Drug-eluting balloon versus bare-mental stent and drug-eluting stent for de novo coronary artery disease: A systematic review and meta-analysis of 14 randomized controlled trials

Drug-Coated Balloon-Only Strategy for De Novo Coronary Artery Disease: A Meta-analysis of Randomized Clinical Trials

Backgrounds

Many clinical trials have demonstrated the value of drug-coated balloons (DCB) for in-stent restenosis. However, their role in de novo lesions is not well documented. The aim of this study is to evaluate the safety and efficacy of the DCB-only strategy compared to other percutaneous coronary intervention strategies for de novo coronary lesions.

Methods

The PubMed, Embase, Web of Science, and Cochrane Library Central Register of Controlled Trials (CENTRAL) electronic databases were searched for randomized controlled trials published up to May 6, 2023. The primary outcomes were major adverse cardiac events and late lumen loss.

Results

A total of eighteen trials with 3336 participants were included. Compared with drug-eluting stents, the DCB-only strategy was associated with a similar risk of major adverse cardiac events (risk ratio (RR) = 0.90; 95% confidence interval (CI): 0.59 to 1.37, P = 0.631) and a significant decrease in late lumen loss (standardized mean difference (SMD) = -0.29, 95% CI: -0.53 to -0.04, P = 0.021). This effect was consistent in subgroup analysis regardless of indication, follow-up time, drug-eluting stent type, and dual antiplatelet therapy duration. However, DCBs were inferior to DESs for minimum lumen diameter and percentage diameter stenosis. The DCB-only strategy showed significantly better outcomes for most endpoints compared to plain-old balloon angioplasty or bare metal stents.

Conclusions

Interventions with a DCB-only strategy are comparable to those of drug-eluting stents and superior to plain-old balloon angioplasty or bare metal stents for the treatment of selected de novo coronary lesions. Additional evidence is still warranted to confirm the value of DCB before widespread clinical utilization can be recommended.

Treatment effect of metformin combined with atorvastatin in reducing in-stent restenosis after percutaneous coronary intervention in coronary artery disease patients with type 2 diabetic patients

To investigate the effectiveness of metformin and atorvastatin in preventing in-stent restenosis (ISR) on coronary patients with type 2 diabetes mellitus with percutaneous coronary intervention within 8 to 12 months after rapamycin-eluting stent implantation. A total of 1278 consecutive patients implanted with rapamycin-eluting stent from January 2012 to December 2019, who underwent coronary computed tomography or coronary angiography within 8 to 12 months. The patients were categorized into atorvastatin 20 mg, or atorvastatin 20 mg + metformin 1.5/d, or atorvastatin 40 mg + metformin 1.5/d groups. The clinical characteristics of the 3 groups were compared. The correlation between variables and ISR was analyzed. A total of 701 patients participated in the study. The ratio of ISR/nonstenosis (P = .039) and fasting blood sugar (P = .001) differed significantly in the 3 groups. Logistic regression showed that d, L, different therapeutic agents, and dosage groups were independent risk factors of ISR. The longer L and smaller d may increase ISR incidence with 8 to 12 months after percutaneous coronary intervention. Both metformin and atorvastatin are beneficial in reducing stent restenosis by a dose-dependent manner. An increasing dose of atorvastatin and a combination of metformin decreases the incidence of ISR in patients.

Efficacy of Drug-Coated Balloon Approaches for de novo Coronary Artery Diseases: A Bayesian Network Meta-Analysis

Background and Objective

The de novo coronary lesions are the most common form of coronary artery disease, and stent implantation still is the main therapeutic strategy. This network meta-analysis aims to evaluate the efficacy of drug-coated balloons only (DCB only) and DCB combined with bare-metal stents (DCB+BMS) strategies vs. drug-eluting stents (DES) and BMS approaches in coronary artery de novo lesion.

Method

PubMed, EMBASE, and Cochrane Library databases were retrieved to include the relevant randomized controlled trials that compared DCB approaches and stents implantation in patients with de novo coronary artery diseases. The primary outcome was major adverse cardiac events (MACE). The clinical outcomes included target lesion revascularization (TLR), all-cause death, and myocardial infarction. The angiographic outcomes consisted of in-segment late lumen loss (LLL) and binary restenosis. The odds ratio (OR) and 95% confidence intervals (95% CIs) for dichotomous data, and weighted mean differences for continuous data were calculated in the Bayesian network frame.

Result

A total of 26 randomized controlled trials and 4,664 patients were included in this study. The DCB-only strategy was comparable with the efficacy of MACE, clinical outcomes, and binary restenosis compared with DES. In addition, this strategy can significantly reduce the in-segment LLL compared with the first-generation (MD −0.29, −0.49 to −0.12) and the second-generation DES (MD −0.15, −0.27 to −0.026). However, subgroup analysis suggested that DCB only was associated with higher in-segment LLL than DES (MD 0.33, 0.14 to 0.51) in patients with acute coronary syndrome. Compared with DES, the DCB+BMS strategy had a similar incidence of myocardial infarction and all-cause death, but a higher incidence of MACE, TLR, and angiographic outcomes. In addition, DCB+BMS was associated with a similar incidence of myocardial infarction and all-cause death than BMS, with a lower incidence of MACE, TLR, and angiographic outcomes.

Conclusion

The DCB only is associated with similar efficacy and lower risk of LLL compared with DES. In addition, the DCB+BMS strategy is superior to BMS alone but inferior to DES (PROSPERO, CRD 42021257567).

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

Incidence of Restenosis Following Rapamycin or Paclitaxeleluting Stent in Coronary Stent Implantation

BACKGROUND & OBJECTIVES

Coronary artery disease (CAD) is chiefly characterized by atherosclerosis and plaque formation in coronary arteries. The aim of this study was to evaluate the correlation of coronary anatomy as a predictor of restenosis and stent thrombosis in coronary artery disease (CAD) patients 5 years after percutaneous coronary intervention (PCI).

METHODS

In this prospective study, 1070 patients with stent restenosis or stent thrombosis over past 5 years were enrolled. Coronary angiography was performed to evaluate coronary restenosis and stent thrombosis 5 years after PCI. Stent restenosis was defined as >50% angiographic in-stent lumen reduction. Stent thrombosis was defined as sudden complete occlusion of stent presenting with acute myocardial infarction in that territory. Demographic data, clinical features and anatomic factors were prospectively reviewed. Baseline, procedural, and post-procedural characteristics of patients were recorded for analysis.

RESULTS

Among demographic characteristics, cardiovascular risk factors (hypertension and diabetes mellitus) and anatomic factors were predictive risk factors for restenosis/thrombosis, p=0.001. The most common site for stent restenosis was proximal to the mid part of the LAD artery, followed by RCA and LCX. A greater diameter of LCX, a greater angle of LM-LAD than LM-LCX and left dominancy increase the incidence of LAD stent restenosis/thrombosis. In this study, the least common restenosis/thrombosis rate in relation to the total number of PCI was in the Ramus intermedius artery.

CONCLUSION

The outcomes of the study indicated that anatomic factors can predict increased risk of restenosis among CAD patients who underwent PCI.

[Fibrinolytics: from the thrombolysis to the processes of blood vessels growth and remodeling, neurogenesis, carcinogenesis and fibrosis]

One of the most outstanding scientific achievements in the thrombolysis is the development and administration of fibrinolysin - the first Soviet drug that lyses blood clots. Intracoronary administration of fibrinolysin reduced the mortality of patients with myocardial infarction by almost 20%. For his work in this field Yevgeny Chazov was awarded the Lenin Prize in 1982. Over the next decades, under his leadership, the Cardiology Center established scientific and clinical laboratories that created new generations of drugs based on fibrinolytics for treating patients with myocardial infarction, restoration of blood flow in ischemic tissue, and also studying the mechanisms of remodeling of blood vessels involving the fibrinolysis system. It have been found new mechanisms of regulation of the navigation of blood vessels and nerves growth, tumor growth and its metastasis with the participation of the fibrinolysis system proteins. The review reports the role of the fibrinolysis system in the thrombolysis, blood vessels growth and remodeling, neurogenesis, carcinogenesis and fibrosis. The article is dedicated to the 90th anniversary of academician E.I. Chazov.

Drug-coated balloon versus drug-eluting stent in de novo small coronary vessel disease: A systematic review and meta-analysis

BACKGROUND

Drug-coated balloon as a novel therapeutic strategy has been used to treat restenosis in cases of bare metal and drug-eluting stents. However, evidence of its safety and efficacy is scarce in de novo small coronary artery vessel disease. This meta-analysis aimed to compare the safety and efficacy of the drug-coated balloon and the drug-eluting stent.

METHODS

The PubMed, EMBASE, Web of Science, and Cochrane library databases were searched for studies published up to October 17, 2018. Studies comparing the drug-coated balloon with the drug-eluting stent strategy in patients with de novo small coronary artery vessel disease (reference diameter, <3 mm) were identified. The clinical outcomes were nonfatal myocardial infarction, cardiac death, all-cause death, target lesion revascularization, and target-vessel revascularization. Data were analyzed using the statistical software RevMan (version 5.3). Fixed effects models were performed to calculate the pooled odds ratios (ORs) and 95% confidence intervals (95% CIs). Sensitivity analyses were used to detect potential sources of heterogeneity, while subgroup analyses were implemented to assess the differential effects.

RESULTS

Three randomized controlled trials and 3 nonrandomized controlled studies were identified. Six studies including a total of 1800 patients compared the differences between the drug-coated balloon and the drug-eluting stent strategies in patients with de novo small coronary artery vessel disease. The results indicated that the drug-coated balloon strategy was associated with a significant reduction in nonfatal myocardial infarction (OR 0.53, 95% CI 0.31-0.90, P = .02) compared with the drug-eluting stent strategy, while insignificant inter-strategy differences were observed in cardiac death (OR 1.56, 95% CI 0.73-3.33, P = .25), all-cause death (OR 0.56, 95% CI 0.25-1.23, P = .15), target lesion revascularization (OR 1.24, 95% CI 0.73-2.1, P = .43), and target-vessel revascularization (OR 0.95, 95% CI 0.59-1.52, P = .84).

CONCLUSIONS

This meta-analysis suggests that the drug-coated balloon strategy is noninferior to the drug-eluting stent strategy, delivering a good outcome in nonfatal myocardial infarction, and can be recommended as an optimal treatment strategy in patients with de novo small coronary artery vessel disease. Larger randomized controlled studies with longer follow-up periods are needed to further confirm the benefits of the drug-coated balloon strategy.

Drug-Eluting Balloons and Drug-Eluting Stents in the Treatment of Peripheral Vascular Disease

In the last 20 years, peripheral artery disease (PAD) has been increasingly recognized as a significant cause of morbidity and mortality in the United States. The endovascular treatment of PAD has seen a marked rise as minimally invasive techniques and devices have been refined. Two newer devices, drug-eluting stents and drug-eluting balloons, are on the forefront of the battle against limb loss from PAD. This review focuses on the data backing the use of drug-eluting technologies for use in the peripheral arterial system.

Elastic fiber fragmentation increases transmural hydraulic conductance and solute transport in mouse arteries

Transmural advective transport of solute and fluid was investigated in mouse carotid arteries with either a genetic knockout of Fibulin-5 (Fbln5-/-) or treatment with elastase to determine the influence of a disrupted elastic fiber matrix on wall transport properties. Fibulin-5 is an important director of elastic fiber assembly. Arteries from Fbln5-/- mice have a loose, non-continuous elastic fiber network and were hypothesized to have reduced resistance to advective transport. Experiments were carried out ex vivo at physiological pressure and axial stretch. Hydraulic conductance (Lp ) was measured to be 4.99·10-6 ± 8.94·10-7, 3.18·-5 ± 1.13·10-5 (P < 0.01), and 3.57·10-5 ± 1.77·10-5 (P < 0.01) mm·s-1·mmHg-1 for wild-type, Fbln5-/-, and elastase-treated carotids, respectively. Solute fluxes of 4, 70, and 150 kDa FITC-dextran were statistically increased in Fbln5-/- compared to wild-type by a factor of 4, 22, and 3 respectively. 70 kDa FITC-dextran solute flux was similarly increased in elastase-treated carotids by a factor of 27. Solute uptake by Fbln5-/- carotids was decreased compared to wild-type for all investigated dextran sizes after 60 minutes of transmural transport. These changes in transport properties of elastic fiber compromised arteries have important implications for the kinetics of biomolecules and pharmaceuticals in arterial tissue following elastic fiber degradation due to aging or vascular disease.

Comprehensive analysis of predictive factors for rapid angiographic stenotic progression and restenosis risk in coronary artery disease patients underwent percutaneous coronary intervention with drug-eluting stents implantation

BACKGROUND

This study aimed to explore the correlation of baseline, procedural, and postprocedure characteristics with the risk of rapid angiographic stenotic progression (RASP) and restenosis in coronary artery disease (CAD) patients after percutaneous coronary intervention (PCI) with drug-eluting stents implantation.

METHODS

Two hundred fourteen CAD patients underwent PCI with drug-eluting stents implantation were consecutively enrolled. Baseline, procedural, and postprocedure characteristics of patients were collected for analysis. Coronary angiography was performed to evaluate coronary stenosis before PCI and at 12 months after PCI. RASP of nontarget lesions and restenosis of stent-implanted target lesions were then assessed.

RESULTS

37.8% CAD patients occurred RASP at 12 months after PCI and compared to non-RASP group, RASP group presented with increased diabetes mellitus (DM) complication, higher concentration of serum uric acid (SUA), cardiac troponin I, N-terminal probrain natriuretic peptide, and high sensitive C-reactive protein (hs-CRP) as well as elevated occurrence of multivessel artery lesions. In addition, DM, SUA, hs-CRP, and multivessel artery lesions independently predicted high RASP risk. For restenosis, 21.0% patients occurred restenosis at 12 months after PCI, and patients in restenosis group presented with increased hypertension and DM occurrence, higher concentrations of SUA, LDL-C, and hs-CRP, as well as longer target lesion and length of stent in surgery compared to nonrestenosis group. Also, DM, SUA, LDL-C, hs-CRP, and length of target lesion independently predicted increased restenosis risk.

CONCLUSION

Diabetes mellitus, SUA, and hs-CRP are potential predictive factors for increased risk of both RASP and restenosis in CAD patients underwent PCI and drug-eluting stents implantation.

Influence of Atrial Fibrillation on Outcomes in Patients Who Underwent Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Atrial fibrillation (AF) is a common co-morbidity among patients presenting with acute ST-segment elevation myocardial infarction (STEMI). Previously, small studies have reported an association between AF and poorer outcomes among patients with STEMI. We performed this study to investigate the impact of AF on in-hospital outcomes in patients with STEMI treated with primary percutaneous coronary intervention (PPCI) using a large national database. The study population constituted of patients 18 years and older with a primary discharge diagnosis of STEMI and who underwent PPCI. Using a 2:1 matching protocol, matched groups of patients with AF (N = 24,680) and without (N = 49,198) were developed. Among 1,493,859 patients with STEMI who underwent PPCI, 129,354 patients (8.7%) had AF. In the propensity-matched cohort, adjusted in-hospital mortality was significantly higher for patients with AF compared with patients with no AF (10.3% vs 9.4%) (adjusted odds ratio [OR] 1.10; confidence interval [CI] 1.06 to 1.16; p <0.0001). Patients with AF were also at higher risk of heart failure, cardiogenic shock, acute stroke, acute kidney injury, vascular complications, need for blood transfusion, and a composite outcome of gastrointestinal and retroperitoneal bleeding. Patients with AF were less likely to be treated with drug-eluting stent compared with patients without AF (51.4% vs 56.6%) (adjusted OR 0.81; CI 0.79 to 0.84; p <0.001). Among patients presenting with STEMI and who underwent PPCI, AF is present in about 8% of patients. In a propensity-matched analysis using a large national database, AF was found to be independently associated with a higher risk of in-hospital mortality and of other complications in these patients.