Very long versus overlapping drug eluting stents for the management of long coronary artery lesions

BACKGROUND

The prevalence of long diffuse coronary artery disease (CAD) is increasing nowadays due to increase prevalence of multiple risk factors and population ageing. We aimed in our study to show the differences clinically or angiographically (guided by IVUS) between the use of single long stent versus overlapping stents in very long coronary lesions (≥40 mm) in patients presented with chronic coronary syndromes.

METHODS

550 patients presenting with chronic coronary syndromes were included: 320 treated with a single long stent (≥40 mm) and 230 patients with two or more overlapping stents. Angiographic follow-up (guided by IVUS) 6 months after PCI was performed only in 50 patients. We assessed the procedural characteristics and the occurrence of major adverse cardiovascular events (MACE) after a median follow-up of 24 months.

RESULTS

Total stent length was 56.16 ± 14.85 mm and mean diameter was 3.05 ± 0.36 mm. At the end of follow-up, MACE rate in the single long stent group was 4.1% vs. 7.8% in the overlapping stents group, with higher incidence in overlapping stents group but non-statistically significant (p value = 0.059). PCI using overlapping stents consumed more contrast volume (248 ± 85.36 vs 164.5 ± 70.43 ml, p < 0.001), and higher fluoroscopy time (23.65 ± 9.19 vs 19.72 ± 9.19 min, p < 0.001). Regarding IVUS subgroup follow-up, there was no significant difference between both groups regarding in-stent restenosis and MACE.

CONCLUSIONS

We can conclude that long or overlapping stents are both acceptable therapeutic choices for patients with long CAD. There was no difference between both strategies regarding angiographic follow-up guided by IVUS after 6 months.

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.

Mechanisms, pathophysiology, and clinical aspects of incomplete stent apposition

Incomplete stent apposition (ISA) is characterized by the lack of contact of at least 1 stent strut with the vessel wall in a segment not overlying a side branch; it is more commonly found in drug-eluting stents than bare-metal stents. The accurate diagnosis of ISA, initially only possible with intravascular ultrasound, can currently be performed with higher accuracy by optical coherence tomography, which also enables strut-level assessment due to its higher axial resolution. Different circumstances related both to the index procedure and to vascular healing might influence ISA occurrence. Although several histopathology and clinical studies linked ISA to stent thrombosis, potential selection bias precluded definitive conclusions. Initial studies usually performed single time point assessments comparing overall ISA percentage and magnitude in different groups (i.e., stent type), thus hampering a comprehensive understanding of its relationship with vascular healing. Serial intravascular imaging studies that evaluated vascular response heterogeneity recently helped fill this gap. Some particular clinical scenarios such as acute coronary syndromes, bifurcations, tapered vessels, overlapping stents, and chronic total occlusions might predispose to ISA. Interventional cardiologists should be committed to optimal stent choices and techniques of implantation and use intravascular imaging guidance when appropriate to aim at minimizing acute ISA. In addition, the active search for new stent platforms that could accommodate vessel remodeling over time (i.e., self-expandable stents) and for new polymers and/or eluting drugs that could induce less inflammation (hence, less positive remodeling) could ultimately reduce the occurrence of ISA and its potentially harmful consequences.

Safety and efficacy outcomes of overlapping second-generation everolimus-eluting stents versus first-generation drug-eluting stents

The safety and efficacy outcomes of stent overlap with second-generation drug-eluting stents (DES) have not been well established. This study aimed to compare the 1-year clinical outcomes of overlapping everolimus-eluting stents (EES) with those of overlapping first-generation DES. This retrospective analysis included 350 patients treated with overlapping EES (169 patients with 237 lesions), sirolimus-eluting stents (SES, 102 patients with 252 lesions), or paclitaxel-eluting stents (PES, 79 patients with 182 lesions). End points were major adverse cardiovascular events (MACE: defined as the composite of death, myocardial infarction, or target lesion revascularization), target vessel revascularization, and definite stent thrombosis at 1 year. During a follow-up of 1 year, overall MACE occurred in 6.5% of EES-, 16.8% of SES-, and 10.1% of PES-treated patients (p = 0.026). Myocardial infarction was lowest in the EES group versus SES and PES groups (0 vs 1.0% vs 2.5%, respectively; p = 0.080), and mortality was similar (3.6% vs 9.0% vs 5.1%, p = 0.162). The EES patients showed a trend toward lower rates of 1-year target lesion revascularization (3.1% vs 8.2% vs 6.5%, p = 0.181) and target vessel revascularization (3.7% vs 9.1% vs 11.7%, p = 0.051) compared with the SES- and PES-treated patients. The cumulative incidence of definite stent thrombosis was lowest in the EES group (0 for EES vs 3.9% for SES vs 2.5% for PES, p = 0.014). In conclusion, stent overlap with EES versus first-generation DES was associated with lower rates of MACE and stent thrombosis. Our results suggest that the use of EES when deploying overlapping stents is effective and safe.