Randomized study to assess the effectiveness of slow- and moderate-release polymer-based paclitaxel-eluting stents for coronary artery lesions

Unravelling the progress and potential of drug-eluting stents and drug-coated balloons in cardiological insurgencies

AIM

Coronary artery disease (CAD) is the leading cause of mortality. Though percutaneous transluminal angioplasty followed by stenting is still the default treatment of choice for revascularization of obstructive CAD, the high rate of restenosis compromises the outcomes of endovascular procedures. To overcome restenosis, drug-eluting stents (DES) and drug-coated balloons (DCB) are designed that release antiproliferative drugs like sirolimus, paclitaxel, everolimus, etc., over time to inhibit cell growth and proliferation. Our review aims to summarize the challenges and progress of DES/DCBs in clinical settings.

MATERIAL AND METHODS

The comprehensive review, search and selection encompasses in relevant articles through Google Scholar, Springer online, Cochrane library and PubMed that includes research articles, reviews, letters and communications, various viewpoints, meta-analyses, randomized trials and quasi-randomized trials. Several preclinical and clinical data have been included from National Institutes of Health and clinicaltrials.gov websites.

KEY FINDINGS

Challenges like delayed endothelialization, stent thrombosis (ST), and inflammation was prominent in first-generation DES. Second-generation DES with improved designs and drug coatings enhanced biocompatibility with fewer complications. Gradual absorption of bioresorbable DES over time mitigated long-term issues associated with permanent implants. Polymer-free DES addressed the inflammation concerns but still, they leave behind metallic stents in the vasculature. As an alternative therapeutic strategy, DCB were developed to minimize inflammation in the vessel. Although both DES and DCBs have shown considerable progress, challenges persist.

SIGNIFICANCE

This review illustrates the advancements in the designs, preparation technologies, biodegradable materials, and drugs used as well as challenges associated with DES and DCBs in clinical settings.

Endovascular Drug Delivery

Drug-eluting stents (DES) and balloons revolutionize atherosclerosis treatment by targeting hyperplastic tissue responses through effective local drug delivery strategies. This review examines approved and emerging endovascular devices, discussing drug release mechanisms and their impacts on arterial drug distribution. It emphasizes the crucial role of drug delivery in modern cardiovascular care and highlights how device technologies influence vascular behavior based on lesion morphology. The future holds promise for lesion-specific treatments, particularly in the superficial femoral artery, with recent CE-marked devices showing encouraging results. Exciting strategies and new patents focus on local drug delivery to prevent restenosis, shaping the future of interventional outcomes. In summary, as we navigate the ever-evolving landscape of cardiovascular intervention, it becomes increasingly evident that the future lies in tailoring treatments to the specific characteristics of each lesion. By leveraging cutting-edge technologies and harnessing the potential of localized drug delivery, we stand poised to usher in a new era of precision medicine in vascular intervention.

Computational modeling of in-stent restenosis: Pharmacokinetic and pharmacodynamic evaluation

Persistence of the pathology of in-stent restenosis even with the advent of drug-eluting stents warrants the development of highly resolved in silico models. These computational models assist in gaining insights into the transient biochemical and cellular mechanisms involved and thereby optimize the stent implantation parameters. Within this work, an already established fully-coupled Lagrangian finite element framework for modeling the restenotic growth is enhanced with the incorporation of endothelium-mediated effects and pharmacological influences of rapamycin-based drugs embedded in the polymeric layers of the current generation drug-eluting stents. The continuum mechanical description of growth is further justified in the context of thermodynamic consistency. Qualitative inferences are drawn from the model developed herein regarding the efficacy of the level of drug embedment within the struts as well as the release profiles adopted. The framework is then intended to serve as a tool for clinicians to tune the interventional procedures patient-specifically.

Temporal trends in percutaneous coronary intervention in Australia: A retrospective analysis from 2000-2021

OBJECTIVE

The aim of this study was to describe the trend in percutaneous coronary intervention (PCI) with insertion of a stent in Australia from 2000/01 to 2020/21 and investigate trends in same-day versus non-same-day discharge following PCI. A secondary aim was to compare the rate of coronary artery bypass grafting (CABG) with PCI procedures, while a third aim was to compare marked PCI trend changes with the PCI guidelines during the study period.

BACKGROUND

PCI with stent deployment is the most common form of interventional treatment for coronary artery disease, and its use has been expanding since 2000. However, there is a lack of descriptive studies of the national trend in Australia.

METHODS

All procedures for PCI and CABG were extracted across 21 years (2000/01 to 2020/21) from the Australian Institute of Health and Welfare data. Age-standardized rates were calculated using the Australian standard population as of June 2001. The ratio of PCI to CABG procedures was also calculated. Trends for PCI were stratified by age, gender, and same-day or overnight discharge episodes. Linear regression analysis was done to compare the age-standardized rates across different age categories. Segmented regression analysis was performed to ascertain the change in the age-standardized rates of PCI during the study period. Whether the changepoints in the trend were matched with guideline updates was also assessed.

RESULTS

There were 751 728 PCI procedures in persons aged 30 years and above between 2000/01 and 2020/21. The age-standardized rate for the study period showed that persons aged 60-74 years had a higher rate of procedures (102.7) compared to persons aged 30-59 years (81.3) and 75 years and older (61.8) (P < 0.001). There were two statistically significant changepoints in the overall trend; 2005/06 and 2013/14, matched with the change in PCI guidelines. Despite the lower number of procedures for same-day discharge episodes, there has been an increasing trend since 2014/15. More than two-thirds of all stenting procedures were the insertion of a single stent. PCI to CABG procedure ratio increased from 0.6 in 2000/01 to 1.8 in 2020/21.

CONCLUSIONS

There was a varying trend in the age-standardized rate of PCI with a peak in 2005/06. The trend appears to be stabilizing in the later part of the study period, but the rate for same-day discharge episodes showed an increasing trend after 2014/15. There is consistency with changepoints in the trend and updated PCI guideline recommendations. The ratio of PCI with insertion of a stent to CABG procedure increased substantially across the study period.

Development of a novel tool: a nomogram for predicting in-hospital mortality of patients in intensive care unit after percutaneous coronary intervention

BACKGROUNDS

Increased risk of in-hospital mortality is critical to guide medical decisions and it played a central role in intensive care unit (ICU) with high risk of in-hospital mortality after primary percutaneous coronary intervention (PCI). At present，most predicting tools for in-hospital mortality after PCI were based on the results of coronary angiography, echocardiography, and laboratory results which are difficult to obtain at admission. The difficulty of using these tools limit their clinical application. This study aimed to develop a clinical prognostic nomogram to predict the in-hospital mortality of patients in ICU after PCI.

METHODS

We extracted data from a public database named the Medical Information Mart for Intensive Care (MIMIC III). Adult patients with coronary artery stent insertion were included. They were divided into two groups according to the primary outcome (death in hospital or survive). All patients were randomly divided into training set and validation set randomly at a ratio of 6:4. Least absolute shrinkage and selection operator (LASSO) regression was performed in the training set to select optimal variables to predict the in-hospital mortality of patients in ICU after PCI. The multivariate logistical analysis was performed to develop a nomogram. Finally, the predictive efficiency of the nomogram was assessed by area under the receiver operating characteristic curve (AUROC)，integrated discrimination improvement (IDI), and net reclassification improvement (NRI), and clinical net benefit was assessed by Decision curve analysis (DCA).

RESULTS

A total of 2160 patients were recruited in this study. By using LASSO, 17 variables were finally included. We used multivariate logistic regression to construct a prediction model which was presented in the form of a nomogram. The calibration plot of the nomogram revealed good fit in the training set and validation set. Compared with the sequential organ failure assessment (SOFA) and scale for the assessment of positive symptoms II (SAPS II) scores, the nomogram exhibited better AUROC of 0.907 (95% confidence interval [CI] was 0.880-0.933, p <  0.001) and 0.901 (95% CI was 0.865-0.936, P <  0.001) in the training set and validation set, respectively. In addition, DCA of the nomogram showed that it could achieve good net benefit in the clinic.

CONCLUSIONS

A new nomogram was constructed, and it presented excellent performance in predicting in-hospital mortality of patients in ICU after PCI.

Efficacy and safety of dual antiplatelet therapy after percutaneous coronary drug-eluting stenting: A network meta-analysis

BACKGROUND

To evaluate the efficacy and safety of dual antiplatelet regimens after coronary drug-eluting stenting by network meta-analysis (NMA).

METHODS

PubMed, The Cochrane Library, Embase, and Web of Science databases were electronically searched to collect randomized controlled trials (RCTs) of the comparison of different dual antiplatelet regimens after coronary drug-eluting stenting from inception to September 1st, 2021. Two reviewers independently screened literature, extracted data, and assessed the risk bias of included studies. Stata 16.0 software was used for NMA.

RESULTS

A total of 27 RCTs involving 79,880 patients were included. The results of NMA: in terms of myocardial infarction (MI), other 3 interventions were higher than the long-term dual antiplatelet therapy (L-DAPT) (the standard dual antiplatelet therapy [Std-DAPT] [odds ratio [OR] = 1.82, 95%confidence interval [CI]: 1.49-2.21), the aspirin monotherapy after short-term dual antiplatelet therapy (S-DAPT + As) (OR = 2.06, 95%CI: 1.57-2.70), the P2Y12 inhibitor monotherapy after short-term dual antiplatelet therapy (S-DAPT + P2Y12) (OR = 1.71, 95%CI: 1.29-2.28)]. In terms of stent thrombosis, other 3 interventions were higher than L-DAPT [Std-DAPT (OR = 2.18, 95%CI: 1.45-3.28), S-DAPT + As (OR = 2.32, 95%CI: 1.52-3.54), S-DAPT + P2Y12 (OR = 2.31, 95%CI: 1.22-4.36)]. There was no statistically significant difference among the 4 interventions in prevention of stroke and all-cause mortality (P > .05). In terms of cardiovascular and cerebrovascular adverse events, other 3 interventions were higher than L-DAPT (Std-DAPT [OR = 1.28, 95%CI: 1.12-1.45], S-DAPT + As [OR = 1.27, 95%CI: 1.09-1.48], S-DAPT + P2Y12 [OR = 1.24, 95%CI: 1.01-1.52]). In terms of safety, bleeding rate of other 3 interventions were lower than L-DAPT (Std-DAPT [OR = 0.67, 95%CI: 0.52-0.85], S-DAPT + As [OR = 0.51, 95%CI: 0.39-0.66], S-DAPT + P2Y12 [OR = 0.36, 95%CI: 0.26-0.49]). Two interventions were lower than L-DAPT (S-DAPT + As [OR = 0.77, 95%CI: 0.65-0.90], S-DAPT + P2Y12 [OR = 0.54, 95%CI: 0.44-0.66]). S-DAPT + As was higher than L-DAPT (OR = 1.42, 95%CI: 1.10-1.83).

CONCLUSIONS

S-DAPT + P2Y12 has the lowest bleeding risk, while L-DAPT has the highest bleeding risk. In the outcome of MI, stent thrombosis, and cardiovascular and cerebrovascular adverse events, L-DAPT has the best efficacy. In the outcome of stroke and all-cause mortality, the 4 interventions were equally effective.

Evolution of drug-eluting coronary stents: a back-and-forth journey from the bench-to-bedside

Coronary stents have revolutionized the treatment of coronary artery disease. Compared with balloon angioplasty, bare-metal stents effectively prevented abrupt vessel closure but were limited by in-stent restenosis due to smooth muscle cell proliferation and neointimal hyperplasia. The first-generation drug-eluting stent (DES), with its antiproliferative drug coating, offered substantial advantages over bare-metal stents as it mitigated the risk of in-stent restenosis. Nonetheless, they had several design limitations that increased the risk of late stent thrombosis. Significant advances in stent design, including thinner struts, enhanced polymers' formulation, and more potent antiproliferative agents, have led to the introduction of new-generation DES with a superior safety profile. Cardiologists have over 20 different DES types to choose from, each with its unique features and characteristics. This review highlights the evolution of stent design and summarizes the clinical data on the different stent types. We conclude by discussing the clinical implications of stent design in high-risk subsets of patients.

Coronary intravascular brachytherapy for in-stent restenosis: A review of the contemporary literature

Intracoronary stent restenosis (ISR) is a clinically relevant challenge in the modern era. Heterogeneity in patient- and lesion-specific factors can further compound this clinical challenge. Coronary intravascular brachytherapy (IVBT) was the standard therapeutic approach for ISR prior to the advent of drug-eluting stents (DES). Despite prospective data describing the superiority of DES over IVBT for treating de novo ISR, IVBT remains a treatment option for patients with complex disease. The purpose of this review is to evaluate the historical and contemporary literature surrounding IVBT in order to elucidate its role in modern cardiac care and to describe opportunities for future investigations to improve patient selection. Herein, we provide a review of the contemporary literature describing IVBT as a safe and effective treatment option for patients with recurrent, refractory ISR after multilayer DES and no good surgical or mechanical option. Combination therapy with emerging technologies such as DCBs may further increase efficacy.

Nanotechnology for cardiovascular diseases

Cardiovascular diseases have become the major killers in today's world, among which coronary artery diseases (CADs) make the greatest contributions to morbidity and mortality. Although state-of-the-art technologies have increased our knowledge of the cardiovascular system, the current diagnosis and treatment modalities for CADs still have limitations. As an emerging cross-disciplinary approach, nanotechnology has shown great potential for clinical use. In this review, recent advances in nanotechnology in the diagnosis of CADs will first be elucidated. Both the sensitivity and specificity of biosensors for biomarker detection and molecular imaging strategies, such as magnetic resonance imaging, optical imaging, nuclear scintigraphy, and multimodal imaging strategies, have been greatly increased with the assistance of nanomaterials. Second, various nanomaterials, such as liposomes, polymers (PLGA), inorganic nanoparticles (AuNPs, MnO2, etc.), natural nanoparticles (HDL, HA), and biomimetic nanoparticles (cell-membrane coating) will be discussed as engineered as drug (chemicals, proteins, peptides, and nucleic acids) carriers targeting pathological sites based on their optimal physicochemical properties and surface modification potential. Finally, some of these nanomaterials themselves are regarded as pharmaceuticals for the treatment of atherosclerosis because of their intrinsic antioxidative/anti-inflammatory and photoelectric/photothermal characteristics in a complex plaque microenvironment. In summary, novel nanotechnology-based research in the process of clinical transformation could continue to expand the horizon of nanoscale technologies in the diagnosis and therapy of CADs in the foreseeable future.

In vitro corrosion study of PLA/Mg composites for cardiovascular stent applications

The present investigation explores the impact of Mg volume fraction (V_Mg) as a controlling parameter of degradation rate in designing patient-specific cardiovascular stents made of PLA/Mg composites. For the purpose of this research, PLA/Mg composite plates containing 1, 3, 5, and 10% V_Mg are produced by melt blending and hot press molding. Characterization techniques such as scanning electron microscopy (SEM), differential scanning calorimetry (DSC) and X-ray diffraction (XRD) are employed to study the microstructure of PLA/Mg composites. For in vitro corrosion tests, stent prototypes and composite samples are immersed in baths of simulated body fluid (SBF). According to in vitro corrosion tests, increasing V_Mg increases the corrosion rate of the composites by accelerating the corrosion of the particles and the crystalline zones surrounding them. In addition, a 2% raise in the Mg content (from 1% to 3%), increases the overall Mg weight loss by more than 4 times. Composite samples and prototype stents containing more than 5% V_Mg exhibit cracking and brittleness after 7 days of immersion in SBF. In light of the compression tests results and also the failures and cracks observed during immersions, the upper limit of Mg content for PLA/Mg stent fabrication purposes is found to be below 3%.

Vascular Lesion-Specific Drug Delivery Systems: JACC State-of-the-Art Review

Drug delivery is central to modern cardiovascular care, where drug-eluting stents, bioresorbable scaffolds, and drug-coated balloons all aim to restore perfusion while inhibiting exuberant healing. The promise and enthusiasm of these devices has in some cases exceeded demonstration of efficacy and even understanding of driving mechanisms. The authors review the means of drug delivery in each device, outlining how the technologies affect vascular behavior. They focus on how drug retention and response are governed by lesion morphology: lipid displacing drug-specific binding sites, calcium inhibiting diffusion, blocking thrombi or promoting luminal washout, and vascular healing steering hyperplastic developments. In this regard, the authors outline the fundamental impact of vascular structure on drug delivery and review the development of contemporary and future devices for coronary and peripheral intervention. They look toward a future where incorporating information on lesion distribution is central to therapeutic success and envision a transition toward lesion-specific treatment for improved interventional outcomes.

Coronary Revascularization and Long-Term Survivorship in Chronic Coronary Syndrome

Ischemic heart disease (IHD) persists as the leading cause of death in the Western world. In recent decades, great headway has been made in reducing mortality due to IHD, based around secondary prevention. The advent of coronary revascularization techniques, first coronary artery bypass grafting (CABG) surgery in the 1960s and then percutaneous coronary intervention (PCI) in the 1970s, has represented one of the major breakthroughs in medicine during the last century. The benefit provided by these techniques, especially PCI, has been crucial in lowering mortality rates in acute coronary syndrome (ACS). However, in the setting where IHD is most prevalent, namely chronic coronary syndrome (CCS), the increase in life expectancy provided by coronary revascularization is controversial. Over more than 40 years, several clinical trials have been carried out comparing optimal medical treatment (OMT) alone with a strategy of routine coronary revascularization on top of OMT. Beyond a certain degree of symptomatic improvement and lower incidence of minor events, routine invasive management has not demonstrated a convincing effect in terms of reducing mortality in CCS. Based on the accumulated evidence more than half a century after the first revascularization procedures were used, invasive management should be considered in those patients with uncontrolled symptoms despite OMT or high-risk features related to left ventricular function, coronary anatomy, or functional assessment, taking into account the patient expectations and preferences.

Meta-analysis of Duration of Continuous Dual Antiplatelet Therapy and Late Stent Thrombosis After Second-Generation Drug Stent Implantation

INTRODUCTION

The aim of the present study was to perform a systematic comparison of the incidence of late and extremely late stent thrombosis (ST) with short-term and long-term dual antiplatelet therapy (DAPT) after a second-generation drug-eluting stent (DES) implantation.

METHODS

Randomized controlled trials using short-term and long-term DAPT and reporting late ST (30 days-1 year) and extremely late ST (longer than 1 year) after a percutaneous coronary intervention (PCI) with DES were searched and compared in the Life Sciences and Biomedical Information Bibliographic Database (MEDLINE), EMBASE, Cochrane Central, and ClinicalTrials.com. ST was used as the primary endpoint of the therapeutic outcome, and the fixed-effects model (I² < 50%) or random-effects model (I² ≥ 50%) was adopted for the combined analysis. The odds ratio (OR) and 95% confidence interval (CIs) were used to represent the results. P < 0.05 in the combined result indicated that the difference was statistically significant.

RESULTS

A total of five randomized controlled trials consisting of 7142 patients were included, with 3556 cases of short-term DAPT (at most 6 months), and 3586 cases of long-term DAPT (at least 12 months). There was no significant difference between late ST and administration duration of DAPT (OR 0.98, 95% CI 0.30-3.18; P = 0.97, I² = 0%). There was also no significant difference between the incidence of extremely late ST and the duration of DAPT application (OR 0.30, 95% CI 0.03-2.95; P = 0.31).

CONCLUSION

The duration of continuous DAPT application had no effect on the occurrence of late and extremely late ST.

The Use of Bioactive Polymers for Intervention and Tissue Engineering: The New Frontier for Cardiovascular Therapy

Coronary heart disease remains one of the leading causes of death in most countries. Healthcare improvements have seen a shift in the presentation of disease with a reducing number of ST-segment elevation myocardial infarctions (STEMIs), largely due to earlier reperfusion strategies such as percutaneous coronary intervention (PCI). Stents have revolutionized the care of these patients, but the long-term effects of these devices have been brought to the fore. The conceptual and technologic evolution of these devices from bare-metal stents led to the creation and wide application of drug-eluting stents; further research introduced the idea of polymer-based resorbable stents. We look at the evolution of stents and the multiple advantages and disadvantages offered by each of the different polymers used to make stents in order to identify what the stent of the future may consist of whilst highlighting properties that are beneficial to the patient alongside the role of the surgeon, the cardiologist, engineers, chemists, and biophysicists in creating the ideal stent.

Paclitaxel exposure: Long-term safety and effectiveness of a drug-coated balloon for claudication in pooled randomized trials

BACKGROUND

Paclitaxel drug-coated balloons (DCB) prevent recurrent claudication after angioplasty, yet data from randomized trials with incomplete follow-up have raised uncertainty regarding long-term mortality.

OBJECTIVES

To evaluate the effect of paclitaxel exposure on the long-term safety and efficacy of angioplasty of femoropopliteal artery lesions in the combined IN.PACT randomized trials.

METHODS

The IN.PACT randomized trials (SFA, N = 331 and Japan, N = 100) each compared the DCB with standard percutaneous transluminal angioplasty (PTA) for claudication, and consented patients for 5 and 3 years, respectively. To address long-term safety, sites were requested to obtain vital status follow-up. In the pooled, updated data set, we examined the association between randomized treatment and mortality by cumulative incidence and hazard ratio (HR), and freedom from clinically driven target lesion revascularization (CD-TLR). Multivariable Cox regression with adjustment for baseline characteristics was used to evaluate the dose effect. Causes of death were adjudicated by a blinded clinical events committee that included oncologists with paclitaxel expertise.

RESULTS

The rate of long-term vital status ascertainment increased from 81% to 97% for DCB and from 85% to 97% for PTA in the IN.PACT SFA trial. The cumulative incidence of mortality was 14.7% DCB versus 12.0% PTA at 5 years, HR 1.39, log-rank p = .286. Paclitaxel dose (mg) was not an independent predictor of mortality (HR 1.02, p = .381), but was an independent predictor of reduced risk of CD-TLR (HR 0.79; p < .001). Causes of death did not differ by treatment arm.

CONCLUSIONS

In pooled randomized trial data with updated vital status ascertainment, paclitaxel was associated with improved efficacy but was not associated with increased mortality.

Abluminus DES+ for the treatment of coronary artery disease in patients with diabetes mellitus

Diabetes mellitus (DM) is a rising global epidemic affecting more than 10% of the world population and predisposes patients to develop highly progressive and complex coronary artery disease. Despite numerous advancements in percutaneous coronary intervention procedural techniques and coronary stent platforms, clinical outcomes in DM patients have improved little compared with non-DM patients. Abluminus DES+, a biodegradable polymer sirolimus-eluting stent deployed with a drug-coated balloon, has been specifically designed to provide adequate coverage for DM patients and reduce adverse clinical outcomes.

Vascular Stents Coated with Electrospun Drug-Eluting Material: Functioning in Rabbit Iliac Artery

A stenting procedure aimed at blood flow restoration in stenosed arteries significantly improves the efficiency of vascular surgery. However, the current challenge is to prevent neointimal growth, which reduces the vessel lumen, in the stented segments in the long run. We tested in vivo drug-eluting coating applied by electrospinning to metal vascular stents to inhibit the overgrowth of neointimal cells via both the drug release and mechanical support of the vascular wall. The blend of polycaprolactone with human serum albumin and paclitaxel was used for stent coating by electrospinning. The drug-eluting stents (DESs) were placed using a balloon catheter to the rabbit common iliac artery for 1, 3, and 6 months. The blood flow rate was ultrasonically determined in vivo. After explantation, the stented arterial segment was visually and histologically examined. Any undesirable biological responses (rejection or hemodynamically significant stenosis) were unobservable in the experimental groups. DESs were less traumatic and induced weaker neointimal growth; over six months, the blood flow increased by 37% versus bare-metal stents, where it increased by at least double the rate. Thus, electrospun-coated DESs demonstrate considerable advantages over the bare-metal variants.

Health Care Monitoring and Treatment for Coronary Artery Diseases: Challenges and Issues

In-stent restenosis concerning the coronary artery refers to the blood clotting-caused re-narrowing of the blocked section of the artery, which is opened using a stent. The failure rate for stents is in the range of 10% to 15%, where they do not remain open, thereby leading to about 40% of the patients with stent implantations requiring repeat procedure within one year, despite increased risk factors and the administration of expensive medicines. Hence, today stent restenosis is a significant cause of deaths globally. Monitoring and treatment matter a lot when it comes to early diagnosis and treatment. A review of the present stent monitoring technology as well as the practical treatment for addressing stent restenosis was conducted. The problems and challenges associated with current stent monitoring technology were illustrated, along with its typical applications. Brief suggestions were given and the progress of stent implants was discussed. It was revealed that prime requisites are needed to achieve good quality implanted stent devices in terms of their size, reliability, etc. This review would positively prompt researchers to augment their efforts towards the expansion of healthcare systems. Lastly, the challenges and concerns associated with nurturing a healthcare system were deliberated with meaningful evaluations.

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

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

Prospective evaluation of an ultrathin strut biodegradable polymer-coated sirolimus-eluting stent: 12 months' results from the S-FLEX UK registry

OBJECTIVE

To prospectively evaluate safety and efficacy of the ultrathin strut biodegradable polymer-coated Supraflex sirolimus-eluting stent (S-SES) in 'real world' patient population requiring percutaneous coronary intervention (PCI).

METHODS

National, prospective, multicentre, single-arm, all-comers, observational registry of 469 patients treated with S-SES from July 2015 and November 2016 in 11 centres in UK. Primary endpoint was target lesion failure (TLF) at 12 months (cardiac death, target vessel myocardial infarction (MI) or clinically driven target lesion revascularisation (TLR)). Secondary endpoints included safety and performance outcomes at 12 months-overall stent thrombosis (ST), all-cause mortality, any MI, target vessel failure (TVF) and major adverse cardiac events (MACE-composite of cardiac death, MI, emergent or repeat revascularisation).

RESULTS

At 12 months, the primary endpoint occurred in 11 (2.4%) of 466 patients, consisting of 4 (0.9%) cardiac deaths, 3 (0.6%) target vessel MI and 7 (1.5%) TLR. Secondary endpoints findings included all-cause mortality in 6 (1.3%), TVF of 14 (3%), no definite ST, 1 (0.2%) probable ST and 3 (0.6%) possible ST. Overall MACE was observed in 18 (3.9%).

CONCLUSIONS

The S-FLEX UK registry showed that the S-SES is safe with a low incidence of TLF in routine clinical practise in patients with coronary artery disease being treated by PCI.

Long-term safety of bioresorbable scaffolds: insights from a network meta-analysis including 91 trials

AIMS

The aim of this study was to investigate the long-term safety and efficacy of biodegradable scaffolds and metallic stents.

METHODS AND RESULTS

We analysed a total of 91 randomised controlled trials with a mean follow-up of 3.7 years in 105,842 patients which compared two or more coronary metallic stents or biodegradable scaffolds and reported the long-term clinical outcomes (≥2 years). Network meta-analysis showed that patients treated with the Absorb bioresorbable vascular scaffold (BVS) had a significantly higher risk of definite or probable scaffold thrombosis (ScT) compared to those treated with metallic DES. The risk of very late ScT was highest with the Absorb BVS among comparators. Pairwise conventional meta-analysis demonstrated that the elevated risk of ScT with Absorb BVS compared to cobalt-chromium everolimus-eluting stents was consistent across the time points of ≤30 days (early), 31 days - 1 year (late) and >1 year (very late) ScT. In addition, target lesion failure rates were significantly higher in the Absorb BVS cohort, driven by both increased risk of target vessel myocardial infarction and ischaemia-driven target lesion revascularisation.

CONCLUSIONS

Absorb BVS implantation was associated with increased risk of long-term and very late ScT compared to current-generation metallic DES. The risk of ScT occurred with a rising trend beyond one year.

Improving the anti-keloid outcomes through liposomes loading paclitaxel-cholesterol complexes

Background

Keloids represent benign fibroproliferative tumors which result from elevated expression of inflammation. Paclitaxel (PTX) was an effective chemotherapeutic agent and has been reported to have anti-fibrotic effects, but the strong hydrophobicity brings a challenge for its clinical application.

Purpose

The objective of this study was to improve the water solubility of PTX and investigate its anti-keloid effects.

Methods

We prepared a PTX-cholesterol-loaded liposomes (PTXL) by thin film evaporation fashion and characterized their physicochemical properties. We also investigated the effects of PTX on proliferation, invasion and fibrosis of keloid fibroblasts in vitro and in vivo.

Results

The prepared PTXL have a spherical appearance, a particle size of 101.43 nm and a zeta potential of −41.63 mV. PTXL possessed a high drug entrapment efficiency of 95.63% and exhibited a good stability within 30 days. The drugs in PTXL were released in a slow and sustained mode. The PTXL could be effectively uptaken into human keloids fibroblast (HKFs) in a time-dependent manner. In vitro, PTXL showed better ability on inhibiting cell proliferation, migration and invasion, and effectively on promoting apoptosis and arresting cell cycle in G₂/M phase compared to PTX. Meanwhile, in vivo studies indicated that the PTXL had better performance on inhibiting the keloids growth compared to the PTX in keloid-bearing BALB/c nude mice model. Finally, we found PTX treatment suppressed the production of tumor necrosis factor alpah (TNF-α), interleukin 6 (IL-6) and transforming growth factor beta (TGF-β) and inhibited the expression of alpha smooth muscle actin (α-SMA) and collagen I in HKFs. The activation of protein kinase B (AKT)/glycogen synthase kinase 3 beta (GSK3β) signaling pathway also blocked by PTX in cultured HKFs and keloid tissues. LY294002, a PI3K (phosphatidylinositol 3-kinase)/AKT inhibitor, also suppressed the expression of TNF-α, IL-6 and TGF-β, and simultaneously, reduced the production of α-SMA and collagen I in HKFs. The inhibition of AKT/GSK3β signaling pathway contribute to inhibit the generation of fibrogenic cytokines by PTXL on ameliorating fibrosis progress in keloids.

Conclusion

Our results suggested that the developed PTXL would become a promising therapeutic agent in the field of anti-keloid therapy.

Targeted Delivery of Bioactive Molecules for Vascular Intervention and Tissue Engineering

Cardiovascular diseases are the leading cause of death in the United States. Treatment often requires surgical interventions to re-open occluded vessels, bypass severe occlusions, or stabilize aneurysms. Despite the short-term success of such interventions, many ultimately fail due to thrombosis or restenosis (following stent placement), or incomplete healing (such as after aneurysm coil placement). Bioactive molecules capable of modulating host tissue responses and preventing these complications have been identified, but systemic delivery is often harmful or ineffective. This review discusses the use of localized bioactive molecule delivery methods to enhance the long-term success of vascular interventions, such as drug-eluting stents and aneurysm coils, as well as nanoparticles for targeted molecule delivery. Vascular grafts in particular have poor patency in small diameter, high flow applications, such as coronary artery bypass grafting (CABG). Grafts fabricated from a variety of approaches may benefit from bioactive molecule incorporation to improve patency. Tissue engineering is an especially promising approach for vascular graft fabrication that may be conducive to incorporation of drugs or growth factors. Overall, localized and targeted delivery of bioactive molecules has shown promise for improving the outcomes of vascular interventions, with technologies such as drug-eluting stents showing excellent clinical success. However, many targeted vascular drug delivery systems have yet to reach the clinic. There is still a need to better optimize bioactive molecule release kinetics and identify synergistic biomolecule combinations before the clinical impact of these technologies can be realized.

Antiplatelet agents in uncertain clinical scenarios-a bleeding nightmare

Despite over 40 years since the first percutaneous coronary intervention (PCI) was performed, the optimal dual antiplatelet therapy (DAPT) regime poses a significant challenge for clinicians, especially in certain scenarios. DAPT is the standard of care in PCI following an acute coronary syndrome (ACS) or for elective patients with obstructive coronary artery disease (CAD). There remains significant uncertainty regarding DAPT in patients at high risk of bleeding, such as the elderly and patients requiring anticoagulation. More and more clinicians are faced with a dilemma of weighing risks and benefits from the increasing list of potent, new antiplatelet agents and direct oral anticoagulants (DOACs) in a growing, aging population. Historically, most studies failed to recognize bleeding risk, instead focusing on ischemic risk. In recent years however, bleeding has been recognized as a very significant driver of morbidity and mortality in patients undergoing PCI. There is a paucity of data in this cohort leading to divergent and sometimes conflicting recommendations, largely based on expert consensus of opinion. In the current review, we critically evaluate the available evidence in these uncertain scenarios.

Biomimetic Tissue Engineering: Tuning the Immune and Inflammatory Response to Implantable Biomaterials

Regenerative medicine technologies rely heavily on the use of well-designed biomaterials for therapeutic applications. The success of implantable biomaterials hinges upon the ability of the chosen biomaterial to negotiate with the biological barriers in vivo. The most significant of these barriers is the immune system, which is composed of a highly coordinated organization of cells that induce an inflammatory response to the implanted biomaterial. Biomimetic platforms have emerged as novel strategies that aim to use the principle of biomimicry as a means of immunomodulation. This principle has manifested itself in the form of biomimetic scaffolds that imitate the composition and structure of biological cells and tissues. Recent work in this area has demonstrated the promising potential these technologies hold in overcoming the barrier of the immune system and, thereby, improve their overall therapeutic efficacy. In this review, a broad overview of the use of these strategies across several diseases and future avenues of research utilizing these platforms is provided.

9-year clinical follow-up of patients with ST-segment elevation myocardial infarction with Genous or TAXUS Liberté stents

Objectives

This matched-cohort retrospective study investigated the long-term (9-year) safety and efficacy outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and primary percutaneous coronary intervention (pPCI) with Genous (n = 102) versus TAXUS Liberté (n = 101) stents in 2006–2008.

Background

In the era of off-label use of drug-eluting stents for pPCI in patients with STEMI, the use of first-generation Genous stents (endothelial progenitor cell capture stents that have a passive coating and accelerate re-endothelialization) was proposed.

Methods

The primary endpoint was 9-year major adverse cardiac and cerebrovascular events (MACCE), including all-cause death, re-infarction, target vessel revascularization (TVR), and stroke. The secondary endpoints were the separate primary endpoint events at pre-defined time-points (in-hospital, 6 months, and yearly) and stent thrombosis. Time-dependent 9-year composite MACCE, all-cause death, and TVR were compared using Kaplan-Meier estimates and multivariate Cox regression models.

Results

Propensity score analysis confirmed the comparability of the groups. Patients in the Genous and TAXUS groups had 7 and 1 acute definitive stent thrombosis events, respectively (p<0.001). There was a trend towards higher in-hospital MACCE in the Genous group (10.8%) versus the TAXUS group (4.0%). Kaplan-Meier analysis showed that 9-year MACCE was significantly worse in the Genous than in the TAXUS group. The in-hospital, 6-month, 1-year, and 9-year mortality rates were 7.8%, 8.8%, 9.8%, and 23.5% in the Genous group and 2.0%, 3.0%, 4.0%, and 16.8% in the TAXUS group.

Conclusions

Higher peri-procedural, in-hospital, and short-term mortality led to worse outcomes for first-generation Genous stents versus TAXUS Liberté stents for pPCI in STEMI. TAXUS Liberté stents had more favorable 9-year clinical outcomes.

State of the art: duration of dual antiplatelet therapy after percutaneous coronary intervention and coronary stent implantation - past, present and future perspectives

Evidence from studies published more than 10 years ago suggested that patients receiving first-generation drug-eluting stents (DES) needed dual antiplatelet therapy (DAPT) for at least 12 months. Current evidence from randomised controlled trials (RCT) reported within the past five years suggests that patients with stable ischaemic heart disease who receive newer-generation DES need DAPT for a minimum of three to six months. Patients who undergo stenting for an acute coronary syndrome benefit from DAPT for at least 12 months, but a Bayesian network meta-analysis confirms that extending DAPT beyond 12 months confers a trade-off between reduced ischaemic events and increased bleeding. However, the network meta-analysis finds no credible increase in all-cause mortality if DAPT is lengthened from three to six months to 12 months (posterior median odds ratio [OR] 0.98; 95% Bayesian credible interval [BCI]: 0.73-1.43), from 12 months to 18-48 months (OR 0.87; 95% BCI: 0.64-1.17), or from three to six months to 18-48 months (OR 0.86; 95% BCI: 0.63-1.21). Future investigation should focus on identifying scoring systems that have excellent discrimination and calibration. Although predictive models should be incorporated into systems of care, most decisions about DAPT duration will be based on clinical judgement and patient preference.

The evolution of coronary stents

INTRODUCTION

Percutaneous coronary intervention (PCI) is 40 years old this year. From its humble beginnings of experimental work, PCI has transitioned over years with coronary artery stenting now a standard medical procedure performed throughout the world. Areas covered: The conversion from plain old balloon angioplasty (POBA) to the present era of drug eluting stents (DES) has been driven by many technological advances and large bodies of clinical trial evidence. The journey to present day practice has seen many setbacks, such as acute vessel closure with POBA; rates of instant restenosis with bare metal stents (BMS) and more recently, high rates of stent thrombosis with bioabsorbable platforms. This work discusses POBA, why there was a need for BMS, the use of inhibiting drugs to create 1^st generation DES, the change of components to 2^nd generation DES, the use of absorbable drug reservoirs and platforms, and possible future directions with Prohealing Endothelial Progenitor Cell Capture Stents. Expert commentary: This paper reviews the evolution from the original pioneering work to modern day practice, highlighting landmark trials that changed practice. Modern day contemporary practice is now very safe based on the latest drug eluting stents and supported by large datasets.

Engineering Cardiovascular Implant Surfaces to Create a Vascular Endothelial Growth Microenvironment

Cardiovascular disease (CVD) is generally accepted as the leading cause of morbidity and mortality worldwide, and an increasing number of patients suffer from atherosclerosis and thrombosis annually. To treat these disorders and prolong the sufferers' life, several cardiovascular implants have been developed and applied clinically. Nevertheless, thrombosis and hyperplasia at the site of cardiovascular implants are recognized as long-term problems in the practice of interventional cardiology. Here, we start this review from the clinical requirement of the implants, such as anti-hyperplasia, anti-thrombosis, and pro-endothelialization, wherein particularly focus on the natural factors which influence functional endothelialization in situ, including the healthy smooth muscle cells (SMCs) environment, blood flow shear stress (BFSS), and the extracellular matrix (ECM) microenvironment. Then, the currently available strategies on surface modification of cardiovascular biomaterials to create vascular endothelial growth microenvironment are introduced as the main topic, e.g., BFSS effect simulation by surface micro-patterning, ECM rational construction and SMCs phenotype maintain. Finally, the prospects for extending use of the in situ construction of endothelial cells growth microenvironment are discussed and summarized in designing the next generation of vascular implants.

Rationale of a novel study design for the BIOFLOW V study, a prospective, randomized multicenter study to assess the safety and efficacy of the Orsiro sirolimus-eluting coronary stent system using a Bayesian approach

BACKGROUND

Traditional study design submitted to the Food and Drug Administration to test newer drug-eluting stents (DES) for marketing approval is the prospective randomized controlled trial. However, several DES have extensive clinical data from trials conducted outside the United States that have led to utilization of a novel design using the Bayesian approach. This design was proposed for testing DES with bioresorbable polymer compared with DES most commonly in use today that use durable polymers for drug elution.

STUDY DESIGN AND OBJECTIVES

This prospective, multicenter, randomized, controlled trial is designed to assess the safety and efficacy of the Orsiro bioresorbable polymer sirolimus-eluting stent (BP SES). Up to 1,334 subjects with up to 3 de novo or restenotic coronary artery lesions who qualify for percutaneous coronary intervention with stenting will be randomized 2:1 to the BP SES versus the Xience durable polymer everolimus-eluting stent (DP EES). Data from this trial will be combined with data from 2 similarly designed trials that also randomize subjects to BP SES and DP EES (BIOFLOW II, N=452 and BIOFLOW IV, N=579) by using a Bayesian approach. The primary end point is target lesion failure at 12 months post index procedure, defined as cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization, and the primary analysis is a test of noninferiority of the BP SES versus DP EES on the primary end point according to a noninferiority delta of 3.85%. Secondary end points include stent thrombosis and the individual components of target lesion failure. Subjects will be followed for 5 years after randomization.

CONCLUSIONS

The BIOFLOW V trial offers an opportunity to assess clinical outcomes in patients treated with coronary revascularization using the Orsiro BP SES relative to a commonly used DP EES. The use of a Bayesian analysis combines a large randomized cohort of patients 2 two smaller contributing randomized trials to augment the efficiency of the comparison.

Temporal trends in percutaneous coronary interventions thru the drug eluting stent era: Insights from 18,641 procedures performed over 12-year period

BACKGROUND

The last decade, regarded as the DES era in PCI, has witnessed significant advances in the management of coronary disease. We aimed to assess temporal trends in the practice and outcome of percutaneous coronary intervention (PCI) during the drug eluting stent (DES) era.

METHODS

We analyzed 18,641 consecutive PCI's performed between January 2004 and December 2016, distinguished by procedural date (Q₁ : 2004-2006, n = 4,865; Q₂ : 2007-2009, n = 4,977; Q₃ : 2010-2012, n = 4,230; Q₄ : 2013-2016, n = 4,569).

RESULTS

At presentation, mean patients age was 65 (±11) years and 22.8% were females. Over time, there was a rise in the relative number of octogenarians (Q₁ : 10.7% vs Q₄ : 15.5%, P < 0.001) and an increase in the burden of most comorbidities (e.g., left ventricular dysfunction ≥ moderate and chronic kidney disease, P < 0.001 for both). Despite a 2-fold increase in the rate of complex interventions, and a 3-fold increase in the rate of unprotected left-main angioplasty (P < 0.001 for both), the radial approach was increasingly adopted (Q₁ : 2% to Q₄ : 63.5%, P < 0.001). DES implantation increased from 43% to 83% at the expense of bare metal stent (BMS) application, and accompanied by drug coated balloon sprout to 1.8%, P < 0.001. Kaplan-Meier survival curves revealed a time-based enhanced outcome, with a decreased rate of death, MI, target vessel revascularization and CABG over the years.

CONCLUSIONS

In the last decade, PCI has evolved to offer better outcome to more elderly, sicker patient population, with more complex coronary disease interventions. The shift to second generation DES and to enhanced PCI techniques may explain part of this progress.

Effect of strut distribution on neointimal coverage of everolimus-eluting bioresorbable scaffolds: an optical coherence tomography study

The thick struts of bioresorbable vascular scaffolds (BRS) are associated with changes in wall shear stress and contribute to neointimal proliferation. We aimed to evaluate the relationship between the BRS strut distribution and the neointimal proliferation. 50 lesions underwent optical coherence tomography, 12 months after BRS implantation. Scaffold area and neointimal thickness were evaluated in each cross-sectional area (CSA). Scaffold eccentricity was defined as follows: (maximum diameter - minimum diameter) × 100/maximum diameter. CSAs of BRS were divided into four quadrants. The maximal neointimal thickness (Maximal-NIT), Minimal-NIT and the number of struts in each quadrant were measured. The number of struts were classified as 1, 2, 3 and ≥ 4. Furthermore, the mean-NIT acquired in each quadrant was divided by the average-NIT of all struts in the same CSA, which was defined as the unevenness score. In addition, Maximal-NIT minus Minimal-NIT was divided by the average-NIT of all struts in the same CSA, which was defined as heterogenicity of neointimal proliferation. There was a significant difference in the association between the number of struts and not only the unevenness score (no. of strut = 1 (N = 440), unevenness score 1.04 ± 0.34; 2 (N = 696), 0.98 ± 0.27; 3 (N = 994), 0.96 ± 0.23; ≥4 (N = 1202), 1.04 ± 0.22, P < 0.01) but also Maximal-NIT and Minimal-NIT. Furthermore, a significant correlation was observed between scaffold eccentricity in each CSA and the heterogeneity of neointimal proliferation in the same CSA (N = 892, R = 0.38, p = 0.01). Crowding of struts is associated with increased neointimal proliferation after BRS implantation. The scaffold eccentricity causes heterogeneity of neointimal proliferation.

Effect of nonionic surfactants in release media on accelerated in-vitro release profile of sirolimus eluting stents with biodegradable polymeric coating

It is a well-known fact that sirolimus (SRL) undergoes degradation process via hydrolysis in aqueous media, leading to incorrect assessment of drug amount and thus release characteristics of formulations. The main objective of the present study was to evaluate the effect of nonionic surfactants in media on in-vitro release profiles for sirolimus eluting stents (SES) coated with biodegradable polymeric matrix. Phosphate buffer and acetate buffer incorporating nonionic surfactants with varying concentrations were examined for adequate solubility and stability (by RP-HPLC). Good sink condition was achieved in phosphate buffer (at pH 4.0) with 1.0% Tween 20, 1.0% Brij 35% and 0.5% Brij 58. Hydrodynamic size (by DLS) and the micelle-water partition coefficient (P) with standard free energy of solubilization (∆G_s°) of drug were evaluated to get some understanding about the solubilization phenomena. About 80% of drug release during the period of 48 h was achieved in optimized drug release media which was 1.0% Tween 20 in phosphate buffer pH 4.0. The obtained accelerated SRL release profile in optimized medium correlated well with the real time in-vitro release in phosphate buffer (pH 7.4). Surface morphology changes (by SEM), changes in gravimetric weights and molecular weight change (by GPC) were examined before and after drug release to understand the drug release mechanism which explains that the polymer did not undergo degradation during the drug release.

Restenosis of the Coronary Arteries: Past, Present, Future Directions

Restenosis is a pathologic response to vascular injury, characterized by neointimal hyperplasia and progressive narrowing of a stented vessel segment. Although advances in stent design have led to a dramatic reduction in the incidence of restenosis, it continues to represent the most common cause of target lesion failure following percutaneous coronary intervention. Efforts to maximize restenosis prevention, through careful consideration of modifiable risk factors and an individualized approach, are critical, as restenosis, once established, can be particularly difficult to treat. Novel approaches are on the horizon that have the potential to alter the natural history of this stubborn disease.

Safety and efficacy outcomes of 3rd generation DES in an all-comer population of patients undergoing PCI: 12-month and 24-month results of the e-Biomatrix French registry

Objectives

The French Ebiomatrix registry aimed to confirm the results of the Leaders trial in an all‐comer population in France.

Background

The Leaders trial showed the Biolimus‐eluting‐sent (BES) to be equivalent to the Cypher stent in terms of safety and efficacy at 1 year and superior regarding stent thrombosis after 1 year.

Methods

BES recipients were enrolled in 42 French centers with up to 24‐month clinical follow up.

Results

2365 patients were included. Mean age: 65.7 ±11.2 years, 76.1% males, 31.8% had diabetes, 36.5% ACS (28.7% non‐ST‐elevation MI and 7.8% with ST‐elevation MI). 1.7 ± 1.0 stents/patient were implanted and procedural success was 99.5%. 12‐month follow‐up was completed in 94.3% patients and 24 months in 91.4%. MACCE rates at 12 and 24 months were 5.8% and 9% (all cause‐death 1.5% and 2.2%; stent thrombosis definite/probable 0.4% and 0.6%), respectively. MACCE were not significantly higher in diabetic patients compared with non‐diabetics but cardiac death was higher (1.6% vs. 0.6%, P = 0.01 at 1 year and 1.9% vs. 0.6, P = 0.005 at 2 years) as was stent thrombosis (0.9% vs. 0.2%, P = 0.009 and 1.2 vs. 0.3% P = 0.008). Compared with non‐ACS patients, MACCE was significantly higher in the ACS subgroup (7.5% vs. 4.8%, P = 0.001 at 1 year and 10.3% vs.8.1%, P = 0.07 at 2 years).

Conclusion

In this large real‐world registry, the BES with biodegradable polymer showed excellent acute and mid‐term outcomes with a 5.8% and 9% rate of MACCE at one and 2 years and a very low rate of stent thrombosis between 1 and 2 years (0.2%), thus demonstrating the replicability of the LEADERS trial in a registry population. © 2017 The Authors Catheterization and Cardiovascular Interventions Published by Wiley Periodicals, Inc.

Selective use of contemporary drug-eluting stents in primary angioplasty for ST-elevation myocardial infarction: pooled analysis of COMFORTABLE AMI and EXAMINATION

AIMS

Selective use of DES only in patients at higher risk of MACE is common practice, particularly in healthcare systems with a large premium payable for DES. We aimed to identify subgroups of patients in which the use of BMS in primary percutaneous coronary intervention (PPCI) for STEMI can still be justified.

METHODS AND RESULTS

We performed a patient-level pooled analysis of COMFORTABLE AMI and EXAMINATION comparing contemporary DES with BMS in PPCI. A risk score was applied using three parameters: lesion length >15 mm, vessel size <3 mm, and diabetes mellitus. Individual data were available for 2,655 patients. The incidence of MACE at one year was incrementally higher in patients with risk scores of 1 or 2/3. MACE rates were lower in patients with a risk score 0 or 1 who were treated with DES (p=0.0073 and p=0.008). No difference in death or reinfarction was seen between DES and BMS in any group. There was a significant reduction in TLR with DES in all three groups.

CONCLUSIONS

A score comprising vessel size, lesion length, and diabetes did not identify patients at low risk with equivalent or better results from BMS use. The results suggest that the practice of only selective use of DES in primary PCI should be discouraged.