Ductus Arteriosus Stent Compared with Surgical Shunt for Infants with Ductal-Dependent Pulmonary Blood Flow: A Systematic Review and Meta-Analysis

The aim of this study was to perform a systematic review and meta-analysis to evaluate the safety and efficacy of ductus arteriosus stent (DAS) compared with surgical systemic-pulmonary artery shunt (SPS) in patients with ductal-dependent pulmonary blood flow. A literature search was conducted in PubMed, Embase, and the Cochrane Library databases from their inception to December 2020. Two reviewers independently screened the articles, evaluated the quality of the articles, and collected the data. Meta-analyses were conducted using fixed and random effects models. We used the I-square (I² ) test to examine heterogeneity and the funnel plot Egger’s test was used to test for publication bias. We analyzed nine studies including 842 patients were included in the present study (DAS: n = 295; SPS: n = 547). There was a benefit in favor of DAS group for medium-term mortality (RR, 0.63; 95% CI, [0.40, 0.99]; P = 0.91, I² = 0%). DAS group demonstrated a reduced risk for complications compared with SPS (RR, 0.46; 95% CI, [0.29, 0.72]; P = 0.78, I² = 0%). There was an increased risk for unplanned reintervention for DAS (RR, 1.77; 95% CI, [1.42, 2.20]; P = 0.61, I² = 0%). DAS demonstrated shorter mean intensive care unit length of stay (MD, –5.12; 95% CI, [–7.33, –2.91]; P = 0.005, I² = 76%). There was also demonstrated higher postprocedure oxygen saturation for SPS over DAS (MD, 1.78; 95% CI, [0.92, 2.64]; P = 0.46, I² = 0%). There was no difference between the two groups in terms of mortality within 30 days, Nakata Index, and hospital length of stay. Conclusions: In terms of initial palliative surgical in the ductal-dependent pulmonary blood flow, DAS demonstrated a lower risk of medium-term mortality, lower risk of complications, higher risk of unplanned reintervention, shorter ICU length of stay, and higher postprocedure oxygen saturation compared with SPS.     

Stent Implantation of the Arterial Duct in Newborns with a Truly Duct‐Dependent Pulmonary Circulation: A Single‐Center Experience with Emphasis on Aspects of the Interventional Technique

Introduction: Ductal stenting for pulmonary blood supply in newborns with cyanotic congenital heart disease (CHD) might be a low risk and safe alternative to the surgical aorto‐to‐pulmonary artery (AP) shunt in dual‐source lung perfusion. Ductal stenting in truly duct‐dependent pulmonary circulation has not been evaluated. Methods: Prospective interventional and clinical follow‐up trial. Ductal stenting based on variable access sites, a 2‐wire technique when crossing a tortuous ductus, and use of premounted coronary stents. Primary outcome measures were procedural success and complication rates presented as early and mid‐term results. Results: From 2003–2009, 58 duct‐dependent newborns underwent ductal stenting; 27 of them were truly duct dependent, 20 had pulmonary atresia (PA)/ventricular septum defect or complex CHD, 4 had PA/intact ventricular septum, 2 had PA with Ebstein anomaly, and 1 had PA with tricuspid atresia. Ductal stenting was performed without procedure‐related mortality; 3 of 27 required an acute surgical AP‐shunt (stent migration in 1, acute duct obstruction in 2). During mid‐term follow‐up, 4 of 24 needed an AP‐shunt and two others stent redilation. Three patients died prior to follow‐up surgery (1 unexpectedly at home and 2 due to syndromatic disease). Fifteen patients received staged univentricular palliation, 8 had a biventricular repair, and 1 is awaiting follow‐up operation. Conclusion: Ductal stenting is a feasible, safe, and effective palliation in newborns with truly duct‐dependent pulmonary circulation irrespective of duct morphology. Vasucular access from various locations is important for technical success rate. Ductal stenting is a minimally invasive procedure to achieve adequate pulmonary artery growth for subsequent palliative or corrective surgery. (J Interven Cardiol 2010;23:581–588)     

Occupational Hantavirus Infections in Agricultural and Forestry Workers: A Systematic Review and Metanalysis

Hantaviruses are zoonotic pathogens that can cause serious human disorders, including hemorrhagic fever with renal syndrome and hantavirus cardiopulmonary syndrome. As the main risk factor for human infections is the interaction with rodents, occupational groups such as farmers and forestry workers are reportedly at high risk, but no summary evidence has been collected to date. Therefore, we searched two different databases (PubMed and EMBASE), focusing on studies reporting the prevalence of hantaviruses in farmers and forestry workers. Data were extracted using a standardized assessment form, and results of such analyses were systematically reported, summarized and compared. We identified a total of 42 articles, including a total of 28 estimates on farmers, and 22 on forestry workers, with a total workforce of 15,043 cases (821 positive cases, 5.5%). A pooled seroprevalence of 3.7% (95% confidence interval [95% CI] 2.2–6.2) was identified in farmers, compared to 3.8% (95% CI 2.6–5.7) in forestry workers. Compared to the reference population, an increased occurrence was reported for both occupational groups (odds ratio [OR] 1.875, 95% CI 1.438–2.445 and OR 2.892, 95% CI 2.079–4.023 for farmers and forestry workers, respectively). In summary, our analyses stress the actual occurrence of hantaviruses in selected occupational groups. Improved understanding of appropriate preventive measures, as well as further studies on hantavirus infection rates in reservoir host species (rodents, shrews, and bats) and virus transmission to humans, is needed to prevent future outbreaks.     

Successful Treatment of a Stenosed Modified Blalock-Taussig Shunt Using a Palmaz-Schatz Stent: A Case Report

Case report of a 15-year-old white male with complex cyanotic heart disease and multiple cardiac surgery including bilateral modified Blalock-Taussig shunt. The patient developed worsening cyanosis and exercise intolerance for the last several months. He underwent percutaneous balloon angioplasty and placement of a PS 204 Palmaz-Schatz balloon expandable stent for correction of severe stenosis at the junction of the right subclavian artery and a 6-mm interposition Gore-Tex graft. Since he was not a candidate for definitive surgery, this palliative procedure was performed to avoid repeat thoracotomy and to provide long-term relief of the stenosis. Stent placement in children can be challenging due to vascular access and complex anatomy. We suggest long-term follow-up to validate the success of this procedure.     

Growth of the Pulmonary Valve Annulus after the Modified Blalock-Taussig Shunt in Patients with Tetralogy of Fallot

Background: The surgical outcomes of tetralogy of Fallot (TOF) have evolved dramatically and have resulted in lower mortality rate. Currently, the many cardiac centers have a trend to early single-stage complete repair more than a staged repair. However, the patients who have an early primary repair were required transannular patch augmentation of a pulmonary valve frequently. This effect has been developed a chronic pulmonary insufficiency may lead to right ventricular dilation, dysfunction. In this era, the aim of treatment of TOF is attempted to preserve pulmonary valve annulus for prevent right ventricular dysfunction in the future. The systemic to pulmonary artery shunt is a palliative procedure or known as staged repair for symptomatic patients with TOF. The modified Blalock-Taussig shunt (mBTS) is the most useful systemic to pulmonary shunt and perform as an initial procedure before complete repair. The mBTS can provide increase pulmonary blood flow as well as improve oxygenation and also promote pulmonary artery (PA) growth. However, the effect of this procedure to promote growth of a pulmonary valve annulus is still debate. Objectives: To compare a growth of pulmonary valve annulus between after staged repair and primary repair in patients with TOF (without pulmonary atresia). Methods: A retrospective case-control study, review of patients with TOF underwent total repair at our hospitals from January 2005 and December 2017 was performed, a total number of 112 patients underwent TOF repair. Twenty-nine patients (26%) underwent a staged repair (mBTS group) and 83 (74%) underwent total repair only or primary repair (PR group). We evaluated diameter of pulmonary valve annulus by using echocardiography at the time of first diagnosis and before complete repair on both groups. Results: The age of diagnosis of mBTS group were younger than PR group (p = 0.011). Therefore, pulmonary valve annuls were smaller in mBTS group. (Z-score, −2.93 ± 1.42 vs. −1.89 ± 0.97; p = 0.001). However, the growth potential of pulmonary valve annulus was increase more than PR group significantly (Z-score, −1.46 ± 1.02 vs. −2.11 ± 1.19; p = 0.009) Even though a patent ductus arteriosus was found commonly in PR group (p = 0.018). Conclusions: Our results suggest the systemic to pulmonary shunt or mBTS can promote growth of pulmonary valve annulus in patients with TOF.     

Papillary Fibroelastoma of the Pulmonary Valve – A Systematic Review

The pulmonary valve is the least affected site for valvular papillary fibroelastoma. With increasing use of routine echocardiography and other modalities of imaging, pulmonary valve papillary fibroelastomas (PVPFE) are being recognized more frequently. PVPFE is more often an incidental diagnosis and symptomatic patients usually present with shortness of breath. Embolic phenomena and right ventricular outflow tract obstruction are the most serious complications of PVPFE. Since PVPFE is rare, the purpose of this systematic review is to address demographic characteristics, the clinical presentation, management, and outcome of this benign tumor of the pulmonary valve.     

Midterm Outcome of Stent Dilatation of Patent Ductus Arteriosus in Ductal‐dependent Pulmonary Circulation

Objective. We sought to assess the outcome of transcatheter ductus arteriosus stenting in newborns with ductal‐dependent pulmonary circulation. Background. Better results of ductal stenting have been reported using stents with better scaffolding and ensuring stenting of the entire length of the ductus arteriosus. Methods. Twenty‐one patients with ductal‐dependent pulmonary circulation were brought to the catheterization laboratory for ductal stenting. Five patients did not qualify because of a complex tortuous ductus arteriosus or branch pulmonary artery stenosis. Stent implantation was successful in 14 patients. The duct was accessed with a 0.014‐inch guidewire. A low profile premounted coronary stent was implanted in the duct without using a long delivery sheath. Attempts were made to cover the entire length of the ductus arteriosus. Results. The mean age of the patients at the time of stent implantation was 24 ± 17.5 days. The mean body weight was 2.9 ± 0.35 kg. The ductus was mildly tortuous in four, moderately tortuous in four, conical in four, and vertical in four patients. Ductal stenting was successful in 14 patients. The mean ductal diameter was 3.9 ± 0.5 mm. The mean diameter and the length of the stent implanted were 3.9 ± 0.72 and 15.4 ± 3.16 mm, respectively. Mean fluoroscopy and procedure times were 22.16 ± 12.5 and 107.9 ± 34.5 minutes, respectively. Out of the 14 successful stent implantations, the ductus arteriosus was not completely covered with the stent in five patients at the time of primary procedure, four of them required re‐stenting for significant desaturation. One of these patients died despite successful re‐stenting. Another patient died due to aspiration pneumonia. Of the 12 survivors, five underwent Glenn shunt (two deaths related to pulmonary hypertension), two underwent biventricular repair, one patient was lost to follow‐up, and the remaining four are doing well with a mean oxygen saturation of 85% at a mean follow‐up of 13 ± 6 months. Conclusion. Stenting of ductus arteriosus, including moderately tortuous ducts, is a safe palliation for patients with ductal‐dependent pulmonary circulation. Incomplete stenting of the duct invariably results in ductal stenosis and compromised pulmonary flow.     

Longevity of Neonatal Ductal Stenting for Congenital Heart Diseases with Duct‐dependent Pulmonary Circulation

Introduction. Ductal stent (DS) in duct‐dependent pulmonary circulation is less morbid than neonatal Blalock–Taussig shunt. However, there is concern if DS provides an adequately long palliation before definitive repair. Methods. This is a retrospective review of clinical follow‐up of all consecutive infants after successful DS performed by a single operator. They were divided into three anatomic groups. Group A neonates had balloon valvotomy for critical pulmonary stenosis or pulmonary atresia with intact ventricular septum, who needed DS patency until the right ventricle was adequate to provide antegrade pulmonary flows. Group B patients with tetralogy of Fallot and pulmonary atresia suited for later biventricular repair needed ductal patency until conduit surgery was completed. Group C patients with functionally univentricular hearts needed DS patency until bidirectional Glenn shunt completion. Results. Among 22 infants, four Group A patients followed for 26–54 months after balloon pulmonary valvotomy had adequate oxygen saturation and needed only short‐term DS patency. In six out of nine Group B patients, corrective biventricular repair using conduits was performed after 5–14 months at a body weight of 5–7.5 kg. Bidirectional Glenn shunt and confluence repair were performed in seven of nine Group C patients weighing 6–8.5 kg after 8–15 months. The hilar pulmonary artery growth in B and C groups was adequate for surgical repair. No patient needed stent redilatations or additional shunts on follow‐up for hypoxia. Four patients had sudden death. Conclusions. The short‐term patency of DS was adequate after balloon valvotomy for critical pulmonary stenosis or pulmonary atresia with intact ventricular septum. Duration of palliation by DS was also sufficient in univentricular hearts to allow adequate somatic growth before Glenn surgery. In patients with biventricular anatomy treated by DS, conduit repair had to be performed at a relatively early age. Interstage mortality was 18%.     

CT-Base Pulmonary Artery Measurementin the Detection of Pulmonary Hypertension: A Meta-Analysis and Systematic Review

To summarize the performance of CT-based main pulmonary artery diameter or pulmonary artery to aorta ratio (PA:A ratio) measurement in detection of pulmonary hypertension by a systematic review and meta-analysis.A comprehensive literature search was performed to identify studies determining diagnostic accuracy of main pulmonary artery diameter or PA:A ratio measurement for pulmonary hypertension. The Quality Assessment of Diagnostic Accuracy Studies tool was used to assess the quality of the included studies. A bivariate random-effects model was used to pool sensitivity, specificity, positive/negative likelihood ratio (PLR/NLR), and diagnostic odds ratio (DOR). Summary receiver operating characteristic (SROC) curves and area under the curve (AUC) were used to summarize overall diagnostic performance.This meta-analysis included 20 publications involving 2134 subjects. Summary estimates for main pulmonary artery diameter measurement in the diagnosis of pulmonary hypertension were as follows: sensitivity, 0.79 (95% CI 0.72–0.84); specificity, 0.83 (95% CI 0.75–0.89); PLR, 4.68 (95% CI 3.13–6.99); NLR, 0.26 (95% CI 0.20–0.33); DOR, 18.13 (95% CI 10.87–30.24); and AUC 0.87. The corresponding summary performance estimates for using the PA:A ratio were as follows: sensitivity, 0.74 (95% CI 0.66–0.80); specificity, 0.81 (95% CI 0.74–0.86); PLR, 3.83 (95% CI, 2.70–5.43); NLR, 0.33 (95% CI 0.24–0.44); DOR, 11.77 (95% CI 6.60–21.00); and AUC 0.84.Both main pulmonary artery diameter and PA:A ratio are helpful for diagnosing pulmonary hypertension. Nevertheless, the results of pulmonary artery measurement should be interpreted in parallel with the results of traditional tests such as echocardiography.     

Endoscopic Treatment of Large Bile Duct Stones: A Systematic Review and Network Meta-Analysis

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An International Comparison of Pulmonary Rehabilitation: A Systematic Review

Background: Despite the strong evidence base, the perception remains that the provision of pulmonary rehabilitation (PR) services are extremely limited. Imbalances in PR delivery give rise to unnecessary health costs and underserviced populations. We conducted a systematic review to characterize the international provision of PR, comparing its structure and delivery across countries, and gaining insight into the availability of PR in relation to geographical prevalence. Methods: Electronic databases were searched from inception to September 2013 using the key words “pulmonary rehabilitation” and “survey.” Two authors independently reviewed studies and assessed study quality. Data was extracted and double-checked to ensure accuracy. Results: The majority of programs (55–99%) were offered in an outpatient setting with the exception of Ireland, where the majority of programs were offered in the community (65%). Exercise was the primary component across all programs (77–100%), followed by education (74–100%). Physical therapists were the most common member of the PR team (49–100%). Functional walk tests were the most frequently used outcome measure, although the specific test utilized varied across countries. The current availability of PR services ≤1.2% of individuals with COPD. Conclusion: Components provided in PR are similar, irrespective of country, while patient outcome measures demonstrated variation across countries. Recent surveys report the use of community resources for the delivery of PR programs, although the majority are outpatient based. The small number of potential individuals enrolled in PR suggests that an international increase in access and capacity would improve quality of life and reduce healthcare utilization in this population.     

Fate of Hypoplastic Pulmonary Arteries After Arterial Duct Stenting in Congenital Heart Disease With Duct-Dependent Pulmonary Circulation

ObjectivesThis study sought to evaluate the impact of arterial duct (AD) stenting in promoting catch-up growth of hypoplastic pulmonary artery (PA) tree in congenital heart disease with duct-dependent pulmonary circulation (CHD-DPC).BackgroundSignificant and balanced PA growth following AD stenting has already been consistently reported in the literature. However, no data are so far available about the role of this approach in severe PA hypoplasia, which significantly impacts the risk of surgical repair.MethodsPre-surgical angiographic PA evaluation was performed in 45 patients with confluent PAs submitted to neonatal AD stenting as palliation of CHD-DPC. PA growth was evaluated as Nakata Index and McGoon ratio as well as individual PA z-score changes, both in the whole population and according to the original vessel size (Nakata Index <100 mm²/m², Group I [n = 15] vs. Nakata Index >100 mm²/m², Group II [n = 30]).ResultsControl angiography was performed 7.5 ± 6.5 months (median 6 months) after duct stenting, showing significant and balanced PA growth. The Nakata Index increased from 143 ± 73 mm²/m² to 270 ± 88 mm²/m² (124 ± 118%, p < 0.0001); left PA z-score from −0.7 ± 1.7 to 1.0 ± 1.4; right PA z-score from −0.6 ± 1.3 to 1.2 ± 1.3 (p < 0.0001 for both comparisons). Group I showed a greater increase of global PA growth (Nakata Index increase 227 ± 141% vs. 72 ± 57%, p < 0.001) as compared with Group II. Final PA size did not significantly differ between the groups (246 ± 105 mm²/m² vs. 282 ± 78 mm²/m², p = NS).ConclusionsPercutaneous AD stenting is highly effective in promoting a significant and balanced catch-up growth of diminutive PAs, being therefore advisable in this subset of patients as a reliable alternative to surgical palliation.     

Pulmonary Hypertension Predicts Adverse Outcomes in Renal Patients: A Systematic Review and Meta‐Analysis

In the general population and in heart disease, pulmonary hypertension (PH) is a strong and independent risk factor for mortality and adverse cardiovascular outcomes. We performed a systematic review and meta‐analysis of longitudinal cohort studies of individuals with chronic kidney disease (CKD) of any‐stage (also including end‐stage kidney disease and kidney transplantation) stratified according to presence/absence of PH. Eighteen eligible studies (10 740 participants) were retrieved. PH had an overall pooled prevalence of 33% (95% CI 28–42) and portended a higher risk of all‐cause mortality (RR 2.08; 1.06–4.08), cardiovascular mortality (RR 3.77; 2.46–5.78) and non‐fatal cardiovascular events (RR 1.60; 1.28–1.99). PH is highly prevalent in CKD and end‐stage kidney disease and may represent a novel factor for mortality and cardiovascular risk stratification, particularly in selected sub‐categories. Future high‐quality research is required to confirm the need for clinical attention on PH in the CKD setting.     

Prevalence and Mortality of Pulmonary Hypertension in ESRD: A Systematic Review and Meta-analysis

Lung - Pulmonary hypertension (PH) in the setting of end-stage renal disease (ESRD) has important prognostic and therapeutic consequences. We estimated the prevalence of PH among patients with ESRD...     

Coronary Stent Thrombosis in COVID-19 Patients: A Systematic Review of Cases Reported Worldwide

Approximately 5 million percutaneous coronary interventions are performed worldwide annually. Therefore, stent-related complications pose a serious public health concern. Stent thrombosis, although rare, is usually catastrophic, often associated with extensive myocardial infarction or death. Because little progress has been made in outcomes following stent thrombosis, ongoing research is focusing on further understanding the predictors as well as frequency and timing in various patient subgroups. Coronavirus disease-2019 (COVID-19), a viral illness caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), activates inflammatory mechanisms that potentially create a prothrombotic environment and increases the risk of local micro thromboembolism and all types of stent thrombosis. In-stent thrombosis occurrence increased during the COVID-19 pandemic, however, there is still lack of comprehensive studies describing this population. This review and worldwide analysis of coronary stent thrombosis cases related to COVID-19 summarizes all available data.     

A Systematic Review of the Diagnostic Accuracy of Cardiovascular Magnetic Resonance for Pulmonary Hypertension

Background

The diagnostic accuracy of cardiovascular magnetic resonance (CMR) for pulmonary hypertension (PH) compared with right heart catheterization were assessed. The purpose of this systematic review was to comprehensively evaluate the diagnostic accuracy of CMR in evaluating PH.

Methods

Published literature was obtained from PUBMED, Web of Knowledge, Cochrane library, Embase, Biosis Preview, China National Knowledge Infrastructure, and Chongqing VIP databases, and all studies were inclusive until December 2012. Studies relevant to PH and its imaging in CMR and right heart catheterization were included if correlation coefficient was elucidated clearly. Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) score was used to assess the quality of studies. Sensitivity and specificity were pooled separately and compared with overall accuracy measures: diagnostic odds ratio and symmetric summary receiver operating characteristic.

Results

Sixteen studies were included in the systematic review. Of all the studies, the most widely used index was ventricular mass index (VMI) of CMR. We performed a meta-analysis for VMI among 429 patients in 5 individual studies, which showed a modest diagnostic accuracy of VMI for PH with a summary sensitivity and specificity of 84% (95% confidence interval, 79%-87%) and 82% (95% confidence interval, 73%-89%), respectively. In addition, the summary positive likelihood ratio was 4.894, indicating that VMI of CMR allows a modest ability to distinguish PH patients from healthy subjects with a cutoff point of 0.45 using functional and structural measures.

Conclusions

This systematic review and meta-analysis indicates that VMI seems to have a moderate sensitivity and specificity for detection of PH. The application values of other parameters still need further investigation.     

Early Postinterventional Stent Stenosis of a Ductus Stent Implanted for Palliation in a Newborn with Pulmonary Atresia with Intact Ventricular Septum: Successful Management with Bailout Stenting

A newborn with pulmonary atresia with intact ventricular septum (PA-IVS) was treated with radiofrequency current perforation of the atretic pulmonary valve. As the right ventricle was hypoplastic (z-value of the tricuspid valve: —4) the arterial duct was stented with a Gianturco-Roubin GR II stent. Early postinterventionally, the patient became cyunotic and compromised blood flow across the stented ductus arteriosus despite adequate stent position was detected echographically. The newborn was treated successfully with the implantation of a Palmaz stent (Johnson & Johnson Interventional Systems, Warren, NJ, USA) into the obstructed Gianturco-Roubin GR II stent. The Gianturco-Roubin GR II stents might be associated with the risk of early stent stenosis after implantation in actively contracting tissues like the ductus arteriosus. In patients with early stent stenosis after ductal stenting, bailout implantation of a subsequent stent can be performed. Transcatheter procedures can be effective means for therapy of PA-IVS . (J Interven Cardiol 2000;13:39–44)     

Silent Pulmonary Embolism in Patients with Deep Venous Thrombosis: A Systematic Review

Purpose

To determine, by systematic review of the literature, the prevalence of silent pulmonary embolism in patients with deep venous thrombosis.

Methods

Twenty-eight included published investigations were identified through PubMed. Studies were selected if methods of diagnosis of pulmonary embolism were described; if pulmonary embolism was stated to be asymptomatic; and if raw data were presented. Studies were stratified according to whether silent pulmonary embolism was diagnosed by a high-probability ventilation-perfusion lung scan using criteria from the Prospective Investigation of Pulmonary Embolism Diagnosis, computed tomography pulmonary angiography, or conventional pulmonary angiography (Tier 1), or by lung scans based on non-Prospective Investigation of Pulmonary Embolism Diagnosis criteria (Tier 2).

Results

Silent pulmonary embolism was diagnosed in 1665 of 5233 patients (32%) with deep venous thrombosis. This is a conservative estimate because many of the investigations used stringent criteria for the diagnosis of pulmonary embolism. The incidence of silent pulmonary embolism was higher with proximal deep venous thrombosis than with distal deep venous thrombosis. Silent pulmonary embolism seemed to increase the risk of recurrent pulmonary embolism: 25 of 488 (5.1%) with silent pulmonary embolism versus 7 of 1093 (0.6%) without silent pulmonary embolism.

Conclusion

Silent pulmonary embolism sometimes involved central pulmonary arteries. Because approximately one third of patients with deep venous thrombosis have silent pulmonary embolism, routine screening for pulmonary embolism may be advantageous.     

Coronary Intravascular Brachytherapy for Recurrent Coronary Drug-Eluting Stent In-Stent Restenosis: A Systematic Review and Meta-Analysis

ObjectiveTo examine the outcomes with intravascular brachytherapy (IVBT) in recurrent in-stent restenosis (ISR).BackgroundRecurrent ISR can be challenging to treat and IVBT can be used for recurrent ISR but has received limited study.MethodsWe performed a systematic review and meta-analysis of five observational studies, including 917 patients (1014 lesions) with recurrent ISR, defined as having at least two prior ISR episodes with previous treatment with a stent, who underwent treatment with IVBT. Outcomes of interest included target vessel revascularization (TVR), myocardial infarction (MI), and all-cause mortality.ResultsDuring a mean follow-up of 24 ± 7 months, the incidence of TVR was 29.2% (95% CI 18.0–40.4%). The incidence of MI and all-cause mortality were 4.3% (95% CI 1.7%–6.9%) and 7.3% (95% CI 3.2–11.5%), respectively. At one- and two-years after PCI the incidence of TVR was 17.5% (95% CI 13.6%–21.4%) and 26.7% (95% CI 16.6%–36.9%), respectively and the incidence of MI was 3.1% (95% CI 2–4.2%) and 3.9% (95% CI 1–6.8%), respectively.ConclusionIntravascular brachytherapy can be used to treat recurrent ISR, although TVR is needed in approximately one of four patients at two years.