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

Comparative treatment outcomes of a single long stent vs. overlapped short stents in acute myocardial infarction

Objectives

There is no consensus regarding the optimal choice between single long stent (SLS) and overlapped double short stents (DSS) in patients with acute myocardial infarction (AMI). Therefore, we aimed to compare treatment outcomes among patients with AMI treated with these two different stenting methods.

Methods

In total, 537 patients with AMI from a single tertiary center were categorized into two groups: (1) those who received an SLS (stent length ≥38 mm) (n = 254; 47.3%) and (2) those who received overlapped DSS (individual stent lengths <38 mm) (n = 283; 52.7%). The primary outcome was the incidence of major adverse cardiac and cerebrovascular events (MACCEs) within 1 year.

Results

The mean age of participants was 65.4 years, and 75.0% were male. Patients receiving an SLS had a higher rate of serum creatinine level ≥1.5 mg/dl (16.3% vs. 8.9%, p = 0.009) but a lower rate of hypertension (46.8% vs. 55.8%, p = 0.038), lesser total stent length (38.26 ± 1.31 vs. 45.20 ± 9.25 mm, p < 0.001), total procedure time (41.40 ± 15.74 vs. 53.31 ± 21.75 min, p < 0.001) and total contrast volume (134.13 ± 30.72 vs. 160.57 ± 39.77 ml, p < 0.001) than in those receiving DSS. One-year MACCEs were comparable between the two groups before [hazard ratio (HR), 1.33; 95% confidence interval (CI), 0.80-2.24] and after adjusting for covariates (HR, 1.21; 95% CI, 0.67-2.19).

Conclusions

Stenting with an SLS demonstrated similar outcomes compared to those achieved when using stenting with overlapped DSS in patients with AMI. Therefore, if the deliverability is acceptable, stenting with an SLS appears to be a safe and effective strategy for AMI treatment.

Delayed stenosis regression after drug-coated balloon angioplasty for femoropopliteal artery lesions

Paclitaxel has the potential for inducing lumen enlargement by vessel enlargement, healing of dissection, and plaque regression. This study was carried out to determine the possibility of and the relevant factors of delayed stenosis regression after drug-coated balloon (DCB) angioplasty for femoropopliteal (FP) artery lesions. A total 105 de novo FP lesions were finalized with DCB angioplasty in our institute between May 2018 and June 2020. Among them, cases in which residual stenosis was detected by duplex ultrasonography (DUS) after the procedure were included in this study. Significant stenosis was defined as peak systolic velocity ratio ≥ 2.4 by DUS. Follow-up DUS was routinely performed 6 months after the procedure, and we defined cases without stenosis as cases of delayed stenosis regression according to the follow-up DUS. DUS showed that 26 (25.5%) of 102 lesions had residual stenosis after DCB angioplasty, and delayed stenosis regression was observed in 12 (57.1%) of 21 lesions 6 months after the procedure. The percentage of lesions containing calcified plaque as detected by intravascular ultrasound analysis was significantly higher in the non-regression group than in the regression group (18.2% vs. 77.8%, p = 0.02). Vessel remodeling and dissection patterns were not associated with delayed stenosis regression. The results of our analyses indicate that delayed stenosis regression may occur after DCB angioplasty for FP lesions in more than half of cases with residual stenosis. Delayed stenosis regression may be difficult in cases of calcified lesions.

The Incidence and Possible Predictors of Coronary Restenosis

Objective. Assess time and possible predictors of restenosis after the implantation of first- and second-generation coronary stents and bare metal stents (BMSs) in patients with stable coronary artery disease after elective coronary stenting.

Materials and Methods. From 2010 to 2014, 3,732 (2,897 males, 60 [53; 68] years old) patients with stable exertional angina of functional class I–III underwent coronary stenting. From 2014 to 2017, 1,487 (1,173 males and 314 females) patients returned. Repeat coronary angiography was performed in 699 patients.

Results. A total of 644 first-generation stents, 5,321 second-generation stents, and 473 BMSs were implanted. During the control coronary angiography, contrasting was repeated for 193 first-generation stents, 899 second-generation stents, and 77 BMSs. Restenosis (stenosis of 50 % or more in the previously stented segment) was detected in 28 (14 % of angiographic control) first-generation drug-eluting stents, 94 (10 %) second-generation drug-eluting stents, and 21 (27 %) BMSs. Patients with BMS restenosis returned significantly earlier than patients with restenosis of the first- and second-generation drug-eluting stents (11 [6, 27] months vs. 32 [11; 48]) months and 24 [12; 42] months, respectively; p<0.05). The initial and repeat levels of high-sensitivity C-reactive protein (hs-CRP) were higher in patients with restenosis (2.2 [1.2, 5.0] mg / L vs. 2.1 [1.0, 4.6] mg / L, respectively; p> 0.05) than in patients without restenosis (2.0 [0.9, 4.2] mg / L vs. 1.9 [0.7, 3.5] mg / L respectively, p>0.05). Blood levels of hs-CRP ≥2 mg / L according to receiver operating characteristic curve (ROC) analysis at return visit were used as a predictor to identify restenosis of stents with a diameter <3 mm and a length >25 mm – area under the curve (AUC) 0.67 (95 % confidence interval (CI) 0.51–0.84), p <0.05, odds ratio 3.7 (95 % CI 1.1–12.1), p<0.05. Stent type had a significant effect on the time to restenosis in the survival analysis (p<0.0005).

Conclusion. The time from coronary stenting to the return visit of patients presenting with restenosis after the implantation of first- and second-generation drug-eluting stents is consistent; median time of the return visit of patients with restenosis of the first-generation stents was 2–3 years after coronary stenting. Blood levels of hs-CRP ≥2 mg / L at the return visit is a predictor of restenosis of stents with a diameter <3 mm and a length >25 mm.

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Role of Drug-coated Balloons in Small-vessel Coronary Artery Disease

Percutaneous coronary intervention of small-vessel coronary artery disease (SVD) remains challenging due to difficulties with device delivery and high restenosis rate, even with the use of newer-generation drug-eluting stents. Drug-coated balloons represent an attractive emerging percutaneous coronary intervention option in patients with SVD. Potential advantages of drug-coated balloons in SVD include enhanced deliverability because of their small profile, avoidance of foreign-body implantation, and shorter duration of dual antiplatelet therapy.

Full-metal jacket technique using second-generation drug-eluting stent: clinical and angiographic follow-up in 2 years

The aims of this study are to evaluate the efficacy of percutaneous coronary intervention (PCI) using full-metal jacket (FMJ) with second-generation drug-eluting stents (DES). A single-center, non-randomized, retrospective study was performed from May 2005 to February 2014 at Miyazaki Medical Association Hospital, Japan. PCI using FMJ with DES was performed to treat 240 very long lesions (> 60 mm) in 240 patients. Subjects were divided into a first-generation or second-generation DES group. The primary endpoint was the incidence of major adverse cardiac events (MACE) at 2 years. MACE included all-cause death, myocardial infarction (MI), cerebrovascular event, and target vessel revascularization. The secondary endpoint was binary restenosis (> 50% stenosis) assessed by angiography at 1 year of follow-up. Second-generation DES were implanted to treat 121 lesions, and the first-generation DES were implanted to treat 119 lesions. Since 35 patients were lost to follow-up, the final analysis included 102 patients with second-generation DES and 103 with first-generation DES. At the 2-year follow-up, the incidence of MACE was significantly less in the second-generation DES group (9.8% vs. 20.4%, p = 0.03). The incidence of binary restenosis at 1 year was also significantly lower in the second-generation DES group (6.7% vs 29.1%, p < 0.01). When PCI was performed using FMJ with DES to treat very long lesion, the angiographic and clinical outcomes were better with second-generation than first-generation DES.

Long-Term Follow-Up After Treatment of Drug-Eluting Stent Restenosis and De Novo Lesions Using SeQuent Please Paclitaxel-Coated Balloons

Managing patients with in-stent restenosis (ISR) remains an important clinical challenge. In particular, large, randomized trials assessing the effect of drug-eluting balloons (DEB) in patients with de novo lesions are warranted. We investigated the effect of DEB on procedural complications, target lesion revascularization (TLR), and major adverse cardiac and cerebrovascular events in patients with drug-eluting stent ISR and de novo lesions. The clinical profiles of 238 consecutive patients treated for coronary ISR (n = 174) and de novo lesions (n = 64) using SeQuent Please paclitaxel-coated balloon were analyzed. Study end points were major adverse cardiac events (MACEs). At 1-year follow-up, TLR and MACEs occurred with acceptably low rates (5.0% and 6.3%, respectively). At 2.00 (0.74) years of follow-up, there was a significant difference in the rates of TLR between the ISR and the de novo lesions groups (14.4% [ISR] vs 3.1% [de novo], P = .028), and the occurrence of MACEs distinctly increased in the ISR group compared to the de novo lesions group (21.8% vs 6.2%, P = .009). The long-term outcomes of the ISR group were inferior to those of the de novo group (TLR, log-rank P = .019; MACEs, log-rank P = .010). Drug-eluting balloon for ISR and de novo lesions of small coronary vessels is effective and safe.

Procedural advantages of a novel coronary stent design with ultra-thin struts and bioabsorbable abluminal polymer coating in an all-comers registry

Introduction

The implications of novel drug-eluting stent (DES) design modifications including ultra-thin struts and new concepts of polymer coating for procedural efficacy are still unknown.

Aim

To evaluate procedural efficacy and short-term safety of a novel DES design.

Material and methods

In this all-comers registry, 407 consecutive patients were enrolled upon undergoing percutaneous coronary interventions (PCI) with the thin-strut bioabsorbable abluminal polymer-coated SYNERGY stent. These patients were then compared with the previous 407 patients undergoing PCI performed by the same interventionalists using currently established second-generation DES (Promus Element plus, Xience prime, Resolute Integrity). Several clinical and procedural data were compared, and the coronary artery complexity was assessed by the American College of Cardiology/American Heart Association classification and SYNTAX Score.

Results

The study population consisted of 814 patients. A total of 859 Synergy stents were deployed in 480 target vessels in the Synergy group (n = 407), and 904 stents in 469 vessels in the second-generation DES group (n = 407). Coincidentally, target lesions in the Synergy group (A 2.7%, B1 13.8%, B2 38.6%, C 45.0%) were more complex (p < 0.01) than those in the second-generation DES group (A 4.9%, B1 18.7%, B2 42.3%, C 34.2%). In cases with severe lesions (B2/C), the median contrast agent amount and fluoroscopy time were significantly lower in the Synergy group, indicating improved deliverability (110 ml vs. 150 ml; p < 0.01 and 7.2 min vs. 9.1 min; p = 0.01). Rates of in-hospital major adverse cardiovascular events were comparable between the two groups.

Conclusions

In an all-comers, real-world PCI population, novel stent design modifications including ultra-thin struts and abluminal bioabsorbable polymer coating are associated with improved procedural performance.

Biocompatible Carbon-Based Coating as Potential Endovascular Material for Stent Surface

Stainless steel 316L is a material commonly used in cardiovascular medicine. Despite the various methods applied in stent production, the rates of in-stent restenosis and thrombosis remain high. In this study graphene was used to coat the surface of 316L substrate for enhanced bio- and hemocompatibility of the substrate. The presence of graphene layers applied to the substrate was investigated using cutting-edge imaging technology: energy-filtered low-voltage FE-SEM approach, scanning electron microscopy (SEM), Raman spectroscopy, and atomic force microscopy (AFM). The potential of G-316L surface to influence endothelial cells phenotype and endothelial-to-mesenchymal transition (EndoMT) has been determined. Our results show that the bio- and hemocompatible properties of graphene coatings along with known radial force of 316L make G-316L a promising candidate for intracoronary implants.

Comparison of drug-eluting stents and drug-coated balloon for the treatment of drug-eluting coronary stent restenosis: A randomized RESTORE trial

BACKGROUND

This study sought to evaluate the optimal treatment for in-stent restenosis (ISR) of drug-eluting stents (DESs).

METHODS

This is a prospective, multicenter, open-label, randomized study comparing the use of drug-eluting balloon (DEB) versus second-generation everolimus-eluting stent for the treatment of DES ISR. The primary end point was in-segment late loss at 9-month routine angiographic follow-up.

RESULTS

A total of 172 patients were enrolled, and 74 (43.0%) patients underwent the angiographic follow-up. The primary end point was not different between the 2 treatment groups (DEB group 0.15±0.49 mm vs DES group 0.19±0.41 mm, P=.54). The secondary end points of in-segment minimal luminal diameter (MLD) (1.80±0.69 mm vs 2.09±0.46 mm, P=.03), in-stent MLD (1.90±0.71 mm vs 2.29±0.48 mm, P=.005), in-segment percent diameter stenosis (34%±21% vs 26%±15%, P=.05), and in-stent percent diameter stenosis (33%±21% vs 21%±15%, P=.002) were more favorable in the DES group. The composite of death, myocardial infarction, or target lesion revascularization at 1 year was comparable between the 2 groups (DEB group 7.0% vs DES group 4.7%, P=.51).

CONCLUSIONS

Treatment of DES ISR using DEB or second-generation DES did not differ in terms of late loss at 9-month angiographic follow-up, whereas DES showed better angiographic results regarding minimal MLD and percent diameter stenosis. Both treatment strategies were safe and effective up to 1year after the procedure.

Heart-type fatty acid-binding protein (H-FABP) and highly sensitive troponin T (hsTnT) as markers of myocardial injury and cardiovascular events in elective percutaneous coronary intervention (PCI)

BACKGROUND/INTRODUCTION

Type 4a myocardial infarction (MI) occurs when myocardial injury is combined with either symptoms suggestive of myocardial ischaemia, new left bundle branch block, angiographic loss of patency of a major artery or imaging suggestive of new loss of myocardium. Myocardial injury is defined as a rise of >5 x 99th upper reference limit (URL) of 14 ng/l (i.e. >70 ng/l) for highly sensitive troponin T (hsTnT) at 6 h if hsTnT was normal at baseline or >20% rise from 0 to 6 h if hsTnT was >14 ng/l at baseline.

AIM

To assess the prognostic value of biomarkers of myocardial injury following elective percutaneous coronary intervention (PCI).

DESIGN

A cohort of 209 patients were included of whom 144 (68.9%) were male, mean age was 68.8 years, 28 (13.4%) were smokers, 31 (14.8%) were diabetic, 199 (95.2%) had hypercholesterolaemia and 138 (66.0%) had hypertension.

METHODS

We evaluated hsTnT, heart-type fatty acid-binding protein (H-FABP), troponin I (TnI), creatine kinase MB type (CKMB), myoglobin, glycogen phosphorylase BB (GPBB) and carbonic anhydrase III (CA III) at 0, 4, 6 and 24 h following elective PCI. Patients were followed up at 1 year to assess for major adverse clinical events (MACE).

RESULTS

Myocardial injury was observed in 37 (17.7%) patients. Median hsTnT/H-FABP at 4 h were most predictive. MACE was noted in 6 (2.9%) patients, 3 had type 4a MI post PCI, P = 0.036.

DISCUSSION/CONCLUSIONS

Median 4 h hsTnT/H-FABP were most predictive of myocardial injury following PCI. H-FABP and hsTnT were predictive of MACE.

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

BACKGROUND

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

STUDY DESIGN AND OBJECTIVES

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

CONCLUSIONS

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

Impact of Paclitaxel-Eluting Balloons Compared to Second-Generation Drug-Eluting Stents for of In-Stent Restenosis in a Primarily Acute Coronary Syndrome Population

Background

The place of drug-eluting balloons (DEB) in the treatment of in-stent restenosis (ISR) is not well-defined, particularly in a population of all-comers with acute coronary syndromes (ACS).

Objective

Compare the clinical outcomes of DEB with second-generation drug-eluting stents (DES) for the treatment of ISR in a real-world population with a high proportion of ACS.

Methods

A retrospective analysis of consecutive patients with ISR treated with a DEB compared to patients treated with a second-generation DES was performed. The primary endpoint was a composite of major adverse cardiovascular events (MACE: all-cause death, non-fatal myocardial infarction, and target lesion revascularization). Comparisons were performed using Cox proportional hazards multivariate adjustment and Kaplan-Meier analysis with log-rank.

Results

The cohort included 91 patients treated with a DEB and 89 patients treated with a DES (74% ACS). Median follow-up was 26 months. MACE occurred in 33 patients (36%) in the DEB group, compared to 17 patients (19%) in the DES group (p log-rank = 0.02). After multivariate adjustment, there was no significant difference between the groups (HR for DEB = 1.45 [95%CI: 0.75-2.83]; p = 0.27). Mortality rates at 1 year were 11% with DEB, and 3% with DES (p = 0.04; adjusted HR = 2.85 [95%CI: 0.98-8.32]; p = 0.06).

Conclusion

In a population with a high proportion of ACS, a non-significant numerical signal towards increased rates of MACE with DEB compared to second-generation DES for the treatment of ISR was observed, mainly driven by a higher mortality rate. An adequately-powered randomized controlled trial is necessary to confirm these findings.

Coronary stents and vascular response to implantation: literature review

Drug-eluting stents (DESs) have minimized the limitations of bare-metal stents (BMSs) after percutaneous coronary interventions. Nevertheless, serious concerns remain about possible late complications of stenting, such as stent thrombosis (ST) and in-stent restenosis (ISR), although the introduction of second-generation DESs seems to have softened the phenomenon, compared to the first-generation ones. ST is a potentially catastrophic event, which has been markedly reduced by optimization of stent implantation, novel stent designs, and dual antiplatelet therapy. The exact mechanism to explain its occurrence is under investigation, and, realistically, multiple factors are responsible. ISR of BMSs has been previously considered as a stable condition with an early peak (at 6 months) of intimal hyperplasia, followed by a regression period beyond 1 year. On the contrary, both clinical and histologic studies of DESs have demonstrated evidence of continuous neointimal growth during long-term follow-up, named "late catch-up" phenomenon. The acknowledgment that ISR is a relatively benign clinical condition has been recently challenged by evidences which reported that patients with ISR can experience acute coronary syndromes. Intracoronary imaging is an invasive technology that allows identifying features of atherosclerotic plaque of stent implanted and of vascular healing after stenting; it is often used to complete diagnostic coronary angiography and to drive interventional procedures. Intracoronary optical coherence tomography is currently considered a state-of-the-art imaging technique; it provides, compared to intravascular ultrasound, better resolution (at least >10 times), allowing the detailed characterization of the superficial structure of the vessel wall. Imaging studies "in vivo," in agreement with histological findings, suggest that chronic inflammation and/or endothelial dysfunction may induce late de novo "neoatherosclerosis" inside both BMSs and DESs. So, neoatherosclerosis has become the prime suspect in the pathogenesis of late stent failure.

Drug-Eluting Stents Versus Bare Metal Stents for Percutaneous Coronary Intervention in Kidney Transplant Recipients

BACKGROUND

The comparative effectiveness of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus bare metal stents (BMS) has not been studied in the kidney transplant population.

METHODS

Using the US Renal Data System, we identified 3245 kidney transplant patients who underwent PCI between April 2003 and December 2010; 2400 and 845 patients received DES and BMS, respectively. We used propensity score matching and inverse probability of treatment weighting to create DES- and BMS-treated groups whose observed baseline characteristics were well-balanced. The associations between stent type and the outcomes of (1) death; (2) death or myocardial infarction (MI); (3) death, MI, or repeat revascularization (RR); and (4) hospitalized bleeding were compared using Cox proportional hazards regression.

RESULTS

Drug-eluting stent use increased during the study period, mirroring the trend described in the general population. In the propensity score-matched cohort, no significant association among DES (vs BMS) use and outcomes was observed at 1 and 2 years of follow-up. However, at 3 years, DES was associated with 20% (95% confidence interval [CI], 4-33%) lower risk of death, 15% (95% CI, 1-27%) lower risk of death or MI, and 14% (95% CI, 2-24%) lower risk of death, MI, or repeat revascularization. There were no significant differences in rates of hospitalized bleeding at any time point. Results were similar in the inverse probability of treatment weighting analysis.

CONCLUSIONS

In this retrospective study of US kidney transplant recipients undergoing PCI, DES was associated with better clinical outcomes beyond 2 years of follow-up.

Safety of bailout stenting after paclitaxel-coated balloon angioplasty

BACKGROUND

Bailout stenting after suboptimal paclitaxel-coated balloon (PCB) angioplasty is required in up to 28% of cases. We sought to compare the safety of bailout stenting with drug-eluting stents (DES) compared with the more established combination of PCB with bare metal stents (BMS).

METHODS

We retrospectively evaluated all patients who had stents implanted owing to suboptimal PCB angioplasty results between January 2010 and April 2015. Endpoints analyzed were major adverse cardiac events (MACE) - defined as cardiovascular death, nonfatal myocardial infarction (MI), and target lesion revascularization (TLR) - as well as major and minor bleeding.

RESULTS

Baseline clinical characteristics were comparable with a high proportion of diabetics in both groups (50.0% vs. 45.8%, p = 0.74). BMS and DES sizes were similar (mean diameter 2.72 ± 0.50 mm vs. 2.89 ± 0.56 mm, p = 0.20, length 25.22 ± 13.47 mm vs. 28.08 ± 9.08 mm, p = 0.47). Outcomes were comparable at the end of 1 year (MACE 12.2% vs. 9.5%, p = 1.00, TLR 6.1% vs. 4.8%, p = 1.00, MI 0% vs. 4.8%, p = 0.30). There was no case of stent thrombosis or major bleeding, and the rates of minor bleeding were similar (4.2% vs. 4.8%, p = 1.00).

CONCLUSION

Our initial experience using DES instead of BMS as a bailout after suboptimal PCB results shows that the procedure is safe and effective at 1 year.

Comparison of mid-term clinical outcomes between "complete full-metal jacket strategy" versus "incomplete full-metal jacket strategy" for diffuse right coronary artery stenosis with drug-eluting stents

BACKGROUND

The optimal strategy for diffuse right coronary artery (RCA) stenosis remains unclear.

OBJECTIVE

The objective of this study was to compare the mid-term outcomes of "complete full-metal jacket (c-FMJ) stenting strategy" with "incomplete full-metal jacket (i-FMJ) stenting strategy" for the diffuse long RCA lesion using drug-eluting stents (DES).

METHODS

Between July 2007 and October 2015, 121 patients underwent percutaneous coronary intervention (PCI) for diffuse RCA lesions using DES. Fifty-three patients underwent c-FMJ PCI, whereas 68 patients underwent i-FMJ. Thirty patients received angiographical follow-up in the c-FMJ group, while 34 patients received angiographical follow-up in the i-FMJ group. The primary endpoint was major adverse cardiac events (MACE): cardiac death, stent thrombosis (ST), target lesion revascularization (TLR), and target vessel revascularization (TVR).

RESULTS

The incidence of MACE was significantly lower in the c-FMJ group (13.3%) as compared to the i-FMJ group (41.2%) (p=0.013). There was no cardiac death in either group. The incidence of ST was comparable between the i-FMJ group (2.9%) and c-FMJ group (3.3%) (p=1.00), while TLR was significantly less in the c-FMJ group (6.7%) compared to the i-FMJ group (32.4%) (p=0.011).

CONCLUSIONS

The mid-term MACE was significantly less in the c-FMJ group than in the i-FMJ group, indicating that c-FMJ stenting was a favorable strategy for the diffuse long RCA lesion.

The History of Coronary Stenting

The history of coronary angioplasty began with the groundbreaking work of Andreas Grüntzig, who was the first to use balloon-expandable catheters for the treatment of flow-limiting atherosclerotic coronary artery lesions. Thereafter, early investigators tested self-expanding springs as a solution to abrupt closure and restenosis seen with balloon angioplasty but these devices suffered from difficult delivery and a high complication rate. Julio Palmaz and Richard Schatz introduced the first balloon-expandable stent as a mechanical support to improve vessel patency. Their pioneering work launched a new era in the treatment of coronary artery disease.

Comparison of Angiographic and 1-Year Outcomes Between a Long Single Stent and Overlapping Double Stents in Patients With Newer-Generation Drug-Eluting Stents for Long Narrowings

Although some clinical studies have revealed adverse clinical and angiographic outcomes of early-generation overlapping drug-eluting stents (DES), the safety and efficacy of overlapping newer-generation DES for long narrowings have not been well established. This study aimed to compare angiographic and 1-year clinical outcomes between a long single stent (LSS) and overlapping double stents (ODS) in patients treated with newer-generation DES for similarly long narrowings. We analyzed 8 to 10 months angiographic and 1-year clinical outcomes of 112 lesions of 105 patients with long (30 to 38 mm) narrowings treated with everolimus-eluting stent, a newer-generation DES, using LSS or ODS. We divided our patients into LSS group (46 patients with 49 lesions) and ODS group (59 patients with 63 lesions). As a result, the rates of freedom from major adverse cardiac events (92.9% vs 93.1%, p = 0.91) and target lesion revascularization (94.5% vs 95.1%, p = 0.79) during 1-year follow-up were similar between the 2 groups. There was no stent thrombosis observed between the 2 groups. In conclusion, everolimus-eluting stent provided similar angiographic and 1-year clinical outcomes regardless of overlap status in long narrowings.

Comparing the Clinical Outcomes between Drug Eluting Stents and Bare Metal Stents in Patients with Insulin-Treated Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis of 10 Randomized Controlled Trials

Background

Several studies have shown Drug Eluting Stents (DES) to be better compared to Bare Metal Stents (BMS) in patients with type 2 Diabetes Mellitus (T2DM). Since, the adverse clinical outcomes in patients with Insulin-Treated Type 2 Diabetes Mellitus (ITDM) implanted with DES and BMS have not been previously studied, we aim to compare the clinical outcomes in similar patients with cardiovascular diseases, treated with DES and BMS.

Methods

Randomized Controlled Trials (RCTs) comparing patients treated with DES and BMS were searched from PubMed and EMBASE databases. Outcome data for the patients with ITDM were carefully extracted. Major Adverse Cardiac Events (MACEs), mortality, Target Vessel Revascularization (TVR), Target Lesion Revascularization (TLR), Myocardial Infarction (MI) and Stent Thrombosis (ST) were considered as the clinical endpoints for this analysis. Odds ratios (OR) with 95% confidence intervals (CIs) were calculated and the pooled analyses were performed with RevMan 5.3 software.

Results

Ten RCTs consisting of 830 patients with ITDM (477 patients in the DES group and 353 patients in the BMS group) from a total number of 9,141 patients were included in this analysis. During a follow-up period from one month to one year, MACEs were not increased with the use of DES in these patients with ITDM. At 9 months, MACEs were significantly lower in the DES group with OR: 0.40, 95% CI: 0.23–0.72; P = 0.002 with no increase in mortality. TVR and TLR also favored the DES group with OR: 0.44, 95% CI: 0.22–0.88, P = 0.02 and OR: 0.28, 95% CI: 0.14–0.53; P = 0.0001 respectively at 9 months, and OR: 0.46, 95% CI: 0.23–0.94, P = 0.03 and OR: 0.28, 95% CI: 0.14–0.55; P = 0.0003 respectively at one year. Results for MI, and ST were not statistically significant.

Conclusion

Compared to BMS, DES were associated with a significantly lower rate of repeated revascularization, without any increase in MACEs or mortality in these patients with ITDM during a follow up period of one year. However, due to the very small population size, further studies with a larger number of randomized patients are required to completely solve this issue.

Nanoparticle drug delivery systems and their use in cardiac tissue therapy

Cardiovascular diseases make up one of the main causes of death today, with myocardial infarction and ischemic heart disease contributing a large share of the deaths reported. With mainstream clinical therapy focusing on palliative medicine following myocardial infarction, the structural changes that occur in the diseased heart will eventually lead to end-stage heart failure. Heart transplantation remains the only gold standard of cure but a shortage in donor organs pose a major problem that led to clinicians and researchers looking into alternative strategies for cardiac repair. This review will examine some alternative methods of treatment using chemokines and drugs carried by nanoparticles as drug delivering agents for the purposes of treating myocardial infarction through the promotion of revascularization. We will also provide an overview of existing studies involving such nanoparticulate drug delivery systems, their reported efficacy and the challenges facing their translation into ubiquitous clinical use.

WITHDRAWN: Drug-eluting stents versus bare metal stents for angina or acute coronary syndromes

This review 'topic' has been included in work being carried out as part of a Health Technology Assessment commissioned by the National Institute for Clinical Excellence in England and Wales. Details of this research is available via www.nice.org.uk.

The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the HTA programme, NICE, NIHR, NHS or the Department of Health.

The review has been split into 2 reviews that will be published as "Drug‐eluting stents versus bare‐metal stents for stable ischaemic heart disease" and "Drug‐eluting stents versus bare‐metal stents for acute coronary syndrome".

The editorial group responsible for this previously published document have withdrawn it from publication.

Clinical Coronary In-Stent Restenosis Follow-Up after Treatment and Analyses of Clinical Outcomes

BACKGROUND

Clinical in-stent restenosis (CISR) is the main limitation of coronary angioplasty with stent implantation.

OBJECTIVE

Describe the clinical and angiographic characteristics of CISR and the outcomes over a minimum follow-up of 12 months after its diagnosis and treatment.

METHODS

We analyzed in 110 consecutive patients with CISR the clinical presentation, angiographic characteristics, treatment and combined primary outcomes (cardiovascular death, nonfatal acute myocardial infarction [AMI]) and combined secondary (unstable angina with hospitalization, target vessel revascularization and target lesion revascularization) during a minimal follow-up of one year.

RESULTS

Mean age was 61 ± 11 years (68.2% males). Clinical presentations included acute coronary syndrome (ACS) in 62.7% and proliferative ISR in 34.5%. CISR was treated with implantation of drug-eluting stents (DES) in 36.4%, Bare Metal Stent (BMS) in 23.6%, myocardial revascularization surgery in 18.2%, balloon angioplasty in 15.5% and clinical treatment in 6.4%. During a median follow-up of 19.7 months, the primary outcome occurred in 18 patients, including 6 (5.5%) deaths and 13 (11.8%) AMI events. Twenty-four patients presented a secondary outcome. Predictors of the primary outcome were CISR with DES (HR = 4.36 [1.44-12.85]; p = 0.009) and clinical treatment for CISR (HR = 10.66 [2.53-44.87]; p = 0.001). Treatment of CISR with BMS (HR = 4.08 [1.75-9.48]; p = 0.001) and clinical therapy (HR = 6.29 [1.35-29.38]; p = 0.019) emerged as predictors of a secondary outcome.

CONCLUSION

Patients with CISR present in most cases with ACS and with a high frequency of adverse events during a medium-term follow-up.

Prospective study to evaluate safety and efficacy of Zotarolimus Eluting Stent (PSEZES) in patients with long coronary artery lesions

BACKGROUND

Although the safety and effectiveness of Drug-Eluting Stents (DES) has been established extensively, reports on long term clinical outcome with angiographic findings in patients with long coronary artery lesions are not many.

METHODS

In this single-center prospective registry of 100 patients, a total of 110 denovo long lesions (>20 mm) were treated with Resolute Zotarolimus Eluting Stent (R-ZES). The patients were followed up clinically at 3, 6 and 12 months and follow up coronary angiography was performed at 9-months. The primary end point was one year rate of target lesion failure (TLF) which is a composite of cardiac death, target lesion myocardial infarction or ischemia driven target lesion revascularization (TLR). The secondary end points included definite or probable stent thrombosis, 9-month angiographic restenosis and late lumen loss.

RESULTS

The mean age of patients was 58.7 ± 9.50 years with prevalence of diabetes as high as 60%. The mean lesion length was 24.67 ± 4.87 mm with a mean reference vessel diameter of 2.85 ± 0.32 mm and 67.3% were Type C lesions (ACC/AHA classification). Two patients died during follow-up, of which one was non-cardiac death. One patient had target vessel myocardial infarction and five patients (4.5%) had ischemia driven TLR. The incidence of TLF was 6.36%. Binary restenosis was seen in 7 out of 93 lesions (7.5%). Median late lumen loss at 9 month was 0.22 mm. No stent thrombosis was noted in the study.

CONCLUSION

Implantation of R-ZES in real-world patients with long coronary artery lesions is safe with comparable efficacy to what is observed in the treatment of less complex lesions.

Effect of imatinib mesylate and rapamycin on the preformed intimal hyperplasia in rat carotid injury model

PURPOSE

Intimal hyperplasia (IH) is the main cause of restenosis or occlusion after vascular procedures. Imatinib mesylate and rapamycin are known to prevent IH. The purpose of this study was to evaluate the effect of these drugs on the regression of preformed IH in rat carotid injury model.

METHODS

IH was established in rat carotid arteries using a balloon catheter. The drug effects were assessed in vitro on proliferation, migration, and apoptosis of vascular smooth muscle cells (VSMC) in the neointima. And in vivo studies were carried out in 4 groups: imatinib, rapamycin, combined, and no medication. After 2-week oral medication, morphometric analysis evaluated the number and density of neointimal cells, intima-to-media (I/M) ratio and cross-sectional area. Cell proliferation, apoptosis, and collagen changes were also investigated by immunohistochemical staining (IHCS).

RESULTS

Imatinib and rapamycin significantly inhibited VSMC proliferation and migration, and promoted apoptosis in vitro. In morphometric analysis, the number and density of neointimal cells decreased significantly in all medication groups compared with control group (P < 0.01). However, there was no significant difference in neointimal cross-sectional area and I/M ratio among groups. In IHCS, imatinib and rapamycin inhibited neointimal cell proliferation significantly. However, there was no significant change in cell apoptosis and collagen composition.

CONCLUSION

Combined treatment of with imatinib and rapamycin induced reduction of cell mass in preformed intimal hyperplasia, but failed to induce regression of intimal mass in this short-term medication study. Further studies will be needed with additional strategies of inducing lysis of the extracellular matrix.

Inhibitory effects of roscovitine on proliferation and migration of vascular smooth muscle cells in vitro

Abnormal proliferation and migration of vascular smooth muscle cells (VSMCs) are the major cause of in-stent restenosis (ISR). Intervention proliferation and migration of VSMCs is an important strategy for antirestenotic therapy. Roscovitine, a second-generation cyclin-dependent kinase inhibitor, can inhibit cell cycle of multiple cell types. We studied the effects of roscovitine on cell cycle distribution, proliferation and migration of VSMCs in vitro by flow cytometry, BrdU incorporation and wound healing assay, respectively. Our results showed that roscovitine increased the proportion of G0/G1 phase cells after 12 h (69.57±3.65 vs. 92.50±1.68, P=0.000), 24 h (80.87±2.24 vs. 90.25±0.79, P=0.000) and 48 h (88.08±3.86 vs. 88.87±2.43, P=0.427) as compared with control group. Roscovitine inhibited proliferation and migration of VSMCs in a concentration-dependent way. With the increase of concentration, roscovitine showed increased capacity for growth and migration inhibition. Roscovitine (30 μmol/L) led to an almost complete VSMCs growth and migration arrest. Combined with its low toxicity and selective inhibition to ISR-VSMCs, roscovitine may be a potential drug in the treatment of vascular stenosis diseases and particularly useful in the prevention and treatment of ISR.

Impact of stent overlap on long-term clinical outcomes in patients treated with newer-generation drug-eluting stents

AIMS

Early-generation drug-eluting stent (DES) overlap (OL) is associated with impaired long-term clinical outcomes whereas the impact of OL with newer-generation DES is unknown. Our aim was to assess the impact of OL on long-term clinical outcomes among patients treated with newer-generation DES.

METHODS AND RESULTS

We analysed the three-year clinical outcomes of 3,133 patients included in a prospective DES registry according to stent type (sirolimus-eluting stents [SES; N=1,532] versus everolimus-eluting stents [EES; N=1,601]), and the presence or absence of OL. The primary outcome was a composite of death, myocardial infarction (MI), and target vessel revascularisation (TVR). The primary endpoint was more common in patients with OL (25.1%) than in those with multiple DES without OL (20.8%, adj HR=1.46, 95% CI: 1.03-2.09) and patients with a single DES (18.8%, adj HR=1.74, 95% CI: 1.34-2.25, p<0.001) at three years. A stratified analysis by stent type showed a higher risk of the primary outcome in SES with OL (28.7%) compared to other SES groups (without OL: 22.6%, p=0.04; single DES: 17.6%, p<0.001), but not between EES with OL (22.3%) and other EES groups (without OL: 18.5%, p=0.30; single DES: 20.4%, p=0.20).

CONCLUSIONS

DES overlap is associated with impaired clinical outcomes during long-term follow-up. Compared with SES, EES provide similar clinical outcomes irrespective of DES overlap status.

Impact of stent strut design in metallic stents and biodegradable scaffolds

Advances in the understanding of healing mechanisms after stent implantation have led to the recognition of stent strut thickness as an essential factor affecting re-endothelialization and overall long term vessel healing response after Percutaneous Coronary Interventions (PCI). Emergence of Drug-eluting stents (DESs) with anti-proliferative coating has contributed to reducing the incidence of restenosis and Target Lesion Revascularization (TVR), while progress and innovations in stent materials have in the meantime facilitated the design of newer platforms with more conformability and thinner struts, producing lesser injury and improving integration into the vessel wall. Recent advances in biodegradable metal and polymer materials now also allow for the design of fully biodegradable platforms, which are aimed at scaffolding the vessel only temporarily to prevent recoil and constrictive remodeling of the vessel during the initial period required, and are then progressively resorbed thereby avoiding the drawback of leaving an unnecessary implant permanently in the vessel. The aim of this article is to review recent evolution in stent material and stent strut design while understanding their impact on PCI outcomes. The article describes the different metallic alloys and biodegradable material properties and how these have impacted the evolution of stent strut thickness and ultimately outcomes in patients.

Inhibition of neointimal hyperplasia in rats treated with atorvastatin after carotid artery injury may be mainly associated with down-regulation of survivin and Fas expression

CONTEXT

Atorvastatin is a member of the drug class known as statins, which is used for lowering blood cholesterol.

OBJECTIVE

The present study investigates the effect and mechanism of atorvastatin on neointimal hyperplasia after carotid artery injury (CAI) of rat.

MATERIALS AND METHODS

Fifty male rats were randomly divided into four groups: control group, sham-operated group, model group, and atorvastatin treatment group. The treatment group was fed with atorvastatin (10 mg/kg) with gastro-gavage at 5 p.m. every day for 28 d after surgery. The control group, model group, and sham-operated group were fed with the same volume of distilled water instead. The proliferations of intimal and medial layers were evaluated by hematoxylin & eosin (H&E) staining. The apoptosis of vascular smooth muscle cells (VSMCs) was determined by terminal deoxynucleotidyl transferased UTP nick end labeling (TUNEL) staining. Plasma concentrations of survivin and sFas were detected by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Atorvastatin reduced neointimal formation and increased apoptosis of VSMCs in neointima. VSMCs apoptosis emerged at 3 d (8.42 ± 0.449 μm) and the intimal proliferation peaked by the end of 14 d (41.58 ± 1.64 μm). The plasma levels of survivin and sFas were gradually increased with the neointimal hyperplasia and increasingly decreased after atorvastatin treatment. The plasma levels of survivin and sFas in rats were elevated at 3 d (464.80 ± 105.27 pg/ml and 3256.00 ± 478.20 pg/ml, respectively), reached the peak of survivin at 14 d (1089.20 ± 232.32 pg/ml) and sFas at 7 d (4362.00 ± 639.92 pg/ml) and decreased at 28 d (562.00 ± 90.11 pg/ml and 2148.00 ± 257.14 pg/ml, respectively) in the model group. Compared with the model group, the atorvastatin treatment group has significantly less neointimal hyperplasia and more apoptosis of VSMCs.

CONCLUSIONS

Atorvastatin can inhibit neointimal hyperplasia and promote SMCs apoptosis in neointimal layers, which may be mainly associated with down-regulation of survivin and Fas expression after CAI of rat.

Efficacy and safety of drug-eluting stents in the real world: 8-year follow-up

Background:

Drug-eluting stents have been used in daily practice since 2002, with the clear advantages of reducing the risk of target vessel revascularization and an impressive reduction in restenosis rate by 50%-70%. However, the occurrence of a late thrombosis can compromise long-term results, particularly if the risks of this event were sustained. In this context, a registry of clinical cases gains special value.

Objective:

To evaluate the efficacy and safety of drug-eluting stents in the real world.

Methods:

We report on the clinical findings and 8-year follow-up parameters of all patients that underwent percutaneous coronary intervention with a drug-eluting stent from January 2002 to April 2007. Drug-eluting stents were used in accordance with the clinical and interventional cardiologist decision and availability of the stent.

Results:

A total of 611 patients were included, and clinical follow-up of up to 8 years was obtained for 96.2% of the patients. Total mortality was 8.7% and nonfatal infarctions occurred in 4.3% of the cases. Target vessel revascularization occurred in 12.4% of the cases, and target lesion revascularization occurred in 8% of the cases. The rate of stent thrombosis was 2.1%. There were no new episodes of stent thrombosis after the fifth year of follow-up. Comparative subanalysis showed no outcome differences between the different types of stents used, including Cypher®, Taxus®, and Endeavor®.

Conclusion:

These findings indicate that drug-eluting stents remain safe and effective at very long-term follow-up. Patients in the "real world" may benefit from drug-eluting stenting with excellent, long-term results.

Impact of coronary lesion complexity on drug-eluting stent outcomes in patients with and without diabetes mellitus: analysis from 18 pooled randomized trials

OBJECTIVES

The aim of this study was to investigate whether baseline lesion complexity affects drug-eluting stent (DES) outcomes according to diabetic status.

BACKGROUND

Previous studies have reported conflicting results regarding DES safety and efficacy in patients with and without diabetes mellitus (DM).

METHODS

Patient-level data from 18 prospective randomized trials were pooled. DES treatment outcomes in patients with versus without DM were analyzed in 2 propensity score-matched groups further stratified according to lesion complexity (American College of Cardiology and American Heart Association class A/B1 vs. B2/C). Remaining baseline differences were adjusted for by multivariate analysis.

RESULTS

DM was present in 3,467 of 18,441 patients (18.8%). DM was a predictor of 1-year repeat revascularization (target lesion revascularization: hazard ratio: 1.34; 95% confidence interval: 1.05 to 1.70; target vessel revascularization: hazard ratio: 1.40; 95% confidence interval: 1.15 to 1.72) and cardiac death or myocardial infarction (hazard ratio: 1.40; 95% confidence interval: 1.09 to 1.81). Rates of target lesion and target vessel revascularization were significantly higher in patients with versus those without DM with type B2/C lesions (8.0% vs. 4.5% and 10.6% vs. 5.9%, respectively, p < 0.0001 for both), but not in patients with only type A/B1 lesions (4.6% vs. 4.8%, p = 0.87, and 7.4% vs. 6.8%, p = 0.47, respectively), with a significant interaction between DM and lesion type observed for both endpoints (p = 0.01 and p = 0.02, respectively). No interaction was observed for death or myocardial infarction (p = 0.28).

CONCLUSIONS

In the DES era, patients with DM remain at increased risk for cardiac death or myocardial infarction. However, DM is a risk factor for repeat revascularization only in those patients with complex lesions; patients with DM and noncomplex lesions have similar rates of 1-year freedom from repeat revascularization as do patients without DM.

Review of the TAXUS® Liberté™ SR paclitaxel-eluting coronary stent

The advent of drug-eluting stents has revolutionized the treatment of coronary heart disease. Interventional cardiologists are increasingly treating more complex lesions in patients that would have otherwise required bypass surgery. As a result of technological advances, the second-generation thin strut TAXUS stent--the TAXUS Liberté SR paclitaxel-eluting coronary stent--has now been introduced into routine clinical practice. The Liberté stent has evolved from the currently available TAXUS Express stent to provide enhanced lesion access in challenging anatomies as well as more uniform drug delivery. This article will provide an overview of the TAXUS Liberté stent.

The evolution of coronary stents: a brief review

Percutaneous coronary intervention is the most prevalent method for coronary artery revascularization. Initial interventions using balloon angioplasty had limited efficacy because coronary dissections, arterial recoil, and neointimal formation led to high rates of abrupt vessel closure and clinical restenosis. With the introduction of coronary stents, vascular dissections were stabilized and arterial recoil was eliminated, but neointimal accumulation remained problematic, resulting in the development of in-stent restenosis (ISR) in 20%-30% of cases. Drug-eluting stents (DESs) were developed to release antiproliferative agents at the site of arterial injury to attenuate neointimal formation. Although DESs have incrementally improved outcomes after percutaneous coronary intervention, delayed re-endothelialization and stent thrombosis remain important challenges. Herein we review the pathophysiology of ISR, stent thrombosis, and briefly summarize the clinical evidence behind first- and second-generation DESs. Moreover, we discuss advancements in our understanding of the pathogenesis of ISR and potential novel therapeutic strategies to improve clinical outcomes.