Treatment of left anterior descending coronary artery disease with sirolimus-eluting stents

Application of apical myocardial perfusion quantitative analysis by contrast-enhanced ultrasound utilizing high-frequency linear probe

BACKGROUND

Due to insufficient near-field resolution and artifacts, it is challenging to evaluate the left ventricular apical perfusion with phased-array probes. By combining high-frequency linear probe and contrast-enhanced ultrasound (CEUS), imaging of apical myocardial perfusion could be improved. The study aims to evaluate the preliminary application of CEUS by high-frequency linear probes to assess the apical perfusion.

METHODS

The study enrolled retrospectively 91 patients to test the feasibility of the novel method. In protocol 1, patients were stratified into a group with left anterior descending artery (LAD) stenosis (N = 40) and a group without LAD stenosis or coronary artery disease (N = 41) based on the degree of coronary artery narrowing, quantified by >50% stenosis in coronary angiography. Receiver operating characteristics (ROC) analysis was performed to test the diagnostic value of perfusion parameters. In protocol 2, the reproducibility of high-frequency linear probe in apical perfusion analysis was compared with the conventional phased-array probe in 30 patients.

RESULTS

(1) The novel method is feasible in 81(89.01%) patients. (2) In protocol 1, to detect LAD stenosis, the best cut-off of β, T, A, and MBF were 10.32, 3.28, 9.39, and 4.99, respectively. Area under the curve of β, T, A, and MBF were .880, .881, .761, and .880, respectively. (3) In protocol 2, compared with phased-array probe, the quantitative analysis of high-frequency linear probe is of high reproducibility and could get good curve fitting (R2 = .29 vs. R2 = .71, P < .01).

CONCLUSION

Observation of apical perfusion using this method is feasible and quantitative analysis allows an accurate and convenient identification of LAD stenosis. This method provides an alternative for patients who have difficulties in visualizing the apical region with a phased-array probe.

Angioscopic evaluation after venous stents

BACKGROUND

Venous stenting is increasingly used to manage femoro-ilio-caval venous outflow obstruction/stenosis due to post-thrombotic syndrome. Although the safety, efficacy, and long-term patency of venous stents have been reported, re-interventions due to stent occlusion and in-stent restenosis (ISR) have also been reported. The mechanism of ISR and the in-stent neointimal growth after venous stenting remains unclear. We performed angioscopy to evaluate intraluminal details after venous stenting, allowing real-time direct visualization of the vessel lumen.

METHODS

Ten angioscopic procedures in four patients with post-thrombotic syndrome were performed. All evaluated vessels were stented iliac veins, and their native pathology was chronic post-thrombotic occlusion. Nine procedures in three patients underwent serial evaluation of the neointimal changes after stent implantation to study the natural time course of neointimal proliferation/coverage over the stent. The serial follow-up angioscopic evaluations were performed at the end of the venous stent deployment procedure, and at 6 months, 12 months, and 24 months. One procedure was performed 1 month after the stent implantation to evaluate ISR, which was observed at the first month of routine stent surveillance. A 5.7F angioscope was used to visualize the target veins. Continuous irrigation was used to displace blood and clear the visual field.

RESULTS

At 6 months after stent implantation, stent struts were covered by a thin neointima in two of the three patients. The struts were partially covered in one patient, but there was little neointimal growth overall. Neointimal coverage increased over time, and at 12 months stent struts in 2 patients were almost completely covered. There was no significant change between the 12 and 24 months after stent implantation. In the ISR case, angioscopy demonstrated an overgrown thickened neointima, and the stent struts were fully embedded and invisible in the entire stented area. No thrombus and no webs or trabeculae were found in the area evaluated as an ISR lesion.

CONCLUSIONS

At 6 months after stent placement, the stent struts were almost covered by a neointima. The stent struts were completely covered 1 year after stent implantation. Neointimal coverage was unchanged from the 1-year follow-up to the 2-year follow-up, suggesting that neointimal proliferation proceeded gradually with subsequent neointimal remodeling up to 1 year. The cause of ISR might be the overgrown thickened neointima rather than the formation of thrombosis.

Minimally invasive direct coronary artery bypass graft surgery versus percutaneous coronary intervention of the LAD: costs and long-term outcome

OBJECTIVE

Outcomes and treatment costs for coronary artery disease involving the left anterior descending coronary artery (LAD) are influenced by the type of treatment, which can be either isolated minimally invasive revascularization of the LAD using the internal thoracic artery (ITA) (MIDCAB) or percutaneous coronary intervention (PCI) on the LAD. This retrospective study sought to evaluate long-term survival, freedom from re-intervention and cost analysis after MIDCAB compared to PCI on the LAD.

METHODS

Between 2006 and 2012, from a total of 561 patients, 106 consecutive patients with LAD stenosis underwent a MIDCAB procedure whereas 100 patients underwent elective PCI. Urgent and emergent cases were excluded from the present study (n = 355). Detailed analysis of the outcome data was performed for both groups. A Kaplan-Meier survival estimation with up to 10-year follow-up was applied for both groups for survival analysis and freedom from re-intervention.

RESULTS

There were no statistically significant differences in terms of clinically relevant baseline characteristics. The outcome in the MIDCAB group was superior regarding long-term overall survival, accounting for 100% versus 92.8% at 1 year, 98.5% versus 82.1% at 6 years and 79.6% versus 61.5% at 10 years (Log Rank (Mantel-Cox) p = 0.011) and freedom from re-intervention at 10 years (97.2% vs. 86.7%, Log Rank (Mantel-Cox) p = 0.001). Intensive care unit (ICU) stay (p = 0.020) and total hospital stay (p<0.001) were significantly longer in the MIDCAB group, which was also associated with higher in-hospital costs (10,879 € vs. 4009 €, p<0.001).

CONCLUSIONS

Whereas patients undergoing MIDCAB remained longer on ICU and in hospital, causing higher costs, this procedure was associated with a significantly lower incidence of repeat revascularization and significantly lower mortality compared to PCI on the LAD.

Outcomes of Coronary Artery Bypass Graft Surgery Versus Percutaneous Coronary Intervention in Patients Aged 18-45 Years with Diabetes Mellitus

BACKGROUND

Debate on treatment for young patients with coronary artery disease still exists. This study aimed to investigate the intermediate- and long-term outcomes between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients aged 18-45 years with diabetes mellitus (DM).

METHODS

Between January 2006 and March 2016, a total of 2018 DM patients aged 18-45 years including 517 cases of CABG and 1501 cases of PCI were enrolled in the study. Using propensity score matching (PSM), 406 patients were matched from each group. The intermediate- and long-term data were collected. The primary end point of this study was long-term death. The secondary end points included long-term major adverse cardiovascular and cerebrovascular events (MACCEs), stroke, angina, myocardial infarction (MI), and repeat revascularization.

RESULTS

Before PSM, the in-hospital mortality was 1.2% in the CABG group and 0.1% in the PCI group, with statistically significant difference (P < 0.0001). The 10-year follow-up outcomes including long-term survival rate and freedom from MACCEs were better in the CABG group than those in the PCI group (97.3% vs. 94.5%, P = 0.0072; 93.2% vs. 86.3%, P < 0.0001), but CABG group was associated with lower freedom from stoke compared to PCI group (94.2% vs. 97.5%, P = 0.0059). After propensity score-matched analysis, these findings at 10-year follow-up were also confirmed. Freedom from MACCEs was higher in CABG group compared to PCI group, but no significant difference was observed (93.1% vs. 89.2%, P = 0.0720). The freedom from recurrent MI was significantly higher in CABG patients compared with PCI patients (95.6% vs. 92.5%, P = 0.0260). Furthermore, CABG was associated with a higher rate of long-term survival rate than PCI (97.5% vs. 94.6%, P = 0.0403). There was no significant difference in the freedom from stroke between CABG and PCI groups (95.3% vs. 97.3%, P = 0.9385). The hospital cost was greater for CABG (13,936 ± 4480 US dollars vs. 10,926 ± 7376 US dollars, P < 0.0001).

CONCLUSIONS

In DM patients aged 18-45 years, the cumulative survival rate, and freedom from MI and repeat revascularization for CABG were superior to those of PCI. However, a better trend to avoid stroke was observed with PCI.

Network meta-analysis of balloon angioplasty, nondrug metal stent, drug-eluting balloon, and drug-eluting stent for treatment of infrapopliteal artery occlusive disease

PURPOSE

We aimed to conduct a network meta-analysis of mixed treatments for the infrapopliteal artery occlusive disease.

METHODS

We searched randomized controlled trials (RCTs) regarding balloon angioplasty (BA), nondrug metal stent (NDMS), drug-eluting balloon (DEB), or drug-eluting stent (DES) in PubMed, Embase, CENTRAL, Ovid, Sinomed, and other relevant websites. We selected and assessed the trials that met the inclusion criteria and conducted a network meta-analysis using the ADDIS software.

RESULTS

We included 11 relevant trials. We analyzed data of 1322 patients with infrapopliteal artery occlusive disease, of which 351 were in the NDMS vs. DES trials, 231 in the NDMS vs. BA trials, 490 in the BA vs. DEB trials, 50 in the DEB vs. DES trials, and 200 in the BA vs. DES trials. The network meta-analysis indicated that with NDMS as the reference, DES had a better result with respect to restenosis (odds ratio [OR], 5.16; 95% credible interval [CI], 1.58-18.41; probability of the best treatment, 84%) and amputation (OR, 2.50; 95% CI, 0.81-7.11; probability of the best treatment, 61%) and DEB had a better result with respect to target lesion revascularization (TLR; OR, 3.74; 95% CI, 0.78-17.05; probability of the best treatment, 57%). Moreover, with BA as the reference, NDMS had a better result with respect to technical success (OR, 0.10; 95% CI, 0.00-1.15; probability of the best treatment, 86%).

CONCLUSION

Our meta-analysis revealed that DES is a better treatment with respect to short-term patency and limb salvage rate, NMDS may provide a better technical success, and DEB and DES are good choices for reducing revascularization.

Endovascular versus medical therapy for atherosclerotic renovascular disease

The diagnosis of renal artery stenosis (RAS) has become increasingly common in part due to greater awareness of ischemic renal disease and increased use of diagnostic techniques. Over 90 % of RAS cases are caused by atherosclerotic renovascular disease (ARVD). Patients with ARVD are at high risk for fatal and nonfatal cardiovascular and renal events. The mortality rate in patients with ARVD is high, especially with other cardiovascular or renal comorbidities. Recent clinical studies have provided substantial evidence concerning medical therapy and endovascular interventional therapeutic approaches for ARVD. Despite previous randomized clinical trials, the optimal therapy for ARVD remained uncertain until the results of the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial were released recently. CORAL demonstrated that optimal medical therapy was equally effective to endovascular therapy in the treatment of ARVD. Clinicians can now practice with more evidence-based medicine to treat ARVD and potentially decrease mortality in patients with ARVD using optimal medical therapy.

Coronary artery bypass grafting versus drug-eluting stents in patients with severe coronary artery disease and diabetes mellitus: systematic review and meta-analysis

BACKGROUND

A comprehensive meta-analysis was performed to evaluate the comparative benefits of coronary artery bypass grafting (CABG) versus drug-eluting stents (DES) in patients with diabetes mellitus and severe coronary artery disease (CAD).

METHODS

A comprehensive literature search of PubMed, Embase, and ScienceDirect was undertaken. References cited with the papers were also checked to identify relevant articles.

RESULTS

In all, four randomized controlled trials, two prospective registries, and 11 retrospective studies were identified for review. Pooled analysis demonstrated that DES was associated with lower all-cause mortality at Day 30. However, there was no significant difference between CABG and DES in mortality at 12 months and at maximum follow-up. Furthermore, DES was associated with lower overall and major adverse cardiac and cerebrovascular events (MACCE)-free survival, as well as a higher incidence of myocardial infarction and repeat revascularization. In contrast, CABG was associated with an increased risk of stroke.

CONCLUSIONS

For patients with diabetes mellitus and severe CAD, CABG is superior to DES in that it significantly improves overall and MACCE-free survival and reduces the incidence of myocardial infarction and repeat revascularization in the long term, although it is associated with greater perioperative risk and a higher incidence of stroke. Therefore, CABG should remain the gold standard for these patients.

Meta-analysis of minimally invasive coronary artery bypass versus drug-eluting stents for isolated left anterior descending coronary artery disease

OBJECTIVE

To compare the outcomes between minimally invasive coronary artery bypass (MINI-CAB) and drug-eluting stent (DES) implantation for isolated left anterior descending artery disease.

METHODS

Randomized and observational comparative publications were identified using MEDLINE and Google Scholar databases (January 2003 to December 2013). Studies without outcomes data, without DES use, or using conventional bypass surgery were excluded. The outcomes of interest were cardiac death, myocardial infarction, target vessel revascularization, and periprocedural stroke. Data were compared using the Mantel-Haenszel methods and are presented as odds ratios (ORs), 95% confidence intervals (CIs), and number needed to treat.

RESULTS

From 230 publications, we identified 4 studies (2 randomized and 2 observational) with 941 patients (478 had undergone MINI-CAB and 463 DES implantation). The incidence of target vessel revascularization at maximum follow-up (range, 6-60 months) was significantly lower in the MINI-CAB group (OR, 0.16; 95% CI, 0.08-0.30; P<.0001; number needed to treat, 13). The incidence of cardiac mortality and MI was similar between the MINI-CAB and DES groups during follow-up (OR, 1.05; 95% CI, 0.44-2.47; and OR, 0.83; 95% CI, 0.43-1.58, respectively). In addition, a similar incidence of periprocedural death (OR, 0.85; 95% CI, 0.21-3.47; P=.82), myocardial infarction (OR, 0.98; 95% CI, 0.38-2.58; P=.97), and stroke (OR, 1.36; 95% CI, 0.28-6.70; P=.70) was observed between the 2 treatment modalities.

CONCLUSIONS

Given the available evidence, MINI-CAB will result in lower target vessel revascularization rates but otherwise similar clinical outcomes compared with DESs in patients with left anterior descending artery disease.

Treatment of left anterior descending coronary artery stenosis: stent or surgery

BACKGROUND

Drug-eluting stents have emerged as a solution to the problem of restenosis after bare-metal stent implantation, as an alternative to off-pump coronary bypass, for isolated left anterior descending coronary artery lesions at short-term follow-up. However, long-term follow-up is yet to be defined.

METHODS

From January to December 2004, 64 consecutive patients underwent myocardial revascularization: 31 by drug-eluting stents and 33 by off-pump coronary bypass. The primary endpoint was angiographic outcome, and the secondary endpoint was clinical outcome at 5 years.

RESULTS

There was no early or late mortality in either group. Hospital stay was significantly shorter in the stent group (2.5 ± 2.1 vs. 7.1 ± 4.9 days, p = 0.003). Long-term patency was higher and major adverse cardiac events (recurrence of angina and revascularization of target vessel) were encountered less frequently in the coronary bypass group, although not significantly.

CONCLUSION

The 5-year follow-up showed no significant difference between the off-pump coronary bypass and stent groups for the primary and secondary endpoints. As a significant difference between treatment options is lacking, decision-making for appropriate treatment in this group of patients requires the collaboration of cardiologists and cardiovascular surgeons and an individual approach, to achieve successful long-term outcomes.

Minimally invasive direct coronary artery bypass improves late survival compared with drug-eluting stents in isolated proximal left anterior descending artery disease: a 10-year follow-up, single-center, propensity score analysis

OBJECTIVES

Minimally invasive direct coronary artery bypass (MIDCAB) has been proposed to reduce surgical morbidity and improve long-term outcomes compared with stenting in the treatment of isolated proximal left anterior descending artery. However, the survival benefit from MIDCAB still needs to be demonstrated, in particular, because percutaneous coronary intervention with drug-eluting stents (DES-PCI) continues to be considered the initial treatment strategy. We conducted a 10-year follow-up, single-center, propensity score-matched MIDCAB versus DES-PCI comparison.

METHODS

A total of 1033 patients (303 MIDCAB and 730 DES-PCI) with isolated proximal left anterior descending disease were included. Propensity score matching was used to compare 303 pairs of MIDCAB and DES-PCI patients.

RESULTS

MIDCAB and DES-PCI presented with comparable 30-day mortality (2 of 303 [0.6%] vs 1 of 303 [0.3%]; P=1.0). At 10 years, DES-PCI was associated with a 2.19-fold increased risk of late death (95% confidence interval, 1.15-4.17), a 2.0-fold increased risk of repeat revascularization (95% confidence interval, 1.20-3.47), and a 2.14-fold increased risk of the composite of death and repeat revascularization (95% confidence interval, 1.41-3.24).

CONCLUSIONS

These findings strongly support a survival benefit from MIDCAB at long-term follow-up compared with DES-PCI in the treatment of isolated left anterior descending disease.

Surgical myocardial revascularization versus percutaneous coronary intervention with drug-eluting stents in octogenarian patients

OBJECTIVE

Our goal was to compare the clinical outcomes of octogenarian (or older) patients who are referred for either surgical or percutaneous coronary revascularization.

METHODS

We retrospectively evaluated the outcomes of all patients 80 years of age who had undergone coronary artery bypass grafting (CABG) with an internal mammary artery or had undergone a percutaneous coronary intervention (PCI) with a sirolimus-eluting stent to the left anterior descending artery in our center between May 2002 and December 2006.

RESULTS

Of the 301 patients, 120 underwent a PCI, and 181 underwent CABG. Surgical patients had higher rates of left main disease, triple-vessel disease, peripheral vascular disease, emergent procedures, and previous myocardial infarctions (39.7% versus 3.3% [P = .001], 76.1% versus 28.3% [P = .0001], 19.6% versus 7.5% [P = .004], 15.8% versus 2.5% [P = .0001], and 35.9% versus 25% [P = .04], respectively). CABG patients had a higher early mortality rate (9.9% versus 2.5%, P = .01). There were no differences in 1- and 4-year actuarial survival rates, with rates of 90% and 68%, respectively, for the PCI group and 85% and 71% for the CABG group (P = .85). The rates of actuarial freedom from major adverse cardiac events (MACEs) at 1 and 4 years were 83% and 75%, respectively, for the PCI group, and 86% and 78% for the CABG group (P = .33). The respective rates of freedom from reintervention were 87% and 83% for the PCI group, versus 99% and 97% for the CABG group (P < .001). The 4-year rate of freedom from recurring angina was 58% for the PCI group, versus 88% for CABG patients (P < .001). Revascularization strategy was not a predictor of adverse outcome in a multivariable analysis.

CONCLUSION

Octogenarian CABG patients were sicker and experienced a higher rate of early mortality. The 2 strategies had similar rates of late mortality and MACEs, with fewer reinterventions and recurring angina occurring following surgery.

Sirolimus-Versus Zotarolimus-Eluting Stents in Acute Coronary Syndromes With C Type Left Anterior Descending Artery Lesions: A Three-Year Clinical Follow-Up

Background

Drug-eluting stents have improved the efficacy of percutaneous coronary intervention and made it the preferred therapy in the treatment of ischemic heart diseases including acute coronary syndromes. The objective of the study was to compare the clinical efficacy and safety of sirolimus-eluting stent with that of zotarolimus-eluting stent following percutaneous coronary intervention for acute coronary syndrome patients with C-type left anterior descending stenosis.

Methods

A total of 154 acute coronary syndrome patients with C-type lesions in the left anterior descending artery, requiring a stent > 28 mm in length, were randomized into two groups to receive either sirolimus- (n = 74) or zotarolimus-eluting stent (n = 80). The follow-up period after stent implantation was approximately 36 months. The primary endpoint was a major cardiac event (a composite of cardiac death, myocardial infarction, or ischemia-related target vessel revascularization), and the secondary endpoint included these individual end points plus stent thrombosis.

Results

After 3 years follow-up, the rate of the primary end point (major cardiac event: cardiac death, myocardial infarction, ischemia-related target vessel revascularization) was 16% in the sirolimus group (n = 12) versus 11.2% in the zotarolimus group (n = 9) (P = 0.2). Although there were four cases of stent thrombosis with sirolimus-eluting stent and one with zotarolimus-eluting stent (4.0% sirolimus vs. 1.25% zotarolimus; P = 0.2), neither non-Q myocardial infarction (4.0%sirolimus vs. 1.25% zotarolimus; P = 0.2) nor stent thrombosis, differed significantly.

Conclusions

Although zotarolimus-eluting stent implantation showed more favorable results with respect to stent thrombosis and major adverse cardiac event rates compared to sirolimus-eluting stent implantation, statistically, both stent groups have nearly similar clinical safety and efficacy in the treatment of acute coronary syndromes with C-type lesions in the left anterior descending artery disease.

Extensive reconstruction of the left anterior descending coronary artery with an internal thoracic artery graft

BACKGROUND

Revascularization of the diffusely diseased coronary artery is a big challenge for both cardiologists and cardiac surgeons. Long reconstruction of the diffusely diseased vessel may be a useful surgical option. The aim of this study is to assess clinical and angiographic outcomes of extensive reconstruction (≥4 cm) of the left anterior descending coronary artery (LAD) using an internal thoracic artery (ITA) graft with or without endarterectomy.

METHODS

We retrospectively reviewed 213 patients who underwent extensive reconstruction of the LAD using an ITA graft between September 2004 and July 2009. The diffusely diseased LAD was extensively incised, additional endarterectomy was performed if necessary, and then the LAD was reconstructed with an ITA graft in a long on-lay fashion. Early and 1-year postoperative angiography was performed in 188 patients (88.3%) and 152 patients (71.4%), respectively.

RESULTS

The mean length of the reconstructed LAD was 5.4 ± 1.2 cm. Endarterectomy was performed in 46.0% of the patients. The operative mortality was 1.4%. Low cardiac output and perioperative myocardial infarction were observed in 3.3 and 5.2% of the patients, respectively. Freedom from death and other cardiac or cerebrovascular events was 91.5 ± 2.2% at 3 years. The early and 1-year patency rates of the ITA to LAD grafting were 95.7% and 93.4%, respectively.

CONCLUSIONS

Extensive reconstruction of the diffusely diseased LAD using an ITA graft could be performed safely. Early and 1-year angiographic outcome were excellent. This surgical revascularization is an useful option for revascularization of the diffuse coronary artery disease.

Closed chest hybrid coronary revascularization for multivessel disease - current concepts and techniques from a two-center experience

Hybrid coronary revascularization combining minimally invasive coronary surgery and percutaneous coronary intervention (PCI) allows sternal preserving treatment of multivessel coronary disease. The main principle of the technique includes placement of mammary artery graft to the left anterior descending coronary artery (LAD) and performance of PCI in non-LAD target vessels. This principle is based on increasing data showing equivalent results of PCI with coronary revascularization using saphenous vein grafts in selected patients. Providing that perioperative and long-term results are as good as the results of conventional surgical revascularization, this option seems to be quite appealing for patients and referring cardiologists. This concept has been designed to allow rapid rehabilitation and minimize periprocedural pain under concomitant preservation of the patient's body integrity. Robotically assisted endoscopic approaches for hybrid coronary revascularization set the pace for a closed-chest treatment of multivessel coronary disease. The time point of PCI, the use of different anticoagulation protocols as well as the stent selection are some of the variables, which affect outcome. We additionally report on the midterm results of 130 after-closed-chest hybrid-coronary procedures in two institutions. Hybrid procedures using robotic technology and PCI allow closed chest treatment of multivessel coronary artery disease. Single- and double-bypass grafts are feasible and simultaneous interventions can be performed. The overall safety of the procedure seems to be adequate and perioperative clinical results are satisfactory. Intermediate term survival and freedom from angina are excellent.

Preventing restenosis in early drug-eluting stent era: recent developments and future perspectives

Restenosis is the major limitation of the successful therapy of percutaneous coronary intervention (PCI) for patients with coronary artery disease. The problem was appreciated in the late 1970s to early 1980s. Only in recent years, anti-restenotic therapy has achieved a breakthrough with the development of drug-eluting stents. Here, we provide an overview about pathological mechanisms of restenosis after PCI. Present therapeutic approaches to overcome restenosis and recent clinical results are revisited, and some major concerns in the post-drug-eluting stent era are discussed.

Drug eluting stents versus coronary artery bypass surgery in patients with isolated proximal lesion in left anterior descending artery suffering from chronic stable angina

OBJECTIVE

To compare the efficacy of drug eluting stents (DES) compared with bypass surgery (CABG) with left internal mammary artery (LIMA) in patients with single vessel disease suffering from chronic stable angina.

BACKGROUND

There are a limited number of studies investigating this group of patients.

METHODS

We included 257 consecutive patients with isolated lesion in the proximal segment of left anterior descending artery (LAD). All patients suffered from chronic stable angina or from stress-induced ischemia. Of 257 patients, 147 underwent DES implantation and 110 CABG with LIMA. All patients were followed-up clinically for major adverse cardiac events.

RESULTS

The baseline demographic and angiographic characteristics were similar between the two groups. In the DES group we used sirolimus-, paclitaxel-, and ABT-578-eluting stents. The mean duration of hospitalization after CABG was 7.86 +/- 3.84 days vs. 1.02 +/- 0.19 days after PCI (P < 0.01). The incidence of MACE was 2.72% in the DES and 2.72% in the surgical group during a mean follow-up period of 18.71 +/- 6.27 months for PCI and 18.70 +/- 7.31 months for CABG (P = 0.99). There was one cardiac related death in the DES group and two in the surgical group (P = 0.58). There were three reinterventions in the DES group versus none in the surgical group (P = 0.26). Recurrence of angina was observed in 4.08% of pts in the DES group versus 6.36% in the CABG group (P = 0.57).

CONCLUSIONS

The present study demonstrated that patients suffering from chronic stable angina with isolated lesion in the proximal segment of LAD have excellent long-term outcome in both surgical and DES treatment.

Angiographic and intravascular ultrasound study of the effects of overlapping sirolimus- and paclitaxel-eluting stents: Comparison with same drug-eluting overlapping stents

BACKGROUND

Although complete coverage of diffuse long coronary lesions has warranted the use of overlapping drug-eluting stents (DESs), the effect of stent overlap with different DESs on the neointimal hyperplasia and whether it would result in dose-related side effects are unknown.

METHODS AND RESULTS

Forty-seven consecutive patients, from June 2003 to August 2004, underwent percutaneous coronary intervention (PCI) with 2 of the same or different overlapping DESs for diffuse long lesions. Out of the total of 47 patients, a nine-month angiographic examination and IVUS were performed in 40 (85.1%) patients. Of the 47 overlapping DESs utilized, 14 were overlapped using sirolimus- and paclitaxel-eluting stents (S-P group), 13 using two sirolimus-eluting stents (S-S group) and 20 using two paclitaxel-eluting stents (P-P group). In the follow-up, there was no difference between the three groups in the late loss or area of neointimal hyperplasia. All restenoses were noted at non-overlapping sites (2 at the proximal edge of the proximal stent, and 3 at the distal in-stent). There were no stent thromboses documented or aneurysmal formations at the overlapping site in any of the three groups. One late stent malapposition was observed not at an overlapping site, but in the distal single stent area.

CONCLUSIONS

In conclusion, compared with using the same overlapping DESs, PCI with different overlapping DESs exhibited similar effects on the suppression of neointimal hyperplasia and did not increase the side effects of the DES.

Sirolimus-eluting stent implantation for treatment of proximal left anterior descending coronary artery lesions: long-term outcome and predictors of adverse cardiac events

OBJECTIVES

Acute and long-term results after sirolimus-eluting stent (SES) implantation of proximal left anterior descending coronary artery (LAD) disease were evaluated.

BACKGROUND

Although SES has been used increasingly for the treatment of LAD disease, data regarding their safety and efficacy in a real-world population are limited.

METHODS

We investigate the short- and long-term results in 966 patients who underwent SES implantation for stenosis of proximal LAD.

RESULTS

The procedural success rate was 97.6%, and procedural non-Q-wave myocardial infarction (MI) rate was 14.5%. In-hospital major complications occurred in five patients (0.5%), including three deaths and two Q-wave MIs. During follow-up (20.4 +/- 8.9 months), there were 16 deaths (1.7%; 10 cardiac, 6 noncardiac), 2 Q-wave MIs, and 22 target lesion revascularizations (2.3%). Late stent thrombosis occurred in two patients (0.2%), 14 and 23 months after the procedure. The event-free survival rates for cardiac death/Q-wave MI were 98.6% +/- 0.4% at 1 year and 97.8% +/- 0.6% at 2 years. The cumulative probabilities of survival without major adverse cardiac events (MACE) were 96.7% +/- 0.6% at 1 year and 95.4% +/- 0.8% at 2 years. In multivariate analysis, stented length (HR 1.04, 95%CI 1.01-1.07, P = 0.009) and infarct-related artery (HR 5.18, 95%CI 1.09-24.64, P = 0.039) were independently related to cardiac death/Q-wave MI. In addition, stented length (HR 1.04, 95%CI 1.02-1.06, P < 0.001) and left ventricular dysfunction (HR 2.66, 95%CI 1.07-6.63, P = 0.036) were significant independent predictors of MACE.

CONCLUSIONS

SES implantation for proximal LAD disease appears safe and effective in a real-world population, and the independent predictors of MACE included stented length and left ventricular dysfunction.

Comparison of outcomes of percutaneous coronary intervention on proximal versus non-proximal left anterior descending coronary artery, proximal left circumflex, and proximal right coronary artery: a cross-sectional study

Background

Previous studies have shown that lesions in proximal left anterior descending coronary artery (LAD) may develop more restenosis after balloon angioplasty than lesions in other coronary segments. However, stenting seems to have reduced this gap. In this study, we compared outcomes of percutaneous coronary intervention (PCI) on proximal LAD versus proximal left circumflex (LCX) or right coronary artery (RCA) and proximal versus non-proximal LAD.

Methods

From 1737 patients undergoing PCI between March 2004 and 2005, those with cardiogenic shock, primary PCI, total occlusions, and multivessel or multi-lesion PCI were excluded. Baseline characteristics and in-hospital outcomes were compared in 408 patients with PCI on proximal LAD versus 133 patients with PCI on proximal LCX/RCA (study I) and 244 patients with PCI on non-proximal LAD (study II). From our study populations, 449 patients in study I and 549 patients in study II participated in complete follow-up programs, and long-term PCI outcomes were compared within these groups. The statistical methods included Chi-square or Fisher's exact test, student's t-test, stratification methods, multivariate logistic regression and Cox proportional hazards model.

Results

In the proximal LAD vs. proximal LCX/RCA groups, smoking and multivessel disease were less frequent and drug-eluting stents were used more often (p = 0.01, p < 0.001, and p < 0.001, respectively). Patients had longer and smaller-diameter stents (p = 0.009, p < 0.001, respectively). In the proximal vs. non-proximal LAD groups, multivessel disease was less frequent (p = 0.05). Patients had larger reference vessel diameters (p < 0.001) and were more frequently treated with stents, especially direct stenting technique (p < 0.001). Angiographic success rate was higher in the proximal LAD versus proximal LCX/RCA and non-proximal LAD groups (p = 0.004 and p = 0.05, respectively). In long-term follow-up, major adverse cardiac events showed no difference. After statistical adjustment for significant demographic, angiographic or procedural characteristics, long-term PCI outcomes were still similar in the proximal LAD versus proximal LCX/RCA and non-proximal LAD groups.

Conclusion

Despite the known worse prognosis of proximal LAD lesions, in the era of stenting, our long-term outcomes were similar in patients with PCI on proximal LAD versus proximal LCX/RCA and non-proximal LAD. Furthermore, we had better angiographic success rates in patients with PCI on proximal LAD.

Randomized Comparison of Sirolimus and Paclitaxel Drug-Eluting Stents for Long Lesions in the Left Anterior Descending Artery

OBJECTIVES

The goal of this work was to verify whether the superiority of the sirolimus-eluting stent (SES) in inhibiting neointimal hyperplasia could be demonstrated in complex coronary lesions.

BACKGROUND

Both the SES (Cypher, Cordis, Miami Lakes, Florida) and the paclitaxel-eluting stent (PES) (Taxus, Boston Scientific, Natick, Massachusetts) have shown a marked reduction in neointimal hyperplasia compared with bare-metal stents. Intravascular ultrasound (IVUS) is the best method to assess arterial response to stent deployment, but few IVUS data are available comparing complex lesions treated with SES or PES.

METHODS

We prospectively randomized patients with complex lesions to SES or PES implantation. Intravascular ultrasound and quantitative angiography were performed post-procedure and at 9 months. Mean neointimal hyperplasia area (NIHA), percent of NIHA (NIHA%), mean peristent plaque area (PSPA), and percent of PSPA (PSPA%) were calculated. The primary end point was NIHA% at follow-up. Secondary end points included change in PSPA% and angiographic late luminal loss at follow-up.

RESULTS

Of the 100 patients enrolled, 42 receiving the SES and 43 receiving the PES had adequate IVUS assessment. Vessel, plaque, and lumen areas were comparable at follow-up, but NIHA% was significantly lower with SES than PES (7.4 +/- 4.2% vs. 15.4 +/- 8.1%; p < 0.001). A significant reduction in PSPA% was observed with SES (-4 +/- 10% vs. 0 +/- 8%; p = 0.01). Late loss was significantly lower with SES (0.16 +/- 0.19 mm vs. 0.32 +/- 0.33 mm; p = 0.003).

CONCLUSIONS

The SES shows a significantly higher inhibition of neointimal hyperplasia compared with PES in complex lesions. However, both stents have excellent IVUS and angiographic results at 9 months. A significant reduction in peri-stent plaque is observed only with SES.

A meta-analysis of trials comparing Cypher and Taxus stents in patients with obstructive coronary artery disease

AIMS

Drug-eluting stents have been shown to be superior to bare metal stents in reducing restenosis rates. Recently head-to-head trials comparing sirolimus-eluting stents and paclitaxel-eluting stents have been reported. An early combined analysis of these comparative trials is needed. The present meta-analysis was carried out to compare the effects of sirolimus-eluting stents with paclitaxel-eluting stents on the restenosis rate, major adverse cardiac events and late loss of arterial lumen diameter in patients with obstructive coronary artery disease.

METHODS

Electronic (Medline, Cochrane and Embase) and manual search (Index Medicus and cross references of retrieved articles) were carried out for all the relevant articles up till March 2005. Only randomized trials with adequate data for calculation of odds ratio for restenosis rates and major adverse cardiac events using the method of DerSimonian & Laird and standardized mean difference for late loss of arterial lumen diameter were included.

RESULTS

Four studies were found to be eligible for inclusion in the meta-analysis. Restenosis rate and late loss of arterial lumen diameter were significantly reduced by sirolimus-eluting stents as compared with paclitaxel-eluting stents (OR 0.598, 95% CI 0.400, 0.893, pooled mean difference -0.414, 95% CI -0.492, 0.336, respectively). The incidence of major adverse cardiac events was less with sirolimus-eluting stents as compared with paclitaxel-eluting stents (OR 0.727, 95% CI 0.518-1.018) but the results were not statistically significant.

CONCLUSIONS

Sirolimus-eluting stents are superior to paclitaxel-eluting stents in decreasing restenosis rate and late loss of arterial lumen diameter. However, no statistically significant difference in major adverse cardiac events was noted between the two stents.

Revascularization of Left Anterior Descending Artery With Drug-Eluting Stents: Comparison With Minimally Invasive Direct Coronary Artery Bypass Surgery

BACKGROUND

The proximal left anterior descending artery (LAD) is a challenging area for percutaneous interventions; therefore, coronary artery bypass grafting is often considered and sometimes performed even in patients with single-vessel disease involving the proximal LAD. This study compares mid-term results of LAD revascularization using drug-eluting stents (Cypher) with minimally invasive direct coronary artery bypass grafting (MIDCAB).

METHODS

From May 2002 to December 2003, 376 consecutive patients underwent myocardial revascularization of the LAD, 272 by Cypher and 104 by MIDCAB. After matching for age, sex, and extent of coronary artery disease, two groups of 83 patients each were used to compare the two revascularization modalities. The groups were similar; however, ejection fraction of less than 0.35 was more prevalent in the MIDCAB group and prior percutaneous coronary intervention in the Cypher group.

RESULTS

Thirty-day mortality was 1.1% in the MIDCAB and 0% in the Cypher group. Mean follow-up was 22.5 months. Two late cardiac deaths occurred in the MIDCAB group and one in the Cypher group (p = NS). Angina returned in 35% of the Cypher group and in 8.4% of the MIDCAB group (p < 0.001). There were 14 (16.8%) reinterventions in the Cypher compared with three (3.6%) in the surgical group (p = 0.005). Cox proportional hazard model showed that assignment to the Cypher group was the only independent predictor of reangina (hazard ratio [HR], 6.17, 95% confidence interval [CI], 2.46 to 15.4). Treatment with Cypher was also an independent predictor of reintervention (HR 8.26, 95% CI, 1.68 to 40).

CONCLUSIONS

Despite improved results of percutaneous interventions with Cypher to the LAD, mid-term clinical outcome of patients treated with MIDCAB was better.

Use of drug‐eluting stents in Victorian public hospitals

OBJECTIVE

We aimed to assess the pattern of use of drug-eluting stents (DESs) in patients undergoing percutaneous coronary interventions (PCIs) in Victorian public hospitals.

DESIGN, SETTING AND PATIENTS

Prospective study comparing the use of one or more DESs versus bare-metal stents (BMSs) only, in consecutive patients undergoing 2428 PCIs with stent implantation from 1 April 2004 to 31 December 2005 at seven Victorian public hospitals.

MAIN OUTCOME MEASURES

Adherence to current Victorian Department of Human Services guidelines which recommend DES use in patients with high-risk features for restenosis (diabetes, small vessels, long lesions, in-stent restenotic lesions, chronic total occlusions and bifurcation lesions).

RESULTS

Of the 2428 PCIs performed, at least one DES was implanted in 1101 (45.3%) and BMSs only were implanted in 1327 (54.7%). In 87.7% (966/1101) of PCI with DESs, there was at least one criterion for high risk of restenosis. DESs were more likely to be used in patients with diabetes (risk ratio [RR], 2.45; 95% CI, 2.02-2.97), small vessels (RR, 3.35; 95%CI, 2.35-4.76), long lesions (RR, 3.87; 95% CI, 3.23-4.65), in-stent restenotic lesions (RR, 3.98; 95%CI, 2.67-6.06), chronic total occlusions (RR, 1.30; 95% CI, 0.51-2.88) and bifurcation lesions (RR, 2.23; 95%CI, 1.57-3.17). However, 66.2% (1608/2428) of all PCIs were in patients eligible for DESs according to Victorian guidelines, and in 39.9% (642/1608) of these PCIs, a BMS was used.

CONCLUSION

In Victorian public hospitals, DESs have been largely reserved for patients at high risk of restenosis in accordance with Department of Human Services guidelines. However, many patients with high-risk criteria for restenosis did not receive DESs. Greater use of DESs in these patients may improve outcomes by reducing the need for repeat revascularisation.

Two-year follow-up of sirolimus-eluting stents for the treatment of proximal left anterior descending coronary artery stenosis

INTRODUCTION

Sirolimus-eluting stents (SES) have demonstrated low target vessel revascularizations and low incidence of angiographic restenosis in several clinical scenarios. The aim of the present study was to assess the efficacy and safety of SES for the treatment of proximal left anterior descending coronary artery (pLAD) lesions.

METHODS

Ninety-six patients with severe pLAD stenosis were enrolled. Angiographic and clinical follow-up were performed at 6 and 24 months, respectively. Death, myocardial infarction (MI), new target lesion revascularization (TLR), and target vessel failure (TVF) were registered. Clinical, angiographic, and procedural variables were analyzed to identify predictors of restenosis.

RESULTS

Mean clinical follow-up was 858+/-158 days (26.5+/-8.3 months). Angiographic procedural success was 100%. Angiographic follow-up showed 8.4% of binary restenosis without edge-restenosis phenomenon. Late loss was 0.15+/-0.65 mm; 15.6% of patients had an adverse cardiac event, with 1% of death, 5.2% of MI, 6.3% of TLR, and 9.4% of TVF. At 2 years, the probabilities of cumulative TVF- and TLR-free survival were 90.6% and 93.7%, respectively. Interestingly, no adverse cardiac events were registered between the first and second years. Female gender (OR 10.7 CI 95%[1.7-66.7]) and in-stent restenosis (OR 8.2, CI 95%[1.2-56.4]) were found as independent predictors of binary restenosis. Advanced chronic renal failure showed a strong trend toward worse outcome in terms of binary restenosis (P=0.063).

CONCLUSIONS

SES for the treatment of pLAD stenosis proved safe and effective in a long-term follow-up with low incidence of adverse cardiac events and restenosis. Female gender and in-stent restenosis were predictors of binary restenosis.

Early outcome of treatment of ostial de novo left anterior descending coronary artery lesions with drug-eluting stents

We investigated early and mid-term clinical and angiographic outcomes of patients who had de novo ostial left anterior descending coronary artery (LAD) lesions that were treated with drug-eluting stents (DESs) or bare metal stents (BMSs). We identified 43 consecutive patients who underwent percutaneous intervention for isolated de novo ostial LAD lesions with implantation of DESs and compared them with 43 patients who had similar lesions that were treated with BMSs. All stents were successfully implanted. There were no significant differences with respect to major in-hospital complications between the 2 groups. One patient in the BMS group died during hospitalization. Non-Q-wave myocardial infarction occurred in 2 patients (4.7%) in the DES and in 1 patient (2.3%) in the BMS group. At 9-month follow-up, 3 patients (7%) in the DES group and 11 (25.6%) in the BMS group underwent target lesion revascularization (p = 0.038); major adverse cardiac events were less frequent in the DES than in the BMS group (9.3% vs 32.6%, p = 0.015). Angiographic follow-up was available in 82% of patients in the DES group and 75% of those in the BMS group (p = 0.6) and showed lower binary restenotic rates (5.7% vs 31.3%, p = 0.01) and smaller late loss (0.30 +/- 0.81 vs 1.23 +/- 0.93 mm, p = 0.0001) in the DES group. In conclusion, DES implantation in de novo ostial LAD lesions appears safe and effective and is associated with a significant decrease in restenotic rates compared with historical experience with BMSs.

Comparison between multivessel stenting with drug eluting to the LAD and bilateral internal thoracic artery grafting

BACKGROUND

Reduction of restenosis and reinterventions was reported with drug-eluting stents (Cypher). This study compares results of multivessel Cypher stenting with bilateral internal thoracic artery (BITA) grafting.

METHODS

From January 2002 to June 2004, 725 consecutive patients underwent multivessel myocardial revascularization, 95 by 2 or more Cypher stents and 630 by BITA. After matching for age, sex, and extent of coronary artery disease, 2 groups (87 patients each) were used to compare the 2 revascularization modalities.

RESULTS

The 2 groups were similar; however, left main and the use of an intra-aortic balloon pump were more prevalent in the BITA group. The number of coronary vessels treated per patient was higher in the BITA group (2.71 versus 2.24 for BITA and Cypher, respectively; P = .001). Mean follow-up was 12 months. Thirty-day mortality was 0 in both groups. There were no late deaths in the BITA group and 2 (2.3%) in the Cypher group (P value was not significant). Angina returned in 29.9% of the Cypher group and 12.6% of the BITA group (P = .005). Multivariable Cox analysis revealed percutaneous intervention (PCI) (Cypher group) to be the only independent predictor of angina recurrence (Odds Ratio 2.62, 95% Confidence Interval 1.11-6.17). There were 10 reinterventions (PCI) in the Cypher group compared to 5 in the BITA group. One-year reintervention-free survival (Kaplan-Meier) of the BITA group was 96% compared to 88% in the Cypher group (P = .015).

CONCLUSIONS

Midterm clinical outcome of surgically treated patients is still better. However, the reintervention gap between surgery and percutaneous interventions was reduced by treating 2 or more coronary vessels with Cypher stents.

Drug-eluting stents versus bilateral internal thoracic grafting for multivessel coronary disease

BACKGROUND

Reduction of restenosis and reinterventions was recently reported with percutaneous interventions (PCI), including drug-eluting stents (Cypher; Cordis, Miami Lakes, FL). This study compares results of multivessel Cypher stenting with those of bilateral internal thoracic artery (BITA) grafting.

METHODS

From January 2002 to June 2004, 768 consecutive patients underwent multivessel myocardial revascularization; 138 by PCI including Cyphers and 630 by BITA. After matching for age, sex, ejection fraction, extent of coronary disease, and congestive heart failure, two groups (113 patients each) were used to compare the two revascularization modalities.

RESULTS

Both groups were similar; however, left main and intraaortic balloon were more prevalent in the BITA group. The number of coronary vessels treated per patient was higher in the BITA group (2.87 vs 2.22, p < 0.001). Follow-up ranged between 6 and 34 months. Thirty-day mortality was 0.9% in the BITA and zero in the PCI group (p = 0.32). There were no late deaths in the BITA and three (2.7%) in the Cypher group (p = 0.08). Angina returned in 28.3% of the Cypher and 12.4% of the BITA group, p = 0.003. A Cox proportional hazard model revealed assignment to the Cypher group to be the only predictor of angina recurrence (odds ratio 2.78, 95% confidence interval 1.46-2.56). There were 16 (14.2%) reinterventions in the Cypher group compared with six (5.3%) in the BITA group. One-year reintervention-free survival (Kaplan-Meier) of the BITA was 96% compared with 86.6% in the Cypher group (p = 0.005, log-rank test).

CONCLUSIONS

Despite improved results of PCI with Cyphers, midterm clinical outcome of multivessel patients treated with BITA is still better.

Comparison of Bare-Metal Stenting With Minimally Invasive Bypass Surgery for Stenosis of the Left Anterior Descending Coronary Artery

Background— Randomized trials comparing stenting with minimally invasive direct coronary artery bypass surgery in patients with isolated proximal left anterior descending lesions have shown a significantly higher reintervention rate for stenting and similar results for mortality and reinfarction at short-term follow-up. Long-term follow-up data are sparse.

Methods and Results— Patients with isolated proximal left anterior descending stenosis were randomized to either surgery (n=110) or bare-metal stenting (n=110). At 5 years, follow-up data were obtained with respect to the primary end point of death, reinfarction, or repeated target vessel revascularization. Clinical symptoms were assessed by the Canadian Cardiovascular Society (CCS) classification. Follow-up information was completed for 216 patients (98.2%), and mean follow-up was 5.6±1.2 years. With respect to mortality (surgery, 12%; stenting, 10%; P =0.54) and reinfarctions (surgery, 7%; stenting, 5%; P =0.46), there were no differences between treatment strategies. The need for repeated target vessel revascularization was significantly higher after stenting (32%) compared with surgery (10%; P <0.001). Clinical symptoms improved significantly in both treatment groups compared with baseline; however, there was a favorable trend for surgery (stenting: CCS, 2.6±0.9 to 0.5±0.8, P <0.001; surgery: CCS, 2.6±0.9 to 0.3±0.6, P <0.001; P =0.05, stenting versus surgery).

Conclusions— At the 5-year follow-up, minimally invasive bypass surgery and bare-metal stenting showed similar results for the end points of mortality and reinfarctions. However, the reintervention rate is higher after stenting, and the relief in clinical symptoms is slightly better after surgery.

Coronary Stent Restenosis in Patients Treated With Cilostazol

Background— Restenosis after implantation of coronary artery stents remains a significant clinical problem. We undertook a randomized, double-blind, placebo-controlled trial to determine whether cilostazol, a drug that suppresses intimal proliferation, would reduce renarrowing in patients after stent implantation in native coronary arteries.

Methods and Results— We assigned 705 patients who had successful coronary stent implantation to receive, in addition to aspirin, cilostazol 100 mg BID or placebo for 6 months; clopidogrel 75 mg daily was administered to all patients for 30 days. Restenosis was determined by quantitative coronary angiography at 6 months. The minimal luminal diameter at 6 months for cilostazol-treated patients was 1.77 mm for the analysis segment (stent plus 5-mm borders) compared with 1.62 mm in the placebo group ( P =0.01). Restenosis, defined as ≥50% narrowing, occurred in 22.0% of patients in the cilostazol group and in 34.5% of the placebo group ( P =0.002), a 36% relative risk reduction. Restenosis was significantly lower in cilostazol-treated diabetics (17.7% versus 37.7%, P =0.01) and in those with small vessels (23.6% versus 35.2%, P =0.02), long lesions (29.9% versus 46.6%, P =0.04), and left anterior descending coronary artery site (19.3% versus 39.8%, P =0.001). There was no difference in bleeding, rehospitalization, target-vessel revascularization, myocardial infarction, or death.

Conclusions— Treatment with the drug cilostazol resulted in a significantly larger minimal luminal diameter and a significantly lower binary restenosis rate compared with placebo-treated patients. These favorable effects were apparent in patients at high risk for restenosis.

Revascularization of Left Anterior Descending Coronary Artery in Patients With Single and Multivessel Disease

STUDY OBJECTIVES

The left anterior descending artery (LADA), particularly when the proximal segment of the vessel is involved, is a challenging area for percutaneous coronary interventions (PCIs); therefore, coronary artery bypass grafting is often considered and sometimes performed even in patients with single-vessel disease involving the LADA. This study compares mid-term results of LADA revascularization with a drug-eluting stent (DES), with off-pump coronary artery bypass grafting (OPCAB) in patients with single-vessel or multivessel coronary artery disease (CAD).

DESIGN

Matched-groups, retrospective cohort comparison between the DES and OPCAB.

PATIENTS

From June 2002 to December 2003, 354 patients underwent myocardial revascularization of the LADA by OPCAB, and 168 by DES. After matching for age, sex, and extent of CAD, two groups (116 patients each) were used to compare the two revascularization modalities. The groups were similar; however, an ejection fraction of <30%, old myocardial infarction, and use of an intraaortic balloon pump were more prevalent in the OPCAB group.

RESULTS

The average number of coronary vessels treated per patient in the two groups was similar (OPCAB, 1.97; DES, 1.6; p = 0.581). The 30-day mortality rate was 0.9% in the OPCAB group and 0% in the DES group (p = 0.329). The mean duration of follow-up was 12 months. There was one late death in each group. Angina returned in 31% of patients in the DES group and in 11.2% of the patients in the OPCAB group (p = 0.001). There were 12 reinterventions in the DES group compared to three reinterventions in the surgical group (p = 0.020). The only independent predictor (Cox proportional hazards regression model) of the return of angina (risk ratio [RR], 3.36; 95% confidence interval [CI], 1.57 to 7.14) and reintervention (RR, 3.9; 95% CI, 1.34 to 11.24) was assignment to the DES group.

CONCLUSIONS

The mid-term clinical outcome of OPCAB in patients with CAD, including multivessel disease, was better than that for PCIs with only one DES used in patients with similar extents of CAD.

Clinical and angiographic follow-up in patients with Cypher or Taxus stents in populations with high percentage of trial-excluded lesions

BACKGROUND

Drug-eluting stents (DESs) are being used in real life in patients with complex lesions usually excluded from the published trials. It is reasonable to think that the results could be worse, and the performance may be different between DES when these complex lesions are included.

METHODS AND MATERIAL

To investigate this issue, we studied our first 82 patients with DES (54 patients with Cypher (C) and 28 patients with Taxus (T) (129 lesions, with 1.57 lesions per patient). Seventy-one complex lesions were treated with C stent, 41 with T stent, and 17 with no DES. It was a high-risk population, as reflected by 64% unstable angina and 40% diabetes mellitus. Of the 112 DES complex lesions treated, 38% would have been excluded from the Sirius and Taxus IV trials.

RESULTS

The main data on intra-segment angiographic measures showed a late luminal loss lower for the C stent than for the T stent (0.17+/-0.45 and 0.44+/-0.6, P=.02, respectively). The restenosis and target lesion revascularization percentages were also lower for the C stent (8.4% vs. 24.4%, P=.07 and 5.6% vs. 17.1%, P<.05, respectively). In the complex lesions without restenosis, 28% would have been excluded from the trials, while in complex lesions with restenosis, there were 53% (P=.05) (with a homogeneous percentage between the C and T groups). The predictor variables of restenosis in the 112 DES-treated complex lesions were length (P=.03, IC=0.97-1.6) and the pre-reference diameter (P=.06).

CONCLUSIONS

In our experience, the C stent is superior to the T stent when treating populations with a high percentage of complex lesions excluded from the trials.

Multiple Overlapping Drug-Eluting Stents to Treat Diffuse Disease of the Left Anterior Descending Coronary Artery

OBJECTIVES

We sought to determine the safety and efficacy of using multiple overlapping drug-eluting stents (DES) in patients with diffuse left anterior descending coronary artery (LAD) disease.

BACKGROUND

Diffuse LAD disease represents a therapeutic challenge. Results after coronary artery bypass surgery are suboptimal, whereas the use of bare metal stents is limited by high rates of restenosis. The introduction of DES prompted treatment of long diffuse disease with multiple overlapping stents.

METHODS

All consecutive patients with de novo diffuse LAD disease treated with more than 60-mm long DES from April 2002 to March 2004 were analyzed.

RESULTS

The study population consisted of 66 patients. Thirty-nine patients were treated with sirolimus-eluting stents (SES), average length 84 +/- 22 mm, and 27 patients with paclitaxel-eluting stents (PES), average length 74 +/- 14 mm. The number of stents implanted per patient was 2.8 +/- 0.7, whereas the mean total stent length for the LAD treatment was 80 +/- 20 mm. Angiographic as well as procedural success was achieved in 95% of cases. Eleven (16.6%) patients had in-hospital non-Q-wave myocardial infarction (five SES and six PES), and one patient developed intraprocedural stent thrombosis. All patients had clinical follow-up, and 52 patients (79%) had an angiographic follow-up at six months. Hierarchical major adverse cardiac event rate was 15% (7.5% for SES and 7.5% for PES). No patients died, one patient had non-Q-wave myocardial infarction (non-index vessel), and 10 patients (15%) underwent target vessel revascularization.

CONCLUSIONS

The implantation of multiple overlapping DES in patients with a diffusely diseased LAD is relatively safe and associated with good midterm clinical outcomes.