A Comparison of Drug-Eluting Stents versus Bare Metal Stents in Saphenous Vein Graft PCI Outcomes: A Meta-Analysis

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Choice of Stent for Percutaneous Coronary Intervention of Saphenous Vein Grafts

Background—

There are limited data on comparison of contemporary drug-eluting stent (DES) platforms, previous generation DES, and bare-metal stents (BMS) for percutaneous coronary intervention in saphenous vein grafts (SVG). We aimed to assess clinical outcomes following percutaneous coronary intervention to SVG in patients receiving bare-metal stents (BMS), first-generation DES, and newer generation DES in a large unselected national data set from the BCIS (British Cardiovascular Intervention Society).

Methods and Results—

Patients undergoing percutaneous coronary intervention to SVG in the United Kingdom from January 2006 to December 2013 were divided into 3 groups according to stent use: BMS, first-generation DES, and newer generation DES group. Study outcomes included in-hospital major adverse cardiovascular events, 30-day mortality, and 1-year mortality. Patients (n=15 003) underwent percutaneous coronary intervention to SVG in England and Wales during the study period. Of these, 38% received BMS, 15% received first-generation DES, and 47% received second-generation DES. The rates of in-hospital major adverse cardiovascular events were significantly lower in patients treated with second-generation DES (odds ratio, 0.51; 95% confidence interval, 0.38–0.68; P <0.001), but not with first-generation DES, compared with BMS-treated patients. Similarly, 30-day mortality (odds ratio, 0.43; 95% confidence interval, 0.32–0.59; P <0.001) and 1-year mortality (odds ratio, 0.60; 95% confidence interval, 0.51–0.71; P <0.001) were lower in patients treated with second-generation DES, but not with first-generation DES, compared with the patients treated with BMS.

Conclusions—

Patients receiving second-generation DES for the treatment SVG disease have lower rates of in-hospital major adverse cardiovascular events, 30-day mortality, and 1-year mortality, compared with those receiving BMS.

Current percutaneous treatment strategies for saphenous vein graft disease

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

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

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

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

BACKGROUND

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

HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reinterventions for stent restenosis in patients treated for atherosclerotic mesenteric artery disease

OBJECTIVE

Mesenteric artery angioplasty and stenting (MAS) has been plagued by high restenosis and reintervention rates. The purpose of this study was to review the outcomes of patients treated for mesenteric artery in-stent restenosis (MAISR).

METHODS

The clinical data of 157 patients treated for chronic mesenteric ischemia with MAS of 170 vessels was entered into a prospective database (1998-2010). Fifty-seven patients (36%) developed MAISR after a mean follow-up of 29 months, defined by duplex ultrasound peak systolic velocity >330 cm/s and angiographic stenosis >60%. We reviewed the clinical data, radiologic studies, and outcomes of patients who underwent reintervention for restenosis. End points were mortality and morbidity, patient survival, symptom recurrence, reintervention, and patency rates.

RESULTS

There were 30 patients (25 female and five male; mean age, 69 ± 14 years) treated with reintervention for MAISR. Twenty-four patients presented with recurrent symptoms (21 chronic, three acute), and six had asymptomatic preocclusive lesions. Twenty-six patients (87%) underwent redo endovascular revascularization (rER) with stent placement in 17 (13 bare metal and four covered) or percutaneous transluminal angioplasty (PTA) in nine. The other four patients (13%) had open bypass, one for acute ischemia. There was one death (3%) in a patient treated with redo stenting for acute mesenteric ischemia. Seven patients (27%) treated by rER developed complications, including access site problems in four patients, and distal embolization with bowel ischemia, congestive heart failure and stent thrombosis in one each. Symptom improvement was noted in 22 of the 24 symptomatic patients (92%). After a mean follow-up of 29 ± 12 months, 15 patients (50%) developed a second restenosis, and seven (23%) required other reintervention. Rates of symptom recurrence, restenosis, and reinterventions were 0/4, 0/4, and 0/4 for covered stents, 2/9, 3/9, and 2/9 for PTA, 5/13, 8/13, and 5/13 for bare metal stents, and 1/4, 4/4, and 0/4 for open bypass. For all patients, freedom from recurrent symptoms, restenosis, and reinterventions were 70% ± 10%, 60% ± 10% and 50% ±10% at 2 years. For patients treated by rER, secondary patency rates were 72 ± 12 at the same interval.

CONCLUSIONS

Nearly 40% of patients developed mesenteric artery in-stent restenosis, of which half required reintervention because of symptom recurrence or progression to an asymptomatic preocclusive lesion. Mesenteric reinterventions were associated with low mortality (3%), high complication rate (27%), and excellent symptom improvement (92%).

Drug-eluting versus bare-metal stents in saphenous vein graft lesions (ISAR-CABG): a randomised controlled superiority trial

BACKGROUND

Comparative assessment of clinical outcomes after use of drug-eluting stents versus bare-metal stents for treatment of aortocoronary saphenous vein graft lesions has not been undertaken in large randomised trials. We aimed to undertake a comparison in a randomised trial powered for clinical endpoints.

METHODS

In this randomised superiority trial, patients with de-novo saphenous vein graft lesions were assigned by computer-generated sequence (1:1:1:3) to receive either drug-eluting stents (one of three types: permanent-polymer paclitaxel-eluting stents, permanent-polymer sirolimus-eluting stents, or biodegradable-polymer sirolimus-eluting stents) or bare-metal stents. Randomisation took place immediately after crossing of the lesion with a guidewire, and was stratified for each participating centre. Investigators assessing data were masked to treatment allocation; patients were not masked to allocation. The primary endpoint was the combined incidence of death, myocardial infarction, and target lesion revascularisation at 1 year. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT00611910.

FINDINGS

610 patients were allocated to treatment groups (303 drug-eluting stent, 307 bare-metal stent). Drug-eluting stents reduced the incidence of the primary endpoint compared with bare-metal stents (44 [15%] vs 66 [22%] patients; hazard ratio [HR] 0.64, 95% CI 0.44-0.94; p=0.02). Target lesion revascularisation rate was reduced by drug-eluting stents (19 [7%] vs 37 [13%] patients; HR 0.49, 95% CI 0.28-0.86; p=0.01). No significant differences were seen between drug-eluting stents and bare-metal stents regarding all-cause mortality (15 [5%] vs 14 [5%] patients; HR 1.08, 95% CI 0.52-2.24; p=0.83), myocardial infarction (12 [4%] vs 18 [6%]; HR 0.66, 95% CI 0.32-1.37; p=0.27), or definite or probable stent thrombosis (2 [1%] in both groups; HR 1.00, 95% CI 0.14-7.10; p=0.99).

INTERPRETATION

In patients undergoing percutaneous coronary intervention for de-novo saphenous vein graft lesions, drug-eluting stents are the preferred treatment option because they reduce the risk of adverse events compared with bare-metal stents.

FUNDING

Deutsches Herzzentrum.