Long-Term Outcomes With Drug-Eluting Balloon for the Treatment of In-Stent Restenosis and De Novo Lesions: The Novara-Biella-Trento (NOBITRE) Registry

Drug-coated balloons (DCBs) have emerged for percutaneous coronary interventions (PCI) of in-stent restenosis or particular anatomical subsets. We provide a real-world analysis of the prognostic determinants and long-term outcomes of patients treated with DCB for any lesion in a comprehensive multicenter registry. The primary study endpoint was the occurrence of major cardiovascular events (MACE: composite of all-cause death, myocardial infarction, and target vessel revascularization) at the longest available follow-up. We included 267 patients (196 treated for in-stent restenosis and 71 for de novo lesions), with a median follow-up of 616 [368–1025] days. MACE occurred in 70 (26.2%) of the patients and related with higher rates of in-stent restenosis (P = .04), longer and more type C lesions ( P = .05 and P = .04). At multivariate Cox-regression, type C lesions emerged as the only independent predictor of MACE (adjusted OR [95% CI] = 1.83[1.13–2.97], P = .014), mainly driven by target vessel revascularization (adjusted OR[95% CI] = 1.78[1.05–2.95], P = .03) not conditioning survival. In-stent restenosis emerged as major determinant of TLF (adjusted OR[95% CI] = 2.59[1.17–5.75], P = .02). DCBs represent a treatment option for any lesion; however, type C and restenotic lesions are associated with an increased risk of MACE and target lesion failure, where the optimal strategies for patients’ selection and lesion preparation are still undefined.

In-stent restenosis of drug-eluting stents in patients with diabetes mellitus: Clinical presentation, angiographic features, and outcomes

OBJECTIVE

Diabetes mellitus (DM) is a risk factor for developing in-stent restenosis (ISR) following percutaneous coronary intervention (PCI). This study aimed to examine the presentation and outcomes of drug-eluting stent (DES) ISR in diabetics.

METHODS

This retrospective study included consecutive patients with clinical DES-ISR, who were hospitalized between January 2013 and December 2017 and who were grouped based on the presence or absence of DM. Clinical, angiographic features and 1-year outcomes [composite of death, myocardial infarction (MI), and repeat-target lesion revascularization] were compared.

RESULTS

Baseline characteristics of the DM group (n=109) were comparable to the non-DM group (n=82), except for the higher prevalence of hypertension and dyslipidemia in the former (60.6% vs. 46.3%, p=0.050; 74.4% vs. 57.8%, p=0.034, respectively). Clinical presentation was similar in both groups [acute coronary syndrome (ACS): 62.4% vs. 61%, p=0.843; MI: 34.9% vs. 34.1%, p=0.918). Diabetics had a higher prevalence of stent-edge restenosis (20.3% vs. 9.2%, p=0.019). The treatment strategy was similar in both groups with 52.3% in the DM group and 57.3% in the non-DM group undergoing PCI (p=0.513). One-year outcomes of the DM group were not different from those of the non-DM group (14.7% vs. 17.1%, p=0.683). Age [hazard ratio (HR), 1.05; 95% confidence interval (CI), 1.01-1.10; p=0.017], MI presentation (HR, 2.34; 95% CI, 1.14-4.80; p=0.020), and chronic kidney disease (CKD: HR, 2.82; 95% CI, 1.21-6.58; p=0.016) were predictors of poor outcomes.

CONCLUSION

Stent-edge restenosis is more common in diabetics. Clinical presentation and 1-year outcomes following DES-ISR are similar in diabetics and non-diabetics. Age, MI presentation, CKD, and not DM were predictors of poor outcomes following DES-ISR.

In-stent restenosis of drug-eluting stents: clinical presentation and outcomes in a real-world scenario

BACKGROUND

Drug-eluting stents (DES) have substantially reduced the incidence of coronary in-stent restenosis (ISR), but the problem persists. Clinical presentation and outcomes of DES-ISR in a real-world scenario remains underreported.

RESULTS

In this retrospective study, we examined medical records of 191 consecutive patients with DES-ISR (210 ISR lesions) hospitalized between January 2013 and December 2017. ISR clinical presentation was classified as acute coronary syndrome (ACS) or non-ACS. Clinical, angiographic features and 1-year outcomes [composite of death, myocardial infarction (MI) and repeat-target lesion revascularization] for these two groups were compared. The mean age of study population was 61 ± 10 years and 81.2% were males. ACS was the dominant clinical presentation mode occurring in 118 (61.8%) patients. MI was seen in 66 (34.6%) patients. Female gender (odds ratio, 2.71; 95% confidence interval [CI], 1.13-6.52; P = 0.026) and chronic kidney disease (odds ratio, 3.85; 95% CI, 1.05-14.20; P = 0.043) correlated significantly with ACS ISR presentation. A majority [104 (54.5%)] of patients underwent percutaneous coronary intervention (PCI), of whom 72 (69.2%) received a new DES. The rest either underwent CABG (26.2%) or received medical therapy (19.4%). Patients presenting with ACS had a significantly worse clinical outcome at 1-year follow-up (ACS versus non-ACS presentation: hazard ratio [HR], 2.66; 95% CI, 1.09-6.50; P = 0.032).

CONCLUSIONS

DES-ISR presents most commonly as ACS. Female gender and chronic kidney disease seem to be associated with ACS presentation. ACS presentation of ISR is associated with worse 1-year outcomes. Early identification of those with ACS risk and closer follow-up may improve outcomes.

Effect of combination of non-slip element balloon and drug-coating balloon for in-stent restenosis lesions (ELEGANT study)

BACKGROUND

In-stent restenosis (ISR) remains a problematic issue of coronary intervention. The non-slip element balloon (NSE) is a balloon catheter with 3 longitudinal nylon elements which are attached proximally and distally to the balloon component. The expectation is that this design of balloon is able to achieve a larger lumen area due to the elements, as well as reducing balloon slippage. We investigated whether NSE pre-dilatation improves angiographic outcomes compared to a high pressure non-compliant balloon pre-dilatation, followed by a drug-coating balloon (DCB) for treatment of ISR lesions with optical coherence tomographic imaging (OCT).

METHODS

Patients were eligible for the study if one or more in-stent restenosis lesions were treated with a paclitaxel-coating balloon. Patients were randomized to NSE pre-dilatation (NSE group) or high pressure non-compliant balloon pre-dilatation (POBA group) in a 1:1 fashion in 17 hospitals. The primary endpoint was in-segment late loss [post minimal lumen diameter (MLD)-follow-up MLD] at 8 months.

RESULTS

One hundred and five patients were allocated to each group. Balloon slippage (7.9% versus 22.9%, p=0.002) and geographical miss (6.9% versus 21.9%, p=0.002) were observed less in the NSE group compared to the POBA group. Acute gain was significantly larger in the NSE group (1.17±0.42mm versus 1.06±0.35mm, p=0.04), but post minimum stent lumen area analyzed by OCT was similar between the two groups (3.85±1.67mm² versus 3.81±1.93mm², p=0.64). At 8 months, average lesion length was significantly shorter than the POBA group (5.78±3.26mm versus 6.97±4.59mm, p=0.04), but average in-segment late loss was similar between the two groups (0.28±0.45mm versus 0.27±0.38mm, p=0.75).

CONCLUSION

Eight-month angiographic outcomes were similar between NSE and non-compliant balloon pre-dilatation with DCB for treatment of ISR lesions. However, NSE pre-dilatation has advantages such as reduction of balloon slippage and geographical miss during the procedure.

Do outcomes following intervention for drug-eluting stent restenosis depend on whether the restenosed stent was polymer-free or polymer-coated?

INTRODUCTION AND OBJECTIVES

Outcomes of patients undergoing percutaneous intervention for drug-eluting stent (DES) restenosis are poorer than those in patients with bare-metal stent restenosis. It is unknown if this is related to the presence of polymer coating. We sought to compare outcomes after interventions for in-stent restenosis (ISR) of polymer-free DES vs durable polymer DES.

METHODS

Patients enrolled in the ISAR-TEST 5 randomized trial who underwent repeat percutaneous intervention for ISR during follow-up were included. Angiographic outcomes at 6 to 8 months and clinical outcomes at 2 years were analyzed and compared between 2 groups according to whether the restenosed stent was a polymer-free or a durable polymer DES. Multivariate analysis was used to adjust for differences between groups.

RESULTS

A total of 326 patients with ISR were included: 220 with ISR in polymer-free DES and 106 with ISR in durable polymer DES. Angiographic follow-up was available for 83.4% of patients. No difference was observed in recurrent binary restenosis between the 2 groups (31.7% vs 27.0%; P=.38; P_adjusted=.29). At 2 years, the composite of death, myocardial infarction, or repeat target lesion revascularization were similar between the 2 groups (35.7% vs 34.0%; HR=1.04, 95%CI, 0.70-1.55; P=.83; P_adjusted=.79). The rate of repeat target lesion revascularization was also similar in the 2 groups (29.8% vs 31.5%; HR=0.91, 95%CI, 0.60-1.39; P=.68; P_adjusted=.62).

CONCLUSIONS

In patients undergoing reintervention for DES-ISR, we found no evidence of differences in outcomes according to whether the restenosed stent was a polymer-free or durable polymer DES.

Drug-eluting balloon versus second-generation drug-eluting stent for the treatment of restenotic lesions involving coronary bifurcations

AIMS

To report clinical outcomes in patients treated with drug-eluting balloon (DEB) versus second-generation drug-eluting stent (DES) for in-stent restenosis (ISR) involving a bifurcation lesion.

METHODS AND RESULTS

Between February 2007 and November 2012, 167 bifurcation restenoses in 158 patients were treated with either DEB (n=73) or second-generation DES (n=85). The EuroSCORE was significantly higher in the DEB group (4.2±3.8 vs. 2.8±2.1, p=0.004). Regarding restenosed stent type, second-generation DES was more frequently seen in the DEB group (26.9% vs. 6.7%, p<0.001). In this group, there was also a trend towards more frequent stenting for a previous ISR (stent-in-stent) as compared with the DES group (25.6% vs. 15.6%, p=0.074). Over a median follow-up period of 701 days, there was no significant difference in major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction including periprocedural myocardial infarction, target vessel revascularisation, between the two groups (p=0.585). Independent predictors of MACE on multivariate Cox regression analysis included stent-in-stent (HR: 2.16; 95% CI: 1.11 to 4.20; p=0.023) and true bifurcation lesions (HR: 2.98; 95% CI: 1.45 to 6.14; p=0.001).

CONCLUSIONS

DEB for bifurcation restenosis may be an acceptable treatment option, especially in cases where repeat stenting has not already been performed for the treatment of a previous restenosis.

Performance of dual-source CT with high pitch spiral mode for coronary stent patency compared with invasive coronary angiography

OBJECTIVE

To investigate the performance of dual-source computed tomography (DSCT) using high-pitch spiral (HPS) mode for coronary stents patency.

METHODS

We conducted a prospective study on 120 patients with 260 previous stents implanted due to recurred suspicious symptoms of angina scheduled for invasive coronary angiography (ICA), while DSCT were conducted using HPS mode.

RESULTS

There was no significant impact of age, body mass index or heat rate (HR) on image quality (P > 0.05), while HR variability had a slight impact on that (P < 0.05). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of DSCT in detection of in-stent restenosis (ISR) based per-patient were 92.3%, 96.7%, 88.9%, and 97.8%, respectively. And those based per-stent were 87%, 96.8%, 83.3%, and 97.7% with un-assessment stents, 97.4%, 99.5%, 97.4%, and 99.5% without un-assessment stents. There was significant difference on sensitivity, specificity, PPV and NPV between diameter ≥ 3.0 mm group (93.3%, 97.9%, 87.5%, and 98.9%) and diameter < 3.0 mm group (80%, 93.3%, 80.0%, and 93.3%) (P < 0.05), and that between stent number ≥ 3 group (82.3%, 77.8%, 66.7%, and 60%) with < 3 group (97.3%, 80%, 96.5%, and 75%). The effective dose of DSCT (1.4 ± 0.5 mSv) is significantly less than that by invasive coronary angiography [4.0 ± 0.8 mSv (P < 0.01)].

CONCLUSION

DSCT using HPS mode provides good diagnostic performance on stent patency with lower effective dose in patients with HR < 65 beats/min.

Clinical Presentation and Outcomes of Coronary In-Stent Restenosis Across 3-Stent Generations

Background—

Clinical presentation of bare metal stent in-stent restenosis (ISR) in patients undergoing target lesion revascularization is well characterized and negatively affects on outcomes, whereas the presentation and outcomes of first- and second-generation drug-eluting stents (DESs) remains under-reported.

Methods and Results—

The study included 909 patients (1077 ISR lesions) distributed as follows: bare metal stent (n=388), first-generation DES (n=425), and second-generation DES (n=96), categorized into acute coronary syndrome (ACS) or non-ACS presentation mode at the time of first target lesion revascularization. ACS was further classified as myocardial infarction (MI) and unstable angina. For bare metal stent, first-generation DES and second-generation DES, ACS was the clinical presentation in 67.8%, 71.0%, and 66.7% of patients, respectively ( P =0.470), whereas MI occurred in 10.6%, 10.1%, and 5.2% of patients, respectively ( P =0.273). The correlates for MI as ISR presentation were current smokers (odds ratio, 3.02; 95% confidence interval [CI], 1.78–5.13; P <0.001), and chronic renal failure (odds ratio, 2.73; 95% CI, 1.60–4.70; P <0.001), with a protective trend for the second-generation DES ISR (odds ratio, 0.35; 95% CI, 0.12–1.03; P =0.060). ACS presentations had an independent effect on major adverse cardiac events (death, MI, and re-target lesion revascularization) at 6 months (MI versus non-ACS: adjusted hazard ratio, 4.06; 95% CI, 1.84–8.94; P <0.001; unstable angina versus non-ACS: adjusted hazard ratio, 1.98; 95% CI, 1.01–3.87; P =0.046).

Conclusions—

ISR clinical presentation is similar irrespective of stent type. MI as ISR presentation seems to be associated with patient and not device-related factors. ACS as ISR presentation has an independent effect on major adverse cardiac events, suggesting that ISR remains a hazard and should be minimized.

Update on interventional cardiology 2013

The present article reviews the most important publications and studies in the field of interventional cardiology in 2013. Coronary interventions for ST-segment elevation myocardial infarction are among the most important, with studies that assess different devices and pharmacologic and mechanical strategies in primary angioplasty. Increasingly large groups of patients (with diabetes, of advanced age) and the best coronary revascularization strategy are also the focus of exhaustive research. Percutaneous procedures in the left main coronary artery continue to give rise to a significant number of publications, both because of the results of using different types of stent and because of the intravascular imaging techniques used to guide procedures and the results of their use. New bioabsorbable polymer-coated drug-eluting stents or bioresorbable drug-eluting scaffolds are being compared with second-generation drug-eluting stents to show their efficacy in preventing restenosis and reducing incidence of late thrombosis. Percutaneous treatment of structural heart disease continues to produce many publications, especially regarding percutaneous aortic prostheses, but also on closure of foramen ovale and of left atrial appendage. Finally, renal denervation continues to arouse much interest in the medical literature.

A Semiparametric Bivariate Probit Model for Joint Modeling of Outcomes in STEMI Patients

In this work we analyse the relationship among in-hospital mortality and a treatment effectiveness outcome in patients affected by ST-Elevation myocardial infarction. The main idea is to carry out a joint modeling of the two outcomes applying a Semiparametric Bivariate Probit Model to data arising from a clinical registry called STEMI Archive. A realistic quantification of the relationship between outcomes can be problematic for several reasons. First, latent factors associated with hospitals organization can affect the treatment efficacy and/or interact with patient's condition at admission time. Moreover, they can also directly influence the mortality outcome. Such factors can be hardly measurable. Thus, the use of classical estimation methods will clearly result in inconsistent or biased parameter estimates. Secondly, covariate-outcomes relationships can exhibit nonlinear patterns. Provided that proper statistical methods for model fitting in such framework are available, it is possible to employ a simultaneous estimation approach to account for unobservable confounders. Such a framework can also provide flexible covariate structures and model the whole conditional distribution of the response.