effective at one-year with low clinical events in complex, long coronary artery lesions.

Long-term results of stenting of long coronary artery stenosis with consecutive implantation of stents of different types with overlapping edges in patients with acute coronary syndrome without ST-segment elevation and multivessel coronary artery disease

Introduction. In urgent interventional cardiology practice, combinations of drug-eluting stents and bare-metal stents are sometimes forced to treat extended stenosis in a clinic-dependent artery. Objective. A comparison of long-term results of treatment of patients with coronary heart disease and multivessel coronary lesions, which performed stenting of the clinic-dependent artery by two successive partially overlapping stents using stents of the 3rd generation with drug coating or a combination of the 3rd generation stent with drug coating and a bare-metal stent for acute coronary syndrome without St segment elevation and later — complete functional myocardial revascularization by endovascular method. Methods. The minimum overall length sentiremos section was made 55 mm. In main group included 32 patients for whom revascularization clinic-dependent artery performed endovascular intervention with the use of 2 stents 3-generation drug-coated sirolimus and biodegradable polymer implanted overlap. In 30 patients (control group), clinic-dependent artery revascularization was also performed by a combination of implanted overlap stents, one of which was a 3rd generation stent with sirolimus drug coating and biodegradable polymer, and the other was a bare-metal stent. There were no statistically significant differences between the groups in clinical, demographic and operational characteristics. Results. The analysis of the results revealed a significant difference between the groups in the frequency of repeated revascularization of the target artery, which were observed more often in the control group. Conclusion. When performing an extended stenting of the clinic-dependent artery in patients with acute coronary syndrome without ST segment elevation, overlapping of the drug-coated stent and the bare-metal stent should be avoided, since the antirestenotic effect of the drug-coated stent is leveled when overlapping with the bare-metal stent, but this strategy can be used in case of full coverage of the stenotic lesion or closure of the dissection.

Novel ultra-long (48 mm) everolimus-eluting stent for diffusely coronary vessels disease

BACKGROUND

Long drug-eluting stents may limit the need of stent overlaps in patients with diffusely diseased coronary arteries. We evaluated the clinical results of percutaneous-coronary-intervention (PCI) using a novel ultra-long (48 mm) everolimus-eluting stent (EES) in a real-word population.

METHODS

Patients who underwent PCI with 48 mm EES between June 2015 and April 2017 in our Center were enrolled. The only exclusion criteria was cardiogenic shock established before PCI. Target vessels were divided in "very long lesion" (>38 mm) and "multiple focal disease" (multiple stenoses separated by healthy coronary segments >10 mm). Clinical follow-up was obtained to evaluate the occurrence of device-oriented composite endpoint (DOCE) (primary end-point).

RESULTS

A total of 216 patients were identified (70.6±11 years, 48.1% acute coronary syndrome) who were treated on 230 vessels. The target vessel appearance was "very long lesion" in 44.8% of cases and "multiple focal disease" in 55.2%. A single 48-mm EES was implanted in 129 (56.1%), while additional overlapping stents were needed in 101 cases (43.9%). Total stent length was 64.9±24.0 mm. The median follow-up time was of 474 (411-614) days, DOCE occurred in 7% of patients. No stent thrombosis was noticed. At multivariate analysis, diabetes was associated with DOCE increase (P=0.02), while "multiple focal disease" predicted lower DOCE (P=0.02).

CONCLUSIONS

The present real-world experience shows promising clinical results with the use of ultra-long stents in order to limit the need of stents overlaps in patients with diffuse coronary disease undergoing PCI.

Successful Treatment of Symptomatic Intracranial Carotid Artery Stenosis Using a 24-mm Long Bare Metal Coronary Stent

BACKGROUND

Intracranial arterial atherosclerosis represents a common cause of stroke. Despite aggressive and optimal medical management, many patients will unfortunately suffer additional cerebrovascular events. The role of endovascular intervention for intracranial atherosclerotic disease continues to be uncertain, particularly in regard to extensive, symptomatic stenosis.

CASE DESCRIPTION

We present a case of a 42-year-old man with a complex medical history who presented with recurrent ischemic stroke in the ipsilateral hemisphere despite optimal medical management. Given the length of stenosis and the luminal size of the intracranial cavernous and petrous segments of the internal carotid artery, we used a bare metal coronary stent (4.0 mm × 24 mm). This represents one of the longest stents deployed for intracranial disease reported in the literature.

CONCLUSIONS

This case illustrates that a long coronary stent might be successfully used to manage extensive intracranial lesions. We also review the efficacy of using 1 very long stent versus multiple overlapping stents, with reference to the coronary angiography literature.

Stent placement for treatment of long-segment (≥40 mm) carotid atherosclerotic stenosis: results and long-term follow-up in a single-center experience

BACKGROUND

Treatment of long segment carotid stenosis (≥40 mm) with carotid artery stenting (CAS) has rarely been reported. In randomized trials, use of longer stents (>40 mm) has been associated with adverse clinical events. Here, we report our preliminary experience on the stent length and outcome in treating long segment carotid arterial stenosis.

METHODS AND RESULTS

Between August 2003 and February 2013, 22 patients with long segment stenosis of the carotid artery were treated by CAS. The mean stent length was 58.5 mm (50-60 mm). The procedures were successful in all patients, and all reported remarkable relief of symptoms immediately after stent placement. Complications included 1 case of cerebral hemorrhage and one death from myocardial infarction at 10 months. The mean follow up was 27.3 months (10-60 months). One follow-up was lost. 2 patients had late stent thrombosis at 22 and 36 months by CTA follow-up. 18 patients had persistent relief, and angiography/CTA showed normal carotid flow.

CONCLUSIONS

Our study showed that stenting for long carotid stenosis (≥40 mm) can be beneficial. Large scale clinical trial is needed to further evaluate its efficacy and safety.

Stent placement for treatment of long segment (≥80 mm) carotid artery stenosis in patients with Takayasu disease

PURPOSE

To evaluate the effectiveness and safety of carotid artery stent (CAS) placement for treatment of long segment stenosis in patients with Takayasu arteritis.

MATERIALS AND METHODS

Between January 2002 and February 2012, all patients with Takayasu arteritis found to have long segment (≥80 mm) carotid artery stenoses at a single institution were retrospectively analyzed. Five patients treated by CAS placement with either long or multiple self-expandable stents were included. All patients had focal neurologic symptoms, including three strokes and two transient ischemic attacks (TIAs). Six self-expanding stents were used in five patients. The mean follow-up period was 19.2 months (range, 6-30 mo); all patients had clinical evaluation, laboratory examination, and vascular imaging follow-up.

RESULTS

Improvement in clinical symptoms was shown after successful angioplasty. There were no perioperative or in-hospital deaths. Four patients exhibited persistent relief, and repeated angiography or computed tomography (CT) angiography showed normal flow. One patient stopped taking her medications after CAS placement and became symptomatic 8 months later as a result of a severe in-stent stenosis.

CONCLUSIONS

CAS placement was shown to be a feasible option for treating long segment (≥80 mm) stenosis of carotid arteries in patients with Takayasu arteritis with encouraging results.

Outcomes of stenting with overlapping drug-eluting stents versus overlapping drug-eluting and bare-metal stents for the treatment of diffuse coronary lesions

INTRODUCTION

we investigated the outcomes of stenting with overlapping drug-eluting stents (DES) versus overlapping stenting with a combination of drug-eluting and bare metal stents (BMS) in very long coronary lesions (≥ 25 mm).

METHODS AND RESULTS

fifty-two patients treated with either overlapping DES-DES (n = 22) or DES-BMS (n = 30) were selected from a registry of 588 patients with very long coronary lesions. Patients with acute myocardial infarction (MI) within the preceding 48 hours were excluded. The DES-DES combination was more frequently used for longer lesions compared with the DES-BMS group (47.95 ± 9.25 vs 39.98 ± 9.15 mm, p = 0.003). Left anterior descending artery lesions were also more frequently treated with the DES-DES combination (95.5 vs 66.7%, p = 0.02). In four patients in the DES-BMS group, overlapping stents were used for the coverage of dissections. Peri-procedural non-Q-wave MI occurred in one patient in the DES-BMS group. On follow up, only one case of non-fatal MI occurred in a patient with overlapping DES-DES.

CONCLUSION

overlapping a BMS in the proximal part of a long DES instead of exclusive deployment of two or more overlapped DES seems to be a safe and feasible therapeutic strategy in our practice.

Periprocedural and Late Consequences of Overlapping Cypher Sirolimus-Eluting Stents

OBJECTIVES

The purpose of this research was to determine the relative safety and efficacy of multiple (> or =2) overlapping Cypher sirolimus-eluting stents (SES) (Johnson & Johnson, New Brunswick, New Jersey).

BACKGROUND

Overlapping coronary stents are common. The periprocedural and late clinical and angiographic consequences of overlapped coronary stents are not clearly defined, particularly for drug-eluting stents.

METHODS

All patients enrolled into five clinical trials of the SES were analyzed. Three of these trials were prospective randomized comparisons of the SES to the bare-metal stent (BMS), and two were prospective non-randomized trials of SES-treated patients with historical controls. All clinical and angiographic outcomes in overlap-stent-treated patients were compared by stent type and with single-stent-treated patients for the same stent device.

RESULTS

In all, 575 patients with stent overlap (337 SES, 238 BMS) and 1,162 patients with single stents (697 SES, 465 BMS) were analyzed. Stent overlap was associated with a greater late lumen loss in stent and more frequent angiographic restenosis regardless of stent type. Among overlap-stent-treated patients, the SES provided similar magnitude of restenosis benefit as observed for single-stent-treated patients. Overlapped SES was not associated with an increase in myocardial infarction.

CONCLUSIONS

The strategy of SES overlap, when required, is both safe and efficacious in reducing restenosis with no increase in the incidence of myocardial infarction or major adverse cardiovascular events, when compared with a bare metal coronary stent prosthesis.

Subgroup analyses in therapeutic cardiovascular clinical trials: are most of them misleading?

BACKGROUND

Treatment decisions in clinical cardiology are directed by results from randomized clinical trials (RCTs). We studied the appropriateness of the use and interpretation of subgroup analysis in current therapeutic cardiovascular RCTs.

METHODS

We reviewed main reports of phase 3 cardiovascular RCTs with at least 100 patients, published in 2002 and 2004, and from major journals (Circulation, J Am Coll Cardiol, Am Heart J, Am J Cardiol, N Engl J Med, Lancet, JAMA, BMJ, Ann Intern Med). Information on subgroups included prespecification, number, interaction test use, significant subgroups found, and emphasis on findings. We examined appropriateness of reporting and differences according to sample size, overall trial result, and CONSORT adoption.

RESULTS

We selected 63 RCTs, with a median of 496 (range 100-15,245) patients. Thirty-nine RCTs were reported with subgroup analyses and 26 with > 5 subgroups. No trial was specifically powered to detect subgroup effects, and only 14 RCTs were reported with fully prespecified subgroups. Only 11 RCTs were reported with interaction tests. Furthermore, 21 RCTs were reported with claims of significant subgroups and 15 with equal or more emphasis to subgroups than to the overall results. Subgroup analyses in large RCTs (> 500 patients) were reported more often than in small ones (24/30 vs 15/33, P = .005). No differences were found according to overall result (positive/negative) or CONSORT adoption.

CONCLUSIONS

Subgroup analyses in recent cardiovascular RCTs were reported with several shortcomings, including a lack of prespecification and testing of a large number of subgroups without the use of the statistically appropriate test for interaction. Reporting of subgroup analysis needs to be substantially improved because emphasis on these secondary results may mislead treatment decisions.

Drug-Eluting Coronary Stents

The introduction and widespread use of coronary stents have been the most important advancement in the percutaneous treatment of coronary artery disease since the introduction of balloon angioplasty. Coronary artery stents reduce the rate of angiographic and clinical restenosis compared to balloon angioplasty. This angiographic restenosis was further reduced with the introduction of drug-eluting stents and hence further reduction in the frequency of major adverse cardiac events. Herein we present a comprehensive and up-to-date review about the use of drug-eluting stents in the treatment of coronary artery disease.

Latent plaque rupture in a patient undergoing stenting for acute coronary syndrome and diffuse coronary disease: A case report and review of literature

Secondary prevention of plaque rupture following percutaneous coronary intervention in patients with acute coronary syndrome is not well studied. This case report describes a 53-year-old man who experienced plaque rupture between two previously successfully implanted stents in the right coronary artery, as documented during the 3rd intervention using intravascular ultrasound.

Clinical Efficacy of Polymer-Based Paclitaxel-Eluting Stents in the Treatment of Complex, Long Coronary Artery Lesions From a Multicenter, Randomized Trial

Background— Intracoronary polymer-based stent delivery of paclitaxel has been shown to be effective in reducing restenosis in simple coronary lesions, but the evidence base for contemporary use in longer, more complex coronary stenoses is lacking.

Methods and Results— TAXUS VI is a prospective, multicenter, double-blind, randomized trial assessing clinical and angiographic outcomes of the TAXUS Moderate Release paclitaxel-eluting stent in the treatment of long, complex coronary artery lesions. Four hundred forty-eight patients at 44 sites were randomized (1:1) between a drug-eluting TAXUS Express 2 and an uncoated Express 2 control stent. Per protocol, the 9-month follow-up included an angiographic reevaluation in all patients. The primary end point was the rate of target-vessel revascularization 9 months after the study procedure; secondary end points included the rate of target-lesion revascularization and binary restenosis at follow-up. Mean lesion length in the study was 20.6 mm, with a mean stent-covered length of 33.4 mm. Of all lesions, 55.6% were classified as complex lesions (type C of the AHA/ACC classification). At 9 months, target-vessel revascularization was 9.1% in the TAXUS group and 19.4% in the control group ( P =0.0027; relative reduction, 53%). Target-lesion revascularization was reduced from 18.9% to 6.8%, respectively ( P =0.0001). The incidence of major adverse cardiac events was similar in the 2 groups, 16.4% and 22.5% in TAXUS and control, respectively ( P =0.12), including comparable rates for acute myocardial infarction. Binary restenosis in the stented area was reduced from 32.9% in the control group to 9.1% in the TAXUS patients ( P <0.0001).

Conclusions— The finding that the TAXUS Moderate Release stent system is safe and effective in the treatment of long, complex coronary artery lesions provides the evidence base for the more widespread use of drug-eluting stents in contemporary clinical practice.

Very long sirolimus-eluting stent implantation for de novo coronary lesions

Long-length stenting has a poor outcome when bare metal stents are used. The safety and efficacy of the sirolimus-eluting stent (SES) in long lesions has not been evaluated. Therefore, the aim of the present study was to evaluate the clinical and angiographic outcomes of SES implantation over a very long coronary artery segment. Since April 2002, all patients treated percutaneously at our institution received a SES as the device of choice as part of the Rapamycin Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry. During the RESEARCH registry, stents were available in lengths of 8, 18, and 33 mm. The present report includes a predefined study population consisting of patients treated with >36-mm-long stented segments. Patients had a combination of >or=2 overlapping stents at a minimum length of 41 mm (i.e., one 33-mm SES overlapping an 8-mm SES) to treat native de novo coronary lesions. The incidence of major cardiac adverse events (death, nonfatal myocardial infarction, and target lesion revascularization) was evaluated. The study group comprised 96 consecutive patients (102 lesions). Clinical follow-up was available for all patients at a mean of 320 days (range 265 to 442). In all, 20% of long-stented lesions were chronic total occlusions, and mean stented length per lesion was 61.2 +/- 21.4 mm (range 41 to 134). Angiographic follow-up at 6 months was obtained in 67 patients (71%). Binary restenosis rate was 11.9% and in-stent late loss was 0.13 +/- 0.47 mm. At long-term follow-up (mean 320 days), there were 2 deaths (2.1%), and the overall incidence of major cardiac events was 8.3%. Thus, SES implantation appears safe and effective for de novo coronary lesions requiring multiple stent placement over a very long vessel segment.

Overlapping vs. one long stenting in long coronary lesions

Intervention of long coronary lesions remains problematic, and optimal treatment strategy is yet to be determined. Despite advancement of stent technology, data are few regarding the efficacy of overlapping stents vs. a single long stent in long coronary lesions. This study was performed to evaluate the results of those strategies for long coronary lesions and to determine the predictors of in-stent restenosis (ISR). Sixty-four lesions (> 20 mm) in 64 patients were treated with either one long stent (group 1, n = 32) or two overlapping stents (group 2, n = 32). Overlapping stents were used at tortuous or calcified lesions and at lesions with diameter discrepancy or significant dissection. Immediate results, follow-up clinical and angiographic outcomes, and predictors of ISR were evaluated. Procedures were successful in all patients in both groups. Clinical and angiographic follow-ups were performed in 54 (84%) cases and 50 (78%) cases, respectively. During the follow-up, major adverse cardiac event occurred in 36% of group 1 and 29% of group 2 (P = 0.56). Six-month ISR rates were 39% in group 1 and 41% in group 2 (P = 0.91). Age (>/= 65 years old) was an independent risk factor of ISR (54% vs. 23%; OR = 4.4; P = 0.04), and distal reference diameter (RD) of less than 2.5 mm tended to predict ISR in multivariate analysis (60% vs. 25%; OR = 3.5; P = 0.06). In conclusion, stent overlapping can be used with outcome similar to that of one long stent in long coronary lesions. The optimal result may be obtained by considering the patient's age and the distal vessel diameter of the lesion.