Stent strut fracture-induced restenosis in a bifurcation lesion treated with the crush stenting technique.

Percutaneous treatment of a bifurcation lesion still shows a significant complication rate, mainly because of restenosis at the ostial site of the side branch vessel. Different techniques, such as V-stenting, culottes-stenting or crush stenting, allow full ostial coverage and may therefore achieve uniform drug distribution within the lesion. The crush technique results in a strong mechanical constraint on the side branch stent. A case of stent strut fracture-induced restenosis in a bifurcation lesion treated with the crush stenting technique is described.     

The efficacy of adjunctive balloon postdilation at the overlapping site of drug-eluting stent in diffuse long coronary lesion

BACKGROUND: Data regarding the efficacy of adjunctive balloon postdilation (ABP) at the site of two or more overlapping drug-eluting stent (DES) implantation in diffuse long lesion angioplasty are limited. This study was aimed to evaluate the efficacy of routine ABP to the overlapping DES sites in terms of clinical and angiographic outcomes. METHODS: We enrolled 88 patients (55 men, mean age 63.51+/-10.24 years), and 93 lesions with diffuse long lesion were treated with DES. The clinical and angiographic outcomes up to 6 months of 35 patients in the without routine ABP group were compared with those of 53 patients in the with ABP group. RESULTS: Baseline clinical characteristics, procedural characteristics, angiographic lesion length, lesion type and DES type were similar between the two groups. Late loss and binary restenosis at 6 months were similar between the two groups. The death, Q-wave myocardial infarction and the major adverse cardiac events were similar between the two groups (7.9 vs. 9.1% in ABP group, P=NS), but there was a trend toward lesser target lesion and vessel revascularization in no ABP group (2.6 vs. 9.0% in no ABP group, P=0.09). CONCLUSION: The routine ABP at the overlapping site of DES implantations in a diffuse long coronary lesion showed no significant benefits in terms of angiographic and clinical outcomes compared with those of patients without routine ABP.     

Vascular brachytherapy for patients with drug-eluting stent restenosis

Background: The rate of drug‐eluting stent (DES) in‐stent restenosis (ISR) exceeds 10% in complex subsets of patients and lesions. The optimal management of DES ISR remains undetermined. Vascular brachytherapy (VBT) is proven to be effective for the treatment of bare metal stent ISR but its outcome for DES ISR has not been established. Methods: Ninety‐nine consecutive patients who presented with ISR following DES implantation in 122 lesions were subjected to conventional percutaneous coronary intervention with adjunct VBT using either beta radiation (Beta Rail in 74 patients [82.2%] and the Galileo system in 13 patients [14.4%]) or gamma radiation (Checkmate system in 3 patients [3.3%]). Patients were followed clinically for major adverse cardiac events (MACE) during 1‐year follow‐up. Results: A high proportion of patients in this cohort presented with complex ISR; 31.1% had recurrences of ISR to the same site, 55% had diffuse or proliferate pattern of restenosis, and 23 lesions (18.9%) were located in a saphenous vein graft. Procedural success and uneventful in‐hospital course were documented in all patients post VBT. At 12 months' follow‐up, the target lesion revascularization (TLR) rate was 11% and the overall MACE rate was 26%. Patients with multiple episodes of ISR to the same site had a TLR of 16% and MACE rate of 35.5%. Conclusions: VBT for the treatment of DES ISR was found to be effective and safe and should be considered for the treatment of DES ISR, in particular in complex patients with multiple recurrences.     

In-stent restenosis in the drug-eluting stent era

The introduction of the drug-eluting stent (DES) proved to be an important step forward in reducing rates of restenosis and target lesion revascularization after percutaneous coronary intervention. However, the rapid implementation of DES in standard practice and expansion of the indications for percutaneous coronary intervention to high-risk patients and complex lesions also introduced a new problem: DES in-stent restenosis (ISR), which occurs in 3% to 20% of patients, depending on patient and lesion characteristics and DES type. The clinical presentation of DES ISR is usually recurrent angina, but some patients present with acute coronary syndrome. Mechanisms of DES ISR can be biological, mechanical, and technical, and its pattern is predominantly focal. Intravascular imaging can assist in defining the mechanism and selecting treatment modalities. Based upon the current available evidence, an algorithm for the treatment approaches to DES restenosis is proposed.     

Coronary stent strut fracture after drug-eluting stent implantation: a newly recognized complication

Stent strut fracture (SSF) after drug-eluting stent (DES) implantation may be an important complication after DES implantation particularly in patients undergoing sirolimus eluting stent implantation. Since SSF is a highly relevant adverse event which can result in in-stent restenosis and thrombosis, we believe that DES with flexible stent platform or biodegradable DES may be needed to prevent this potential catastrophic complication.     

Intravascular brachytherapy versus drug-eluting stents for the treatment of patients with drug-eluting stent restenosis

Drug-eluting stents (DESs), although promising technology, still are associated with restenosis; therefore, we evaluated the safety and efficacy of intravascular radiation therapy for the treatment of DES in-stent restenosis (ISR). Treatment of DES ISR has not been established, although intravascular radiation therapy is an effective treatment for patients with ISR of bare metal stents. Other modalities are conventional percutaneous coronary intervention (PCI), including restenting with DES. Radiation for Eluting Stents in Coronary FailUrE (RESCUE) is an international, Internet-based registry of 61 patients who presented with ISR of a DES and were assigned to intravascular radiation therapy with commercially available systems after PCI. Outcomes of these patients were compared with those of a consecutive series of 50 patients who presented with ISR of a DES and were assigned to repeat DES (r-DES) treatment. Baseline clinical and angiographic characteristics were similar between groups, except for more Cypher stents as the initial DES that restenosed in the r-DES group than in the intravascular radiation therapy group (88.5% vs 69%, p = 0.01). At 8 months there were fewer overall major adverse cardiac events in the intravascular radiation therapy group compared with the r-DES group (9.8% vs 24%, p = 0.044). The need for target vessel and target lesion revascularizations was similar in the 2 groups at 8 months. There has been no report of subacute thrombosis in either group. In conclusion, intravascular radiation therapy as adjunct therapy to PCI for patients presenting with ISR of a DES is safe and should be considered an alternative therapeutic option for this difficult subset of patients.     

Multiple overlapping drug-eluting stents to treat diffuse disease of the left anterior descending coronary artery

OBJECTIVES: We sought to determine the safety and efficacy of using multiple overlapping drug-eluting stents (DES) in patients with diffuse left anterior descending coronary artery (LAD) disease. BACKGROUND: Diffuse LAD disease represents a therapeutic challenge. Results after coronary artery bypass surgery are suboptimal, whereas the use of bare metal stents is limited by high rates of restenosis. The introduction of DES prompted treatment of long diffuse disease with multiple overlapping stents. METHODS: All consecutive patients with de novo diffuse LAD disease treated with more than 60-mm long DES from April 2002 to March 2004 were analyzed. RESULTS: The study population consisted of 66 patients. Thirty-nine patients were treated with sirolimus-eluting stents (SES), average length 84 +/- 22 mm, and 27 patients with paclitaxel-eluting stents (PES), average length 74 +/- 14 mm. The number of stents implanted per patient was 2.8 +/- 0.7, whereas the mean total stent length for the LAD treatment was 80 +/- 20 mm. Angiographic as well as procedural success was achieved in 95% of cases. Eleven (16.6%) patients had in-hospital non-Q-wave myocardial infarction (five SES and six PES), and one patient developed intraprocedural stent thrombosis. All patients had clinical follow-up, and 52 patients (79%) had an angiographic follow-up at six months. Hierarchical major adverse cardiac event rate was 15% (7.5% for SES and 7.5% for PES). No patients died, one patient had non-Q-wave myocardial infarction (non-index vessel), and 10 patients (15%) underwent target vessel revascularization. CONCLUSIONS: The implantation of multiple overlapping DES in patients with a diffusely diseased LAD is relatively safe and associated with good midterm clinical outcomes.     

Inflammation and delayed endothelization with overlapping drug-eluting stents in a porcine model of in-stent restenosis.

BACKGROUND: This study evaluated the inflammatory reaction at the site of overlapping drug-eluting stents (DES) in a porcine model of in-stent restenosis. METHODS AND RESULTS: Twenty bare metal stents (BMS) (group I; n=10), 20 sirolimus-eluting stents (SES) (group II: n=10), 20 paclitaxel-eluting stent (PES) (group III: n=10), and 10 PES and 10 SES (group IV: n=10) were overlapped in the left anterior descending coronary arteries of 40 pigs. Follow-up coronary angiography and histopathology were performed at 4 weeks after stenting. For the overlapped segments, the minimal luminal diameter at 4 weeks was smaller in group I than in the other groups (1.78+/-0.13 mm, 2.79+/-0.09 mm, 2.90+/-0.04 mm, 2.80+/-0.07 mm, respectively; p<0.001), and the neointimal area (5.51+/-0.58 mm2, 2.38+/-0.53 mm2, 2.07+/-0.37 mm2, 2.39+/-0.58 mm2, respectively; p<0.001) and area stenosis (68.74+/-4.02%, 27.79+/-4.73%, 23.66+/-3.24%, 27.63+/-4.07%, respectively; p<0.001) were higher in group I than in the other groups; however, the inflammatory score was higher in group III than in the other groups (1.80+/-0.42, 2.10+/-0.32, 2.90+/-0.31, 2.50+/-0.52, respectively; p<0.001) and the endothelization score was lower in group III than in the other groups (2.80+/-0.42, 2.30+/-0.67, 1.30+/-0.48, 2.10+/-0.74, respectively; p<0.001). CONCLUSION: Compared with BMS, DES inhibit neointimal hyperplasia, but inflammation and poor endothelization occur at the site of overlapping stents.     

Outcomes of stenting with overlapping drug-eluting stents versus overlapping drug-eluting and bare-metal stents for the treatment of diffuse coronary lesions

Introduction

We investigated the outcomes of stenting with overlapping drug-eluting stents (DES) versus overlapping stenting with a combination of drug-eluting and bare metal stents (BMS) in very long ≥(≥ 25 mm).

Methods and Results

Fifty-two patients treated with either overlapping DES-DES (n = 22) or DES-BMS (n = 30) were selected from a registry of 588 patients with very long coronary lesions. Patients with acute myocardial infarction (MI) within the preceding 48 hours were excluded. The DES-DES combination was more frequently used for longer lesions compared with the DES-BMS group (47.95 ± 9.25 vs 39.98 ± 9.15 mm, p = 0.003). Left anterior descending artery lesions were also more frequently treated with the DES-DES combination (95.5 vs 66.7%, p = 0.02). In four patients in the DES-BMS group, overlapping stents were used for the coverage of dissections. Peri-procedural non-Q-wave MI occurred in one patient in the DES-BMS group. On follow up, only one case of non-fatal MI occurred in a patient with overlapping DES-DES.

Conclusion

Overlapping a BMS in the proximal part of a long DES instead of exclusive deployment of two or more overlapped DES seems to be a safe and feasible therapeutic strategy in our practice.