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Nicolas J, Pivato CA, Chiarito M, Beerkens F, Cao D, Mehran R. Evolution of drug-eluting coronary stents: a back-and-forth journey from the bench-to-bedside. Cardiovasc Res 2022; 119:631-646. [PMID: 35788828 DOI: 10.1093/cvr/cvac105] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Carlo Andrea Pivato
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy.,IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Mauro Chiarito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy.,IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Frans Beerkens
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Cardiovascular Department, Humanitas Gavazzeni, Bergamo, Italy
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Wang XZ, Zhang YJ, Fu GS, Jing QM, Xu B, Han YL. One-year clinical outcomes and multislice computed tomography angiographic results following implantation of the NeoVas bioresorbable sirolimus-eluting scaffold in patients with single de novo coronary artery lesions. Catheter Cardiovasc Interv 2018; 91:617-622. [PMID: 29392879 DOI: 10.1002/ccd.27491] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/27/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Tremendous efforts have been made to establish the concept of vascular restoration therapy with a fully bioresorbable scaffold for coronary artery disease. With an improved scaffold design and technologies, the novel NeoVas scaffold has shown promising clinical performance at 6 months follow-up. OBJECTIVE The aim of this study was to investigate the 1 year clinical outcomes and multislice computed tomography (MSCT) angiographic results after implantation of the NeoVas scaffold in patients with single de novo coronary artery lesions. METHODS The NeoVas first-in-man study was a prospective, two-center, single-arm study enrolling 31 patients who were eligible for the treatment. The composite endpoint of target lesion failure (TLF)-defined as cardiac death, target vessel myocardial infarction, and clinically indicated target lesion revascularization (TLR)-was assessed. Of the 31 patients scheduled for 1 year clinical follow-up, 29 patients received MSCT examinations. RESULTS At 1 year follow-up, there was only 1 (3.2%) TLF, attributed to 1 patient who suffered ischemia-driven TLR at 181 days postprocedure. No cardiac deaths or scaffold thrombosis were observed. MSCT analysis demonstrated excellent vessel patency, with a median in-scaffold lumen area of 10.6 mm2 (interquartile range [IQR]: 8.2-11.7 mm2 ) and a minimal lumen diameter of 2.7 mm (IQR: 2.4-3.0 mm). CONCLUSIONS This study demonstrated the safety and efficacy of the NeoVas scaffold for patients with single de novo coronary artery lesions at 1 year of follow-up. Noninvasive MSCT data confirmed vessel patency and the maintenance of vessel dimensions following implantation of the NeoVas bioresorbable sirolimus-eluting scaffold.
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Affiliation(s)
- Xiao-Zeng Wang
- The General Hospital of Shenyang Military, Shenyang, China
| | - Yao-Jun Zhang
- Xuzhou Third People's Hospital, Jiangsu University, Zhenjiang, China
| | - Guo-Sheng Fu
- Sir Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Quan-Min Jing
- The General Hospital of Shenyang Military, Shenyang, China
| | - Bo Xu
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ya-Ling Han
- The General Hospital of Shenyang Military, Shenyang, China
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3
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Park DS, Park JK, Jeong MH, Bae IH, Lee SY, Jang EJ, Lim KS, Kim JM, Kim JH, Hyun DY, Jeong YA, Kim HK, Sim DS. Tacrolimus-eluting stent with biodegradable polymer is more effective than sirolimus- and everolimus-eluting stent in rabbit iliac artery restenosis model. Macromol Res 2015. [DOI: 10.1007/s13233-015-3139-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Lu C, Filion KB, Eisenberg MJ. The Safety and Efficacy of Absorb Bioresorbable Vascular Scaffold: A Systematic Review. Clin Cardiol 2015; 39:48-55. [PMID: 26395019 DOI: 10.1002/clc.22451] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 08/12/2015] [Indexed: 10/23/2022] Open
Abstract
Bioresorbable stents are novel devices designed to overcome the long-term limitations of permanent stent implantation. The Absorb bioresorbable vascular scaffold (BVS; Abbott Vascular, Santa Clara, CA) was the first bioresorbable stent with Conformité Européenne mark approval in coronary vessels and has been the subject of multiple clinical studies. Despite its potential advantages, the safety and efficacy of BVS remain unclear. To address this, we conducted a systematic review to examine the safety and efficacy of BVS. The MEDLINE, Embase, Current Index to Nursing & Allied Health Literature (CINAHL), Cochrane, and Science Citation Index Expanded (SCIE) databases were searched for studies examining BVS safety and efficacy. Our search was restricted to studies published in English or French. Outcomes of interest include cardiac death, myocardial infarction, target-lesion revascularization, restenosis, and composite endpoints. Eleven studies met our inclusion criteria (n = 2990), which included 1 randomized controlled trial and 10 cohort studies (2 controlled). These studies varied in size (11-1189) and follow-up duration (1-60 months). The incidence of major adverse cardiac events ranged from 2.6% to 15.5%, with no statistically significant difference between BVS and control in studies that included a comparison group. Although available data are limited, current evidence is promising and suggests that the use of BVS is not associated with a significant increase in major cardiac events in the short term. Numerous randomized controlled trials are currently in progress that will further improve our understanding of the safety and efficacy of this device.
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Affiliation(s)
- Chang Lu
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Kristian B Filion
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Division of Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Mark J Eisenberg
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Division of Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.,Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Ko E, Nasu K, Habara M, Tanaka N, Terashima M, Kinoshita Y, Tsuchikane E, Asakura Y, Katoh O, Suzuki T. Long-term serial angiographic outcomes after sirolimus-eluting stent implantation. Catheter Cardiovasc Interv 2013; 81:E29-35. [PMID: 22517538 DOI: 10.1002/ccd.24383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 01/25/2012] [Accepted: 02/17/2012] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We evaluated, using quantitative coronary angiography, the natural history of change that occurred in target lesions after successful sirolimus-eluting stent (SES) implantation. BACKGROUND Percutaneous coronary intervention with drug-eluting stents (DES) has significantly reduced the rate of repeated target lesion revascularization. However, early studies have raised concerns regarding the "late catch-up" phenomenon of DES. METHODS Between June 2004 and March 2007, consecutive 217 patients with 306 lesions without restenosis at early angiographic follow-up underwent late angiographic follow-up (early follow-up: 11.2 ± 2.1 months and late follow-up: 29.4 ± 5.2 months). Predictors of late catch-up were identified with univariate and multivariate regression analyses. RESULTS Although reference vessel diameter did not significantly change during follow-up [3.15 mm (interquartile range (IQR): 2.81-3.49 mm), 3.12 mm (IQR: 2.79-3.47 mm), and 3.08 mm (IQR: 2.76-3.46 mm) at postprocedure, and early and late angiographic follow-up, respectively; P = 0.2653], late loss (LL) significantly increased during follow-up [0.05 mm (IQR: 0.00-0.13 mm) and 0.08 mm (IQR: 0.01-0.19 mm) at early and late follow-up, respectively; P < 0.0001]. Univariate analysis showed previous intervention, adjunctive use of cutting balloon, lesion length, and progression of MLD, LL, %DS at early follow-up as predictors of late catch-up. Multivariate regression analysis identified %DS at early follow-up as a predictor of late catch-up (OR 1.076, CI 1.039-1.114, P < 0.0001). CONCLUSION Significant and continuous progression of neointima after SES implantation was observed in the present study. Larger LL may be a sign of late catch-up phenomenon.
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Affiliation(s)
- Euihong Ko
- Department of Cardiology, Toyohashi Heart Center, Toyohashi, Japan
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7
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Sianos G, Papafaklis MI, van Domburg R, Adams D, van Nierop JW, van der Giessen WJ, Serruys PW. Eight-year clinical outcome after radioactive stent implantation: a treatment failure without irreversible long-term clinical sequelae. EUROINTERVENTION 2011; 6:681-6. [PMID: 21205589 DOI: 10.4244/eijv6i6a116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS To assess the long-term outcome of patients who underwent radioactive stent (RS) implantation. METHODS AND RESULTS The RS study population consisted of 133 consecutive patients who underwent RS implantation between November 1997 and July 2000. They were matched using the propensity score method with 266 patients who underwent bare metal stenting (BMS) in the same span. Long-term survival status and information on MACE (death, non-fatal myocardial infarction or any re-intervention) was retrospectively obtained. Eight-year cumulative survival (90.2% vs. 87.4%, p = 0.57) was similar between the RS and BMS group respectively, while 8-year cumulative MACE-free survival was significantly lower in RS patients (42.1% vs. 64.3%, p < 0.001) due to the difference in events (mainly target lesion revascularisations [TLRs]) during the first year of follow-up (cumulative 1-year MACE-free survival: 59.4% vs. 86.7%, p < 0.001); there was no difference in the MACE rate after the first year (p = 0.71). The TLR rate at six months in the RS group was 29.3%, mainly due to edge restenosis and at one year 36.2% (control group: 9.5%, p < 0.001). CONCLUSIONS A high incidence of MACE and re-intervention was observed during the first year following RS implantation, mainly related to TLR for edge restenosis. After the first year, the clinical outcome of RS patients was similar to the control group indicating that there are no late adverse effects related to low dose-rate intracoronary radiation therapy.
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Affiliation(s)
- Georgios Sianos
- Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Centre, Rotterdam, The Netherlands.
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8
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Khan M, Ron Van Der Wieken L, Riezebos RK, Tijssen JGP, Kiemeneij F, Slagboom T, Laarman GJ. Oral administration of glycine in the prevention of restenosis after coronary angioplasty. A double blind placebo controlled randomized feasibility trial evaluating safety and efficacy of glycine in the prevention of restenosis after angioplasty. ACTA ACUST UNITED AC 2009; 8:58-64. [PMID: 16720430 DOI: 10.1080/14628840600643383] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Evaluation of safety, feasibility, and efficacy of oral administered glycine in prevention of angiographic restenosis six months after percutaneous coronary intervention (PCI). BACKGROUND The amino acid glycine modulates immunological response and enhances the production of endothelial derived nitric oxide (EDNO) factor. This factor has been shown to possess anti-atherosclerotic properties, actions of which are thought to reduce neo-intimal hyperplasia. Furthermore, glycine significantly elevates arginine serum levels. This amino acid has been extensively studied for its effects on the endothelium, nitric oxide (NO) metabolism and effects on several biochemical pathways interfering with the process of restenosis after PCI. METHODS A prospective double blind placebo controlled randomized study evaluated safety and feasibility of chronic oral administration of glycine. In addition, the efficacy was determined by evaluation of six months angiographic restenosis rates. RESULTS 214 patients scheduled for elective PCI were randomized to receive glycine or placebo. At follow-up, there was no significant difference in side effects and in major adverse cardiac events (MACE) between both groups. Six-month angiograms revealed similar restenosis rates for the glycine group (17.5%) and for the placebo group (20.2%) (P = 0.82). CONCLUSION Chronic oral administration of glycine was safe and feasible and had similar side effects compared to placebo. However, chronic oral administration of glycine did not lead to a significant reduction in restenosis rates at six months after elective PCI.
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Affiliation(s)
- Muchtiar Khan
- Amsterdam Department of Interventional Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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9
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Hong MK, Mintz GS, Lee CW, Park DW, Lee SW, Kim YH, Jung IH, Kim SH, Cheong SS, Kim JJ, Park SW, Park SJ. Late target lesion revascularization after implantation of sirolimus-eluting stent. Catheter Cardiovasc Interv 2007; 71:299-303. [DOI: 10.1002/ccd.21327] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Nakazawa G, Finn AV, John MC, Kolodgie FD, Virmani R. The significance of preclinical evaluation of sirolimus-, paclitaxel-, and zotarolimus-eluting stents. Am J Cardiol 2007; 100:36M-44M. [PMID: 17950831 DOI: 10.1016/j.amjcard.2007.08.020] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Comparative preclinical histologic studies remain the most effective method for assessing the healing characteristics of vascular stents. The 2 most commonly used animal models to assess vascular responses to stent implantation are the porcine coronary artery and the rabbit iliac artery. Neither model alone is comparable to the human response to the implantation of a drug-eluting stent (DES). In the rabbit model at 28 days, the pathologies of the zotarolimus-eluting stent (ZES), the paclitaxel-eluting stent (PES), the sirolimus-eluting stent (SES), and a bare metal stent (BMS) were assessed. There was less inflammation with the ZES than with the SES or PES, and there were uncovered struts with the SES and PES but not with the ZES and BMS. In the pig model at 30, 90, and 180 days, the pathologies of the ZES, SES, and BMS were assessed. At 30 days, the thickness of neointima and the grade of inflammation were less with the SES than with the ZES and BMS, but at 90 and 180 days, the measures increased for the SES and were greater than those with the ZES and BMS, whereas the measures for the ZES and BMS did not change over time. In the rabbit model, the endothelialization of overlapping the SES, PES, and ZES was assessed. There was significantly greater endothelialization in the area above stent struts in the overlapping segment for the ZES than for the SES (p = 0.028). The level of endothelialization for the PES was less than that for the ZES, but the difference was not significant. Because arterial healing is multifactorial, it is extremely important that the next generation of DESs undergo preclinical testing in pig and rabbit models to examine endothelialization, inflammation, release kinetics, and neointimal reduction to establish the safety of these devices in humans.
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11
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Ali OA, Lowe H, Kritharides L, Brieger D. Late Restenosis Following Placement of a Sirolimus Eluting Stent for In-Stent Restenosis. Heart Lung Circ 2007; 16:50-1. [PMID: 17196881 DOI: 10.1016/j.hlc.2006.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2006] [Accepted: 08/03/2006] [Indexed: 10/23/2022]
Abstract
Drug eluting stents (DES) are rapidly replacing intravascular brachytherapy for the treatment of bare metal in-stent restenosis (ISR). To date, there are no long-term follow up data supporting this practise. We report symptomatic repeat in-stent restenosis occurring 27 months after sirolimus eluting stent deployment for de novo in-stent restenosis. This case suggests that in a subgroup of patients with ISR, as with brachytherapy, the drug eluting stent may be simply delaying rather than inhibiting the restenotic process.
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Affiliation(s)
- Onn Akbar Ali
- Department of Cardiology, Concord Repatriation General Hospital, Concord, NSW, Australia
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12
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Abstract
The problem of restenosis after percutaneous transluminal coronary angioplasty remains the major limiting factor of the procedure. Over the last 10 years, investigators have been studying the use of radiation therapy for preventing restenosis after angioplasty or stent placement. Since radiotherapy has been proven in other cases to be effective in disrupting the cell cycle regulatory proteins and thereby slowing or stopping growth, it was decided to apply the same principle to neointimal hyperplasia. To review the data that have emerged regarding vascular radiation with an emphasis on irradiated stents, 65 articles were reviewed and both preclinical and clinical experiments were included. Overall, studies with gamma and beta radiation show promising results. Endovascular gamma radiation has been shown effective in randomized trials, even at 3-year follow-up. Beta radiation is preferred because of greater safety and localization, and because it has also shown encouraging results in initial clinical trials, as well as in larger randomized studies. Consequently, the Federal Drug Administration has approved the use of both. In both types of endovascular brachytherapy, it seems the greater the dose, the better the initial response. Safety concerns include an increased incidence of late thrombosis and greater restenosis at margins. With irradiated stents, however, the situation is not as clear. At times, animal models have presented confusing results. These have ranged from significant suppression of hyperplasia to outright adverse effects of radiation on the vessel wall. While some clinical trials have been encouraging, others have not. Follow-up of up to 1 year has been disappointing so far. Many issues, such as the "candy wrapper" effect and rebound hyperplasia, must be dealt with before this becomes a viable form of therapy. It has become clear that radiation therapy in this setting, while having potentially great benefits, can cause deleterious effects as well. However, the mixed bag of positive and negative results seen so far, and the attractiveness of stents or percutaneous transluminal coronary angioplasty being "restenosis-proofed," eventually is cause for cautious optimism.
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Affiliation(s)
- Nabeel Hafeez
- Department of Internal Medicine, University Hospital, State University of New York at Stony Brook, USA.
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Ong ATL, van Domburg RT, Aoki J, Sonnenschein K, Lemos PA, Serruys PW. Sirolimus-Eluting Stents Remain Superior to Bare-Metal Stents at Two Years. J Am Coll Cardiol 2006; 47:1356-60. [PMID: 16580521 DOI: 10.1016/j.jacc.2005.05.102] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2005] [Revised: 05/12/2005] [Accepted: 05/17/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The purpose of this study was to investigate the medium-term (two year) outcome of the unrestricted utilization of sirolimus-eluting stents (SES) in an all-comer population. BACKGROUND Despite the implantation of SES in over a million patients to date, limited data exist on long-term outcomes. METHODS Sirolimus-eluting stents were used as the default strategy as part of the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital (RESEARCH) registry. A total of 508 consecutive patients with de novo lesions exclusively treated with SES were compared with 450 patients who received bare stents in the immediately preceding period (pre-SES group). RESULTS Patients in the SES group more frequently had multivessel disease, more type C lesions, received more stents, and had more bifurcation stenting. At two years, the cumulative rate of major adverse cardiac events (death, myocardial infarction, or target vessel revascularization) was 15.4% in the SES group and 22.0% in the pre-SES group (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.50 to 0.91; p = 0.01). The two-year risk of target vessel revascularization in the SES group and in the pre-SES group was 8.2% and 14.8%, respectively (HR 0.53, 95% CI 0.36 to 0.79; p = 0.002). CONCLUSIONS In an unrestricted population, the beneficial effects of sirolimus-eluting stent implantation extend out to two years compared with bare-metal stents, driven by a reduction in re-intervention rates. These findings should be confirmed by the results of the large randomized trials.
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Affiliation(s)
- Andrew T L Ong
- Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
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Affiliation(s)
- Patrick W Serruys
- Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
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Feres F, Muñoz JS, Abizaid A, Albertal M, Mintz GS, Staico R, Centemero M, Mattos LA, Maldonado G, Tanajura LF, Chaves A, Pinto I, Abizaid AS, Seixas AC, Vaz VD, Sousa A, Sousa JE. Comparison between sirolimus-eluting stents and intracoronary catheter-based beta radiation for the treatment of in-stent restenosis. Am J Cardiol 2005; 96:1656-62. [PMID: 16360353 DOI: 10.1016/j.amjcard.2005.07.081] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2005] [Revised: 07/12/2005] [Accepted: 07/12/2005] [Indexed: 11/18/2022]
Abstract
We report the outcomes of patients who had in-stent restenosis (IRS) that was treated with intravascular brachytherapy (IVBT) or sirolimus-eluting stent (SES) implantation. The benefit of IVBT for treating ISR is well documented. SES implantation decreases first-time ISR and, in preliminary reports, has been used to treat ISR. Fifty consecutive patients who had ISR were treated; the first 25 patients underwent SES implantation and the next 25 patients were treated with IVBT using a beta-Cath System (a 40-mm strontium-90/yttrium-90 source). Quantitative angiographic and intravascular ultrasound follow-up were performed at 5.2 +/- 1.1 and 12.1 +/- 1.2 months; clinical follow-up was performed at 15 months. SES deployment and IVBT were successful in all patients. At 12-month follow-up, 8 patients who underwent IVBT had angiographic recurrence (4 in the stent and 4 at the stent edge); only 1 patient who underwent SES implantation developed recurrent ISR. At 12 months, in-stent late luminal loss was similar between the SES and IVBT groups (0.35 +/- 0.45 vs 0.34 +/- 0.46 mm, p = 0.9); however, in-stent net luminal gain was higher in the SES group than in the IVBT group (1.32 +/- 0.13 vs 0.57 +/- 0.19 mm, p <0.0001), and in-lesion late luminal loss was higher in the IVBT group (0.48 +/- 0.32 vs 0.16 +/- 0.42 mm, p = 0.004). At 12 months, intravascular ultrasound stent volume obstruction was higher after IVBT versus than after SES implantation (38.7% vs 6.7%, p <0.0001). At 15-month clinical follow-up, 64% and 96% (p <0.01) of patients who underwent IVBT and SES implantation, respectively, were free of major adverse cardiac events. In conclusion SES implantation for the treatment of ISR was effective and superior to catheter-based IVBT in preventing recurrent neointimal proliferation and angiographic restenosis at 1-year follow-up.
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Affiliation(s)
- Fausto Feres
- Institute Dante Pazzanese of Cardiology, São Paulo, Brazil.
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Tepe G, Dietrich T, Grafen F, Brehme U, Muschick P, Dinkelborg LM, Greschniok A, Claussen CD, Duda SH. Reduction of Intimal Hyperplasia withRe-188-labeled Stents in a Rabbit Model at 7and 26 Weeks: An Experimental Study. Cardiovasc Intervent Radiol 2005; 28:632-7. [PMID: 16059762 DOI: 10.1007/s00270-004-0308-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The aim of this study was to analyze the feasibility of (188)Re-labeled stents to reduce neointimal formation in a rabbit atherosclerosis model and to test the long-term effects at 7 and 26 weeks. Fifty-nine male New Zealand White rabbits were fed a 0.5% cholesterol diet for 4 weeks before balloon angioplasty and insertion of Palmaz stents in the infrarenal aorta. The animals were sacrificed 7 and 26 weeks after stent implantation. Control stents were compared with (188)Re stents: (dose 1) 11.3 +/- 1.8 MBq; (dose 2) 37.3 +/- 4.2 MBq, and (dose 3) 80.1 +/- 7.8 MBq. Each activity group consisted of a short-term (7 weeks) and a long-term group (26 weeks), resulting in a total of eight study groups. No thrombotic occlusion was observed. The neointimal formation in the control group was 2.11 [95% confidence interval (CI): 0.68--6.52] mm(2) at 7 weeks and 2.10 (0.62--7.11) at 26 weeks. In the treatment groups, neointima reduction was detectable at 7 weeks [dose 1: 0.33 (0.09--1.22) mm(2); dose 2: 0.17 (0.05--0.57) mm(2); dose 3: 0.03 (0.01--0.13) mm(2)]. After 26 weeks, a catch-up of neointimal formation in the radioactive groups was most obvious in the low-dose group [dose 1: 0.80 (0.28--2.29) mm(2); dose 2: 0.18([0.06--0.52) mm(2); dose 3: 0.50 (0.17--1.42) mm(2)]. Compared to the long-term control group, neointimal reduction was still >60%. No induction of neointimal formation was observed at the edges of the stents. Radiation resulted in delayed re-endothelialization. (188)Re stents were capable to reduce intimal hyperplasia and did not cause thrombosis. The edge effect, which was the major limitation of (32)P stents, was not observed in (188)Re stents.
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Affiliation(s)
- Gunnar Tepe
- Department of Diagnostic Radiology, University of Tübingen, Tübingen, Germany.
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Brito FS, Rosa WCM, Arruda JA, Tedesco H, Pestana JOM, Lima VC. Efficacy and safety of oral sirolimus to inhibit in-stent intimal hyperplasia. Catheter Cardiovasc Interv 2005; 64:413-8. [PMID: 15789385 DOI: 10.1002/ccd.20332] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sirolimus systemic administration has shown marked inhibition of neointimal hyperplasia (NIH) after balloon angioplasty in porcine models. In this pilot study, we tested the hypothesis that oral sirolimus is safe and effective to inhibit in-stent NIH and therefore to prevent and treat in-stent restenosis (ISR). Twelve patients (18 lesions) with high risk for ISR, including 8 ISR lesions, were admitted. One day before the procedure, patients were given a 15 mg loading dose of oral sirolimus, followed by 5 mg daily for 28 days, with weekly whole blood level measurements. The daily dose was adjusted to keep the concentration at 10-15 ng/ml. Sirolimus was well tolerated by all patients but one, who died at the end of the third week of treatment. The 4- and 8-month follow-up revealed an angiographic late loss of 0.40 +/- 0.24 and 0.67 +/- 0.45 mm (P < 0.01), respectively. At the same time points, the intravascular ultrasound in in-stent relative volumetric obstruction was 14.4% +/- 9.1% and 23.2% +/- 10.1% (P < 0.01), respectively. At 24-month clinical follow-up, adverse events were one (8.3%) death, two (11.1%) target lesion, and four (22.2%) target vessel revascularizations. In conclusion, in this small group of high-risk ISR patients, oral sirolimus inhibited NIH and therefore may be an effective strategy for the prevention and treatment of ISR.
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Affiliation(s)
- Fábio S Brito
- Hospital São Paulo and Hospital do Rim e Hipertensão, Federal University of São Paulo, Brazil
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18
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Murphy GJ, Bryan AJ, Angelini GD. Hybrid Coronary Revascularization in the Era of Drug-Eluting Stents. Ann Thorac Surg 2004; 78:1861-7. [PMID: 15511503 DOI: 10.1016/j.athoracsur.2004.07.024] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2004] [Indexed: 11/30/2022]
Abstract
Left internal mammary artery to left anterior descending coronary artery bypass grafting integrated with percutaneous coronary angioplasty (hybrid procedure) offers multivessel revascularization with minimal morbidity in high-risk patients. This is caused in part by the avoidance of cardiopulmonary bypass-related morbidity and manipulation of the aorta coupled with minimally invasive techniques. Hybrid revascularization is currently reserved for particularly high-risk patients or those with favorable anatomic variants however, largely because of the emergence of off-pump coronary artery bypass grafting, which permits more complete multivessel revascularization, with low morbidity in high-risk groups. The wider introduction of hybrid revascularization is limited chiefly by the high number of repeat interventions compared with off-pump coronary artery bypass grafting, which occurs because of the target vessel failure rate of percutaneous coronary intervention. Other demerits are the costs and logistic problems associated with performing two procedures with differing periprocedural management protocols. Recently, drug-eluting stents have reduced the need for repeat intervention after percutaneous coronary intervention, and this has raised the possibility that the results of hybrid revascularization may now equal or even better those of off-pump coronary artery bypass grafting. Although undoubtedly effective at reducing in-stent restenosis, drug-eluting stents will not address the issues of incomplete revascularization or the logistic problems associated with hybrid. Uncertainty regarding the long-term effectiveness of drug-eluting stents in many patients, as well as their high cost when compared with those of off-pump coronary artery bypass grafting surgery, also militates against the wider introduction of hybrid revascularization.
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Affiliation(s)
- Gavin J Murphy
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
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19
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Babapulle MN, Joseph L, Bélisle P, Brophy JM, Eisenberg MJ. A hierarchical Bayesian meta-analysis of randomised clinical trials of drug-eluting stents. Lancet 2004; 364:583-91. [PMID: 15313358 DOI: 10.1016/s0140-6736(04)16850-5] [Citation(s) in RCA: 447] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Drug-eluting stents (DES) are associated with lower restenosis rates than bare-metal stents (BMS), but the benefits and safety of the new devices have not been systematically quantified across different trials. We undertook a meta-analysis of randomised trials comparing BMS and stents eluting sirolimus or paclitaxel. METHODS A systematic literature search aimed to identify all randomised clinical trials with 6-12 months of clinical follow-up. Results were pooled by a hierarchical Bayesian random-effects model with prespecified stratification for drug and the presence of carrier polymer. The primary outcomes examined were rates of death, myocardial infarction, target-lesion revascularisation, major adverse cardiac events (death, myocardial infarction, and target-vessel revascularisation), and angiographic restenosis. FINDINGS We identified 11 eligible trials involving 5103 patients. The pooled mortality rates were low for both DES and BMS with no evidence of any difference between them (odds ratio 1.11 [95% credible interval 0.61-2.06]). Pooled rates of myocardial infarction showed no between-group difference (0.92 [0.65-1.25]). The rate of major adverse cardiac events was 7.8% with DES and 16.4% with BMS (0.42 [0.32-0.53]), and the angiographic restenosis rates were also lower for DES (8.9% vs 29.3%; 0.18 [0.06-0.40]). The pooled rates of major adverse cardiac events for each DES type and the respective BMS were: for sirolimus, 6.8% versus 21.0% (0.28 [0.17-0.41]); for polymer-based paclitaxel 8.7% versus 16.7% (0.47 [0.25-0.71]); and for non-polymer-based paclitaxel 7.7% versus 9.5% (0.64 [0.42-1.00]). We did not observe higher rates of edge restenosis, stent thrombosis, or late incomplete stent apposition with DES, although the credible intervals were wide. INTERPRETATION Sirolimus-eluting and polymeric paclitaxel-eluting stents are effective at decreasing rates of angiographic restenosis and major adverse cardiac events compared with BMS. However, there is no evidence that they affect mortality or myocardial-infarction rates. They also appear to be safe in the short to medium term, although definitive conclusions are not possible. Larger studies with longer follow-up are needed to define better the role of these new devices.
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Affiliation(s)
- Mohan N Babapulle
- Division of Cardiology, Royal Victoria Hospital/McGill University Health Center, Montreal, Quebec, Canada
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20
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Abstract
At present there is much excitement about drug-eluting stents, which hold promise for the treatment of coronary artery disease. This ingenious therapy involves coating the outside of a standard coronary stent with a thin polymer containing medication that can prevent scarring at the site of coronary intervention. Early trials with sirolimus coated stents showed that they might prevent coronary artery restenosis, but later studies, involving more complex coronary lesions, did not show a complete absence of restenosis. Recent studies have demonstrated the long term cost effectiveness of drug-eluting stents as they have reduced the need for revascularisation procedures. At present there are few data on the safety and effectiveness of stents over follow up periods exceeding two years, and data obtained from animal models of stenting might not be completely applicable to humans. There are concerns that drug-eluting stents might delay, rather than inhibit, restenosis. Also there is concern regarding the inflammation caused by the polymer substrate. This article reviews the present data on drug-eluting stents and their benefits, shortcomings, and concerns.
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Affiliation(s)
- V Bhatia
- Department of Internal Medicine, State University of New York, Buffalo, New York, USA.
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21
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Hong MK, Mintz GS, Lee CW, Kim YH, Lee SW, Moon DH, Oh SJ, Song JM, Han KH, Kang DH, Song JK, Kim JJ, Park SW, Park SJ. Late intravascular ultrasound findings of patients treated with brachytherapy for diffuse in-stent restenosis. Catheter Cardiovasc Interv 2004; 63:208-14. [PMID: 15390251 DOI: 10.1002/ccd.20118] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This study aimed at evaluating long-term (24-month) effects of beta-irradiation (188Re-MAG3-filled balloon) using intravascular ultrasound (IVUS) in patients with in-stent restenosis (ISR). Long-term effects of beta-irradiation on intimal hyperplasia (IH) within the stented segment and vessel and lumen dimensions of nonstented adjacent segments in patients with ISR have not been sufficiently evaluated. Two-year follow-up IVUS was performed in 30 patients with patent ISR segments at 6-month follow-up angiography. Serial IVUS images were acquired at five equidistant intrastent sites and at three different reference segment sites. IH burden (%) was defined as 100 x (IH/stent area). Mean intrastent IH area and IH burden significantly increased between 6 and 24 months, from 2.1 +/- 1.1 to 2.6 +/- 1.4 mm2 (P < 0.001) and from 26% +/- 10% to 33% +/- 14% (P < 0.001), respectively. There was a significant decrease of mean external elastic membrane (from 10.1 +/- 3.9 to 9.7 +/- 3.9 mm2; P = 0.015) and lumen area (from 5.6 +/- 2.3 to 5.1 +/- 2.3 mm2; P = 0.021) within distal reference segments between 6 and 24 months. Target lesion revascularization (TLR) was performed in six patients (20%) between 6 and 24 months after beta-irradiation therapy. There were no significant differences between TLR and non-TLR groups except for a smaller minimum lumen area at 24 months in the TLR group. Because of a small amount of late loss between 6 and 24 months, most irradiated ISR vessel segments remained stable for up to 2 years. However, quantitative evidence of late catch-up was evident in most patients and was significantly associated with 24-month TLR in some patients.
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Affiliation(s)
- Myeong-Ki Hong
- Department of Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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22
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Saia F, Lemos PA, Hoye A, Sianos G, Arampatzis CA, de Feyter PJ, van der Giessen WJ, Smits PC, van Domburg RT, Serruys PW. Clinical outcomes for sirolimus-eluting stent implantation and vascular brachytherapy for the treatment of in-stent restenosis. Catheter Cardiovasc Interv 2004; 62:283-8. [PMID: 15224289 DOI: 10.1002/ccd.20068] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this study was to compare the mid-term clinical outcome of sirolimus-eluting stent (SES) implantation and vascular brachytherapy (VBT) for in-stent restenosis (ISR). We assessed the 9-month occurrence of major adverse cardiac events (MACE) in 44 consecutive patients with ISR treated with SES implantation and 43 consecutive patients treated with VBT in the period immediately prior. Baseline clinical and angiographic characteristics of the two groups were similar. During follow-up, three patients (7%) died in the VBT group and none in the SES group. The incidence of myocardial infarction was 2.3% in both groups. Target lesion revascularization was performed in 11.6% of the VBT patients and 16.3% of the SES patients (P = NS). The 9-month MACE-free survival was similar in both groups (79.1% VBT vs. 81.5% SES; P = 0.8 by log rank). The result of this nonrandomized study suggests that sirolimus-eluting stent implantation is at least as effective as vascular brachytherapy in the treatment of in-stent restenosis.
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Affiliation(s)
- Francesco Saia
- Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
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23
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Saia F, Lemos PA, Sianos G, Degertekin M, Lee CH, Arampatzis CA, Hoye A, Tanabe K, Regar E, van der Giessen WJ, Smits PC, de Feyter P, Ligthart J, van Domburg RT, Serruys PW. Effectiveness of sirolimus-eluting stent implantation for recurrent in-stent restenosis after brachytherapy. Am J Cardiol 2003; 92:200-3. [PMID: 12860224 DOI: 10.1016/s0002-9149(03)00538-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Francesco Saia
- Erasmus MC, Thoraxcenter, Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
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24
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Klingensmith JD, Schoenhagen P, Tajaddini A, Halliburton SS, Tuzcu EM, Nissen SE, Vince DG. Automated three-dimensional assessment of coronary artery anatomy with intravascular ultrasound scanning. Am Heart J 2003; 145:795-805. [PMID: 12766735 DOI: 10.1016/s0002-8703(03)00089-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Angiography allows the definition of advanced, severe stages of coronary artery disease, but early atherosclerotic lesions, which do not lead to luminal stenosis, are not identified reliably. In contrast, intravascular ultrasound scanning allows the precise characterization and quantification of a wide range of atherosclerotic lesions, independent of the severity of luminal stenosis. METHODS Three-dimensional (3-D) reconstruction of entire coronary segments is possible with the integration of sequential 2-dimensional tomographic images and allows volumetric analysis of coronary arteries. RESULTS Automated systems able to recognize lumen and vessel borders and to display 3-D images are becoming available. CONCLUSION These systems have the potential for on-line 3-D image reconstruction for clinical decision-making and fast routine volumetric analysis in research studies. This review describes 3-D intravascular ultrasound scanning acquisition, analysis, and processing, and the associated technical challenges.
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Affiliation(s)
- Jon D Klingensmith
- Department of Biomedical Engineering, Lerner Research Institute, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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25
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Abstract
Animal models of stenting probably predict human responses as the stages of healing are remarkably similar. What is characteristically different is the temporal response to healing, which is substantially prolonged in humans. The prevention of restenosis in recent clinical trials of drug eluting stents may represent a near absent or incomplete phase of intimal healing. Continued long term follow up of patients with drug eluting stents for major adverse cardiac events and angiographic restenosis is therefore imperative.
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Affiliation(s)
- R Virmani
- Department of Cardiovascular Pathology, Armed Forces Institute of Pathology, Washington DC 20306-6000, USA.
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26
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Hansrani M, Overbeck K, Smout J, Stansby G. Intravascular brachytherapy: a systematic review of its role in reducing restenosis after endovascular treatment in peripheral arterial disease. Eur J Vasc Endovasc Surg 2002; 24:377-82. [PMID: 12435336 DOI: 10.1053/ejvs.2002.1742] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Intravascular brachytherapy (IVBT) utilises the percutaneous insertion of a radioactive source to inhibit myointimal hyperplasia in arteries treated by balloon angioplasty or stenting. A systematic review was performed of trials of IVBT in patients with Peripheral Arterial Disease (PAD). METHODS Search strategy - the reviewers searched Medline, Embase, the Cochrane Peripheral Vascular Diseases Group trials register, DARE, CCT and NHS EED for clinical studies and trials of adjuvant IVBT in PAD. Two reviewers assessed trial quality independently. RESULTS Fourteen clinical trials were identified by the search, representing five clinical studies (all allocated D for not randomised) and one randomised controlled trial (allocated A). The randomised trial showed a benefit for IVBT compared with placebo (OR 0.35, 95% CI 0.24-0.53). In the non-randomised studies, 12 month cumulative patency rates ranged from 60-87%. There were few technical complications. In the only report involving IVBT and routine concurrent stent insertion acute thrombosis occurred in 7 (21%) of patients. CONCLUSION Early reports have confirmed the safety and technical feasibility of IVBT. However, follow-up is too short at present to assess the durability and long-term complications of this new therapeutic option.
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Affiliation(s)
- M Hansrani
- Department of Surgery, University of Newcastle Upon Tyne, UK
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27
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Tanabe K, Degertekin M, Regar E, Ligthart JMR, van der Giessen WJ, Serruys PW. No delayed restenosis at 18 months after implantation of sirolimus-eluting stent. Catheter Cardiovasc Interv 2002; 57:65-8. [PMID: 12203931 DOI: 10.1002/ccd.10266] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Sirolimus-eluting stent is emerging as a potential solution for the prevention of restenosis. Recently, a sustained suppression of neointimal proliferation 12 months after implantation of this stent was reported. This is the first report of angiographic and IVUS images 18 months after the implantation of a sirolimus-eluting stent.
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Affiliation(s)
- Kengo Tanabe
- Department of Cardiology, Thoraxcenter, University Hospital Rotterdam, Rotterdam, The Netherlands
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28
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Abstract
Coronary artery disease is the leading cause of mortality in the West with over 1.2 million angioplasties performed annually. Despite the introduction of stents, restenosis occurs in 30-40% of vessels, which until recently has only been treated effectively by coronary artery bypass surgery. Coronary artery brachytherapy appears to provide an alternative, less invasive remedy. The mechanisms of restenosis and how these are inhibited by radiation are described here. The practicalities of radiation delivery and the history of the development of intravascular radiation as an effective clinical tool are outlined. Finally, the pitfalls of the current technology and the areas in which future research must be targeted for the field to develop are discussed.
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Affiliation(s)
- E C Sims
- Department of Cardiac, Vascular and Inflammation Research, Bart's and The London, Queen Mary's School of Medicine and Dentistry, UK
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29
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Abstract
Patients presenting with in-stent restenosis have an increased risk of need for repeat intervention. Intracoronary brachytherapy is indicated for these patients to prevent recurrent in-stent restenosis. Three intravascular brachytherapy systems are currently FDA-approved for use in patients: one utilizing gamma-radiation (Cordis) and two using beta-radiation (Novoste and Guidant). Current evidence and labeling do not support using intracoronary brachytherapy for prevention of restenosis in de novo lesions. Brachytherapy is absolutely contraindicated in patients unable to take prolonged combination antiplatelet drugs. Aspirin and a thienopyridine should be taken for 6 months if no new stent is placed and 12 months if a new stent is placed. If possible, new stent implementation should be avoided.
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Affiliation(s)
- Phong Nguyen-Ho
- The Methodist DeBakey Heart Center and Baylor College of Medicine, Houston, Texas, USA
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30
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Odurny A. Radiological Investigation and Treatment of the Critically Ischemic Limb—A Review. INT J LOW EXTR WOUND 2002; 1:33-42. [PMID: 15871950 DOI: 10.1177/153473460200100105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The contribution of radiological investigation and treatment in the management of the critically ischemic lower limb is reviewed. The methods of classifying and assessing the cause, level, and severity of the arterial disease causing the ischemia are discussed with comparison of the relative merits of the various invasive and noninvasive techniques of investigation. The development of the methods of interventional radiological management is described with an indication of the relative success of the different techniques. Newer interventional developments, including intravascular brachytherapy and gene therapy are discussed.
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Affiliation(s)
- Allan Odurny
- Southampton General Hospitals Trust NHS, Southampton, UK.
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31
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Building a Better Stent: Bioengineering and Tissue Interactions. J Vasc Interv Radiol 2002. [DOI: 10.1016/s1051-0443(02)70172-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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32
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Affiliation(s)
- G Patrick Clagett
- Division of Vascular Surgery, University of Texas Southwestern Medical Center, Dallas 75390-9157, USA
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33
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Abstract
In-stent restenosis (ISR) is a novel pathobiologic process, histologically distinct from restenosis after balloon angioplasty and comprised largely of neointima formation. As percutaneous coronary intervention increasingly involves the use of stents, ISR is also becoming correspondingly more frequent. In this review, we examine the available studies of the histology and pathogenesis of ISR, with particular reference to porcine and other animal models. An overview of mechanical treatments is then provided, which includes PTCA, directional coronary atherectomy and high speed rotational atherectomy. Radiation-based therapies are discussed, including a summary of current problems associated with this modality of treatment. Finally, novel strategies for the prevention of ISR are addressed, including novel developments in stents and stent coatings, conventional drugs, nucleic acid-based drugs and gene transfer. Until recently, limited pharmacologic and mechanical treatment options have been available for both treatment and prevention of ISR. However, recent advances in gene modification and gene transfer therapies and, more particularly, in local stent-based drug delivery systems make it conceivable that the incidence of ISR will now be seriously challenged.
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Affiliation(s)
- Harry C Lowe
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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34
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Costa MA, Kozuma K, Serruys PW. Why and how to avoid stenting during brachytherapy. INTERNATIONAL JOURNAL OF CARDIOVASCULAR INTERVENTIONS 2001; 4:77-82. [PMID: 12036475 DOI: 10.1080/146288401753258420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Intracoronary radiation is a promising therapy to reduce restenosis after percutaneous coronary intervention. It may be anticipated that radiation and intracoronary stents - the current standard coronary revascularization procedure - have a synergic antirestenosis effect. However, this potential benefit has not been proven in the clinical scenario. Indeed, this combined approach (stenting plus brachytherapy) may even be harmful. Delayed endothelialization and late stent malapposition are important drawbacks of implanting a metallic prosthesis in the setting of radiation therapy. Owing to the relatively high frequency of late thrombosis after stenting irradiated coronary arteries, the Food and Drug Administration required that the labeling of both gamma- and beta-radiation devices recently approved for clinical use explicitly advise avoidance of the placement of new stents. The pathophysiologic aspects as well as the clinical implications of the implantation of a new stent in association with radiation delivered by radioactive stents or catheter-based systems are discussed in this paper.
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Affiliation(s)
- Marco A Costa
- Division of Cardiology, University of Florida, Florida, USA
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35
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Gruberg L, Waksman R. Intravascular radiation for the prevention of recurrence of restenosis in coronary arteries. Expert Opin Investig Drugs 2001; 10:891-907. [PMID: 11322864 DOI: 10.1517/13543784.10.5.891] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite the use of new technology and adjunctive pharmacological therapy, in-stent restenosis continues to hamper the outcome of approximately 150,000 patients who undergo stented coronary angioplasty in the US annually. While coronary stenting eliminates elastic recoil and vessel contracture by acting as a mechanical scaffold within the vessel, it is unable to inhibit excessive neointimal formation and may actually promote it. For years, the growth-inhibiting properties of ionising radiation have been used successfully to control benign proliferative disorders. Based on this experience, vascular brachytherapy, the intravascular delivery of radiation, was viewed as a viable solution to inhibit neointimal hyperplasia. A series of studies performed in animal models identified the mechanisms by which radiation may reduce restenosis. Data from these studies showed that endovascular radiation reduces restenosis by inhibiting cell proliferation and by inducing favourable remodelling. The success of these initial studies led to several double-blind, multicentre, placebo-controlled, randomised, clinical trials evaluating intravascular radiation, with either gamma- or beta-radiation sources, proved to be an effective solution for the prevention of neointimal proliferation and restenosis. However, an increased rate of late thrombosis in patients who had received intracoronary radiation did evolve from the initial use of this therapy. Prolonged antiplatelet therapy and a reduction in the number of new stents placed at the time of radiation has been shown to minimise these complications. Other concerns that still need to be resolved include edge effect and geographical miss. Intravascular brachytherapy is currently the only approved therapy for this complex disease. It is clear that there are still on-going concerns that will eventually be clarified when the long-term results from ongoing clinical trials around the world become available.
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Affiliation(s)
- L Gruberg
- Cardiac Catheterization Laboratory, Cardiovascular Research Institute, Washington Hospital Center, 110 Irving St., NW, Suite 4B-1, Washington, DC 20010, USA.
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