Meta-analysis of long-term outcomes of drug-eluting stent implantations for chronic total coronary occlusions

Background

In the treatment of chronic total occlusions (CTOs), some uncertainty exists regarding the effect of drug-eluting stents (DESs) compared with the effects of bare mental stents (BMSs). We reviewed outcomes of DES vs. BMS implantation for CTO lesions, to evaluate the risk-benefit ratio of DES implantation.

Methods

Relevant studies of long-term clinical outcomes or angiographic outcomes of both BMS and DES implantation were examined. The primary endpoint comprised major adverse cardiovascular events (MACEs), including all-cause deaths, myocardial infarctions (MIs), and target lesion revascularizations (TLRs). A fixed-effect model and random-effect model were used to analyze the pooling results.

Results

Ten studies were included according to the selection criteria. Eight were nonrandomized controlled trials, and two consisted of a randomized controlled comparison between DES and BMS implantation. No significant difference was evident for in-hospital MACE rates between the two groups (odds ratio [OR], 1.07; 95% confidence interval [CI], .53 to 2.13), but the long-term MACE rates in the DES group were significantly lower than in the BMS group (OR, .22; 95% CI, .13 to .38; P < .00001). The rates of stent restenosis and reocclusions were also significantly lower in the DES group (OR, .14; 95% CI, .09 to .20; and OR, .23; 95% CI, .12 to .41, respectively).

Conclusion

Implantation of the DES improves long-term angiographic and clinical outcomes compared with BMS in the treatment of CTO lesions.     

多支冠状动脉病变患者1911例PCI二年疗效

目的评价多支冠状动脉病变（MVD）通过经皮冠状动脉介入（PCI）进行血运重建的长期疗效。方法1995年6月2003年12月连续2028例在我院成功接受PCI的MVD患者,对其心绞痛复发率、造影复查再狭窄率和主要不良心脏事件（MACE）的发生率进行回顾分析。结果2028例MVD患者,完全性血运重建率86.2%（1748/2028）,住院期间共死亡26例（总病死率1.3%）,对存活出院的2002例患者中的1911例随访24个月,随访率95.5%,其心绞痛复发率、造影复查再狭窄率和MACE发生率分别为10.7%、14.6%、25.4%,其中1754例植入普通金属支架（BMS）,157例植入药物洗脱支架（DES）。尽管DES组患者冠心病危险因素多、病变程度复杂,不稳定心绞痛占61.8%、糖尿病占41.4%、慢性完全闭塞病变（CTO）占37.6%、3支病变占58.0%,但心绞痛复发率、造影复查再狭窄率和MACE发生率均显著低于BMS组（分别为4.5%vs11.2%,3.2%vs15.7%,8.9%vs26.9%,均P<0.01）。结论PCI进行血运重建是治疗MVD的有效方法,但仍存在BMS支架术后不良事件发生率高,DES用于治疗MVD具有更好的长期疗效。     

药物洗脱支架治疗冠状动脉小血管病变的疗效分析

目的通过分析比较裸金属支架(BMS)与药物洗脱支架[DES,包括雷帕霉素(Cypher)支架和紫杉醇(TAXUS)支架]治疗冠状动脉小血管病变疗效的差异,为DES治疗多支及单支小血管病变冠心病提供依据。方法连续入选2002年12月至2005年5月沈阳军区总医院首次接受经皮冠状动脉介入治疗(PCI)、靶血管为小血管病变且达到完全血运重建的486例患者,其中多支小血管病变(多支)150例。分为BMS组214例(多支63例)、Cypher组140例(多支46例)和TAXUS组132例(多支41例),对比分析各组患者住院期间及随访6个月的临床情况。结果3组患者冠脉病变特点、PCI成功率及住院期间主要不良心脏事件(MACE)发生率等指标差异均无显著性(P>0·05)。冠脉造影随访显示,两个DES组再狭窄率均明显低于BMS(Cypher组4·9%,TAXUS组7·5%对BMS组29·2%,P<0·05),随访期间MACE发生率亦明显低于BMS(Cypher组2·9%,TAXUS组3·9%对BMS组12·0%,P<0·01)。进一步分析多支小血管病例,发现两个DES组的再狭窄率及随访期间MACE发生率仍然明显低于BMS组(再狭窄率Cypher组6·7%,TAXUS组7·1%对BMS组37·5%,P<0·05;MACE发生率Cypher组4·1%,TAXUS组4·8%对BMS组21·0%,P<0·05)。结论Cypher和TAXUS支架治疗小血管病变安全可行,疗效显著,治疗多支小血管病变可得到相同的疗效。     

药物洗脱支架和金属裸支架治疗弥漫病变的比较研究

目的比较冠心病患者弥漫病变采用药物洗脱支架和金属裸支架治疗的近期和远期预后,分析影响这类病变介入治疗预后的危险因素。方法研究对象为我院2004年4月至2005年8月接受置入单个长度>25.0mm支架治疗并且进行冠状动脉造影随访的205例患者,排除支架置入失败及支架置入位置不理想者。分为置入药物洗脱支架(DES)组(n=128)和置入金属裸支架(BMS)组(n=77)。所有的患者术后均接受阿司匹林300mg、氯吡格雷75mg等规范药物治疗。手术成功判定标准为至少用相互垂直的两个投照体位行冠状动脉造影,肉眼判定残余狭窄<20%和前向血流TIMI3级。再狭窄判定标准以复查冠状动脉造影定量分析支架内或支架邻近血管管腔直径狭窄程度≥50%。患者在支架术后6个月左右接受冠状动脉造影随访。结果共205例患者(男性181例,女性24例)227个靶病变置入382枚支架完成造影随访。其中C型病变占总数的93.8%,B2型病变为6.2%。双支或双支以上血管病变的患者比例达到86.8%。平均术前参考血管直径(2.88±0.43)mm。平均每个病变支架长度(40.09±12.94)mm,54.2%的病变接受了重叠置入支架。比较置入DES组和置入BMS组,两组的患者基本条件差异无统计学意义,在病变基本条件方面,DES组术前参考血管直径明显小于BMS组[(2.80±0.37)mm比(3.10±0.48)mm,P=0.005]。6个月随访结果显示再狭窄率DES组(15.4%)小于BMS组(48.4%),P<0.001。晚期支架内腔径丢失BMS组明显大于DES组[(0.94±0.76)mm比(0.39±0.53)mm,P<0.001]。靶病变血管重建率DES要明显好于BMS(11.6%比38.5%,P<0.001)。支架内再狭窄在置入DES组的局限性再狭窄比例大于置入BMS组(33.3%比18.2%,P=0.029)。对影响复杂弥漫病变支架再狭窄因素的多元logistic回归分析发现,采用支架重叠置入(OR=2.82,P=0.017)和支架类型(OR=5.71,P<0.001)是对复杂弥漫病变支架内再狭窄影响最大的危险因素。结论我们的研究发现对于复杂弥漫病变的治疗,药物洗脱支架有着良好的治疗效果,较金属裸支架能明显减低再狭窄率。对于弥漫病变,我们应该使用长支架,尽可能减少支架重叠置入的数量。     

药物支架和裸支架治疗急性ST段抬高心肌梗死患者的随访研究

目的 评价药物支架和裸支架治疗急性ST段抬高心肌梗死患者疗效和预后方法217例接受了急诊经皮冠状动脉介入治疗急性ST段抬高心肌梗死患者纳入本研究,药物支架组92例、裸支架组125例,收集基线资料并随访6～38个月.结果 裸支架组的平均年龄(64.6±11.9)岁、Killip分级(2、3、4级)为25.9%和支架平均直径为(3.07±0.38)mm,均高于药物支架组(61.2±11.8)岁、12.2%和(2.91±0.40),差异有统计学意义(t=2.09,P=0.037;χ2=5.53,P=0.019;t=2.78,P=0.006),裸支架组平均左心室射血分数(55.4±11.9)%低于药物支架组(60.3±12.8)%,差异有统计学意义(t=-2.57,P=0.011).支架长度[(32.8±16.2)mm、(26.2±11.2)mm]、支架后扩张(45.7%、21.6%)、糖尿病(28.2%、16.0%)药物支架组高于裸支架组(t=-3.54,P=0.001;χ2=13.85,P=0.0002;χ2=4.77,P=0.030).随访期间,主要不良心脏事件(MACE)发生36例,药物支架组6例(6.5%),裸支架组30例(24.0%)(χ2=11.70,P＜0.01).结论 急性ST段抬高心肌梗死急诊介入治疗是安全有效的,同裸支架相比药物支架明显降低随访期MACE发生率而改善预后.     

Prevention of lesion recurrence in chronic total coronary occlusions by paclitaxel-eluting stents

OBJECTIVES: The aim of this research was to assess the efficacy of paclitaxel-eluting stents in chronic total coronary occlusions (CTO). BACKGROUND: Percutaneous coronary interventions for CTOs are characterized by a high target vessel failure rate. METHODS: In 48 consecutive patients, paclitaxel-eluting stents (Taxus, Boston Scientific Corp., Natick, Massachusetts) were implanted after successful recanalization of a CTO (duration >2 weeks). Patients underwent an angiography after 6 months and were followed clinically for 12 months. They were compared with 48 lesion- and risk-matched patients with CTOs treated with bare metal stents (BMS). Primary clinical end point was the one-year incidence of major adverse cardiac events (MACE) (death, myocardial infarction, repeat revascularization); secondary end points were the rate of restenosis and re-occlusion. RESULTS: In-hospital MACE was 4.2% with Taxus, and 2.1% with BMS (p = NS). The one-year MACE rate was 12.5% in the Taxus group, and 47.9% in the BMS group (p < 0.001), which was due to a reduced need for repeat revascularization. The angiographic restenosis rate was 8.3% with Taxus versus 51.1% with BMS (p < 0.001). There was only one late re-occlusion with Taxus (2.1%) as compared with 23.4% with BMS (p < 0.005). The late loss was reduced in the Taxus group by 84% as compared with BMS. All nonocclusive restenoses in the Taxus group were focal and successfully treated by implanting an additional Taxus stent. CONCLUSIONS: The treatment of CTOs with a paclitaxel-eluting stent drastically reduces MACE and restenosis, and almost eliminates re-occlusion, which is typically frequent with BMS in CTOs. Chronic total coronary occlusion should be a preferred indication for drug-eluting stents.     

药物洗脱支架对完全闭塞性病变介入治疗预后影响的评估

目的比较对于完全性闭塞病变采用药物洗脱支架和金属裸支架的近期和远期预后。方法选择我院近期连续接受置入药物洗脱支架(DES)或金属裸支架(BMS)治疗,并且进行冠状动脉造影随访的155例存在完全闭塞病变的冠心病患者。患者在支架术后6个月左右接受冠状动脉造影随访。结果共155例患者(138名男性,17名女性)159处靶病变置入232枚支架完成造影随访,其中慢性完全性闭塞65例,占41.9%。其中C型病变占总数的85.4%。在患者基本条件方面,DES组2型糖尿病比例要多于BMS组(33.8%比18.5%,P=0.030)。在病变基本条件方面,DES组和BMS组C型病变分别占89.6%和72.0%(P=0.005),DES组病变更为复杂。DES组慢性完全闭塞病变比例明显高于BMS组(60.3%比24.4%,P<0.001)。DES组和BMS组的支架长度和病变长度没有差别。DES组参考血管直径小于BMS组[(2.72±0.36)mm比(2.96±0.52)mm,P=0.001]。6个月随访结果显示支架再狭窄DES组明显低于BMS组(15.6%比41.5%,P<0.001)。DES组支架再狭窄更多为局限性(58.3%比17.6%,P<0.001)。DES组的靶病变血管重建率明显低于BMS组(5.8%比19.9%,P=0.001)。病变内晚期腔径丢失DES明显小于BMS[(0.36±0.63)mm比(1.04±0.70)mm,P<0.001]。晚期支架内血栓DES有2例,BMS为0。DES组有1例死亡。术后主要心脏不良事件发生率两组分别是1.4%和11.1%,DES组显著低于BMS组(P=0.032)。结论我们的研究发现对于完全闭塞性病变的治疗,DES有着良好的治疗效果,比BMS有着明显减低的再狭窄率、靶病变血管重建率,并且在随访期间患者有着更少的心血管事件。     

Predictors of long-term major adverse cardiac events and clinical restenosis following elective percutaneous coronary stenting

Limited data exist regarding the predictors of long-term clinical outcomes following elective percutaneous coronary intervention (PCI) in the current era of stenting. The authors investigated the predictors of major adverse cardiac events (MACE) and clinical restenosis in 740 consecutive patients who underwent successful elective PCI with bare metal stents (BMSs) or drug-eluting stents (DESs). At 30-month follow-up, compared with BMS recipients, DES recipients had a significantly lower rate of MACE, which was mainly driven by a decreased repeat target vessel PCI. The rate of 30-month clinical restenosis was significantly lower in DES recipients. The authors conclude that baseline clinical, angiographic, and procedural characteristics determine long-term MACE and clinical restenosis after elective PCI, with DES being the independent predictor for both.     

Immediate procedural and long-term clinical outcomes following drug-eluting stent implantation to ostial saphenous vein graft lesions

BACKGROUND: Ostial saphenous vein graft (OSVG) lesions were excluded from all the clinical trials demonstrating significantly lower restenosis rates with drug-eluting stents (DES) compared to bare metal stents (BMS). This study aimed to evaluate the efficacy of DES in OSVG lesions by assessing angiographic and 12-month clinical outcomes. METHODS: 70 consecutive patients (70 OSVG lesions) underwent coronary stent implantation between May 2003 and April 2006: 37 lesions received DES and 33 lesions BMS. Endpoints were all cause and cardiovascular mortality, myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), examined separately and as a combined end-point (major adverse cardiac events, MACE). RESULTS: Procedural (94.6% for DES and 87.9% for BMS) and angiographic (100% for DES and 100% for BMS) success did not differ between the two groups. The only in-hospital events were non-Q wave MI (DES 8.1% versus BMS 12.1%, P=0.69). At 30-day follow-up, there were no other events. Overall, at 1-year follow-up, the BMS group had a higher TLR (30.3% versus 5.4%, P=0.015), TVR (33.3% versus 10.8%, P=0.045) and MACE rate (36.4% versus 10.8%, P=0.024) compared to the DES group. CONCLUSIONS: Drug-eluting stent implantation to OSVG lesions achieves better clinical results than BMS but is still associated with a relatively high incidence (10.8%) of revascularization at 1-year follow-up.     

Percutaneous intervention on the saphenous vein bypass grafts—Long‐term outcomes

Background/Objective : In this era of drug eluting stents (DES), the long‐term outcome of percutaneous intervention (PCI) on saphenous venous grafts (SVG) is unknown. The objective of the study was to compare the long‐term outcomes of DES versus bare metal stent (BMS) in this population and to determine the predictors of outcomes. Methods : We reviewed the medical records of all patients who had PCI performed during January 2003 to February 2005 to obtain data cardiac risk factors, medications at discharge, angiographic details and outcomes. Results : One hundred and nine patient had PCI to SVG; of these, 37 patients received DES and the remaining had BMS. Over a mean follow‐up of 33 months, the PCI using DES was associated with 30% restenosis, 35% target vessel revascularization (TVR) and major adverse cardiac event (MACE) rate of 46% versus 35% restenosis, 38% TVR and 50% MACE rate with BMS. There was no significant difference in long‐term outcome with DES as compared to BMS. Conclusion : There was no difference in the long‐term outcomes of PCI on SVG irrespective of the type of stent used. © 2008 Wiley‐Liss, Inc.     

Safety and effectiveness of drug eluting stent in patients with ST elevation myocardial infarction undergoing primary angioplasty

Background : Drug eluting stents (DES) have recently been proven to further reduce restenosis and revascularization rate in comparison to bare metal stents in elective procedures. Most early DES trials did not include patients undergoing primary percutaneous coronary intervention (PCI) for ST‐segment elevation MI, because these patients tend to have lower restenosis rates than other patient groups and delayed endothelization of these stents raises concern about a possible increase of thrombotic complications in the setting of STEMI. Aim : To confirm the safety and effectiveness of DES in patients with STEMI in a real‐world scenario. Methods : From January 2004 to December 2006, clinical and angiographic data of 370 patients with STEMI treated with primary PCI have been analyzed. Patients were retrospectively followed for the occurrence of major adverse cardiac events (MACE): death, reinfarction and target vessel revascularization (TVR). Results : Overall, 120 patients received DES (32%, DES group) and 250 received bare metal stents (68%, BMS group) in the infarct related artery. Compared with the BMS group, DES patients were younger, (mean age 56 ± 12 vs. 65 ± 10; P < 0.001) had more often diabetes mellitus (47% vs. 14% P < 0.001), anterior localization (65% vs. 45%; P < 0.0011) and less cardiogenic shock at admission (4% vs. 7%; P < 0.001). The angiographic characteristics in the DES group showed longer lesions (23 mm vs. 19 mm) and smaller diameter of vessels (2.5 mm vs. 3.0 mm). After a median follow‐up of 24 ± 9 months, there was no significant difference in the rate of stent thrombosis (1.6% in the DES group vs. 1.2% in the BMS group, P = ns). The incidence of MACE was significantly lower in the DES group compared with the BMS group (HR 0.56 [95% CI: 0.3–0.8]; P = 0.01), principally due to the lower rate of TVR (HR 0.41 [95% CI: 0.2–0.85]; P = 0.01). Conclusions : Utilization of DES in the setting of primary PCI for STEMI, in our “real world,” was safe and improved the 3‐year clinical outcome compared with BMS reducing the need of TVR. © 2008 Wiley‐Liss, Inc.     

Transition from bare metal to drug eluting stenting in contemporary US practice: effect on incidence and predictors of clinically driven target lesion revascularization.

BACKGROUND: The performance of drug eluting stents (DES) and impact on every day practice in the USA, where complex, nonselective cases are the rule, remain unknown. METHODS: The Brigham and Women's Hospital interventional experience in the bare metal stents (BMS) (6/2002 to 2/2003) and after abrupt and near universal adoption of DES (4/2003 to 9/2004) were compared. Demographic, procedural and in-hospital outcomes for all consecutive cases where investigated. Predictors and angiographic characteristics of patients returning for clinically driven target lesion revascularization (TLR) in both eras were analyzed. RESULTS: Of 2,555 DES cases (3,061 lesions, 87.9% Cypher, 12.1% Taxus), 47 underwent TLR during follow-up (68 lesions, 2.2%). Of the 1,731 BMS cases (1,798 lesions), 162 underwent clinically indicated TLR (209 lesions, 11.6%), representing an 81% DES era TLR risk reduction. Multivariate predictors of TLR in the DES era: left main lesion (LM) (odds ratio (OR) 7.65, 95% confidence interval (CI) 3.33-17.53, P<0.01, treatment of restenosis (OR 5.96, CI 3.21-11.08, P<0.01), and diabetes (OR 1.68, CI 0.92-3.04, P=0.07). Predictors of restenosis in the BMS era included additional clinical, lesion, and stent characteristics, while LM lesion was absent. Angiographic patterns of stent restenosis differed in the DES (focal) and BMS (diffuse) era. CONCLUSIONS: The transition from BMS to DES in the setting of a large USA hospital practice is safe and associated with significant reduction in clinically driven TLR. Treatment of specific lesions types (repeat restenosis, distal LM) and diabetic patients remain suboptimal and warrant further investigation.     

A comparison of drug-eluting stents versus bare metal stents in saphenous vein graft PCI outcomes: a meta-analysis

Aims: Studies demonstrate that percutaneous coronary intervention (PCI) with drug‐eluting stents (DES) is associated with reduced revascularization and major adverse cardiac events (MACE) rates compared to bare metal stents (BMS) in native coronary vessels. Optimal PCI treatment of saphenous vein graft (SVG) lesions remains unclear despite SVG procedures representing up to 10% of PCI cases. We therefore performed a meta‐analysis to compare outcomes between BMS and DES in SVG PCI. Methods and Results: A search (2004–2009) of MEDLINE and conference proceedings for all relevant studies comparing mortality and MACE outcomes in DES versus BMS in SVG PCI and meta‐analysis of the data was performed. Twenty studies were identified from 2005 to 2009 enrolling a total of 5,296 patients. Meta‐analysis revealed a decrease in mortality associated with DES use, odds ratio (OR) 0.68; 95% confidence interval (CI) 0.53–0.88; P = 0.004. Similarly, MACE (OR 0.64; 95% CI 0.51–0.82; P < 0.001), total lesion revascularization (OR 0.60; 95% CI 0.43–0.83; P = 0.002), and total vessel revascularization (OR 0.57; 95% CI 0.41–0.80; P = 0.001) were significantly decreased in the patients in which DES were used compared to BMS. This reduction in mortality and MACE events associated with DES use appears to be limited to registry studies and not randomized controlled studies. Conclusions: Our meta‐analysis suggests DES use to be safe in SVG PCI and associated with reduced mortality and MACE rates with reductions in revascularization also observed. (J Interven Cardiol 2011;24:172–180)     

Drug-Eluting Versus Bare-Metal Stents in Older Patients: A Meta-Analysis of Randomized Controlled Trials

BackgroundDespite the high prevalence of ischemic heart disease in older patients, there is a substantial lack of evidence to guide clinical decision-making in this population. Hence, we performed a meta-analysis to determine the safety and efficacy of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus bare-metal stents (BMS).MethodsElectronic databases were searched for randomized trials comparing DES with BMS in patients ≥70 years-old. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included different ischemic and bleeding events. Subgroup analyses for dual-antiplatelet therapy (DAPT) duration were conducted.ResultsWe included 7 trials with a total of 5449 patients. The use of DES compared with BMS was associated with a significant reduction in MACE (odds ratio [OR]:0.76; 95% confidence interval [CI]:0.62–0.93; P = 0.007) with no increased risk of bleeding events (OR: 1.07; 95% CI: 0.89–1.27; P = 0.48). However, longer duration of DAPT (>6 months) for the DES group increased bleeding events (OR: 1.52; 95% CI: 1.05–2.20; P = 0.03). In contrast, shorter DAPT showed persistent efficacy in reducing MACE in DES-treated patients with no increased bleeding events (OR: 0.72; 95% CI: 0.60–0.87; P < 0.01 and OR: 1.01; 95% CI: 0.84–1.22; P = 0.89, respectively).ConclusionsIn older patients who had undergone PCI, DES showed superior efficacy in reducing MACE with no increased risk of bleeding compared with BMS. Persistent MACE reduction was evident with shorter DAPT durations in DES-treated patients.SummaryThis meta-analysis of randomized clinical trials demonstrated that drug-eluting stents were associated with a significant reduction in major adverse cardiovascular events with no increased risk of bleeding compared with bare-metal stents. The risk of bleeding was high with longer dual antiplatelet therapy duration for patients who underwent DES placement. However, short duration of dual antiplatelet therapy substantially reduced major adverse cardiovascular events with no increased bleeding risk.     

Comparison of one-year cardiac events with drug-eluting versus bare metal stent implantation in rescue coronary angioplasty

Rescue percutaneous coronary intervention (PCI) with bare metal stent (BMS) implantation is useful in patients with acute myocardial infarction (AMI) and failed thrombolysis. Drug-eluting stent (DESs) are more effective in reducing restenosis compared to BMS. No data are available comparing the clinical outcomes between the 2 types of stents nor has information ever been provided about the predictors of events in patients treated with rescue PCI in the current era. The aims of the present study were to evaluate the outcomes of patients undergoing rescue PCI with DES implantation compared to BMS implantation and to determine the independent predictors of events during 1 year of follow-up. The study population consisted of 311 consecutive patients with ST-segment elevation AMI and evidence of failed fibrinolysis undergoing successful revascularization with DES (n = 134) or BMS (n = 177) implantation. The end point of the present study was the incidence of major adverse cardiac events (MACE) defined as death, recurrent AMI, and target vessel revascularization. No differences were found in the number of MACE at 1 year of follow-up between the DES and BMS groups (n = 10 and 19, respectively, p = 0.29). The Cox proportional hazards model identified cardiogenic shock (adjusted hazard ratio 7.05, 95% confidence interval 2.08 to 23.9, p = 0.001), age (hazard ratio 1.51, 95% CI 1.09 to 2.08, p = 0.011), and final minimal lumen diameter (hazard ratio 0.42, 95% confidence interval 0.21 to 0.83, p = 0.013) as independent predictors of MACE at 1 year of follow-up. After propensity score adjustments, the predictors did not change. In conclusion, we found no differences between DESs and BMSs with respect to MACE at 1 year of follow-up in patients with AMI treated with rescue PCI. Cardiogenic shock, age, and final minimal luminal diameter were identified as predictors of MACE.     

冠状动脉支架置入术后不同类型支架再狭窄形式分析

目的通过分析冠状动脉支架置入后造影复查的影像资料,寻找不同支架再狭窄的特点。方法入选行冠状动脉病变介入治疗后造影复查的846处病变,对再狭窄病变行再狭窄形式分析。结果裸支架和药物支架再狭窄中支架近端局限性再狭窄分别占5.69%和33.67%(P=0.000),而支架内弥漫性再狭窄分别占29.27%和9.18%(P=0.000),弥漫性狭窄累及支架两端的分别为20.33%和6.12%(P=0.003),闭塞性再狭窄发生率分别为9.76%和10.20%(P=0.912)。雷帕霉素及其衍生物释放支架和紫杉醇释放支架再狭窄支架边缘局限性再狭窄分别为47.06%和25.00%(P=0.037),支架内弥漫性狭窄分别为1.96%和16.67%(P=0.018)。结论药物支架改变了支架再狭窄模式,弥漫型转为局限型;闭塞性再狭窄时药物支架以支架近端闭塞为主,裸支架以支架内闭塞为主;紫杉醇药物释放支架弥漫性再狭窄发生率较雷帕霉素释放支架有所增加。     

Immediate and mid-term outcomes of sirolimus-eluting stent implantation for chronic total occlusions.

AIMS: To evaluate the outcomes of sirolimus-eluting stent (SES) implantation for the treatment of chronic total occlusion (CTO). METHODS AND RESULTS: We identified 122 patients who underwent revascularization in CTO lesions with SES from April 2002 to April 2004 (SES group). A control group was composed of 259 consecutive patients with CTO lesions treated with bare metal stents (BMS) in the 24 months immediately before the introduction of SES (BMS group). At 6-month follow-up, the cumulative rate of major adverse cardiac events (MACE) was 16.4% in the SES group and 35.1% in the BMS group (P<0.001). The incidence of restenosis was 9.2% in the SES group and 33.3% in the BMS group (P<0.001). The need for revascularization in the SES group was significantly lower, both target lesion revascularization (7.4 vs. 26.3%, P<0.001) and target vessel revascularization (9.0 vs. 29.0%, P<0.001). BMS implantation (HR: 2.97; 95% CI: 1.80-4.89; P<0.001), lesion length (>20 mm) (HR: 2.02; 95% CI: 1.37-2.99; P=0.0004), and baseline reference vessel diameter (>2.8 mm) (HR: 0.62; 95% CI: 0.42-0.92; P=0.02) were identified as predictors of MACE during 6-month follow-up. CONCLUSION: Compared with BMS, SES implantation in CTO lesions appears to be effective in reducing the incidence of restenosis and the need for revascularization at 6 months.     

Treatment of saphenous vein graft lesions with drug-eluting stents: immediate and midterm outcome

OBJECTIVES: The purpose of the present report was to evaluate clinical and angiographic outcomes of drug-eluting stent (DES) implantation in saphenous vein graft (SVG) lesions. BACKGROUND: The safety and efficacy of DES implantation for the treatment SVG lesions remains uncertain. METHODS: We evaluated in-hospital and six-month outcomes in 61 consecutive patients treated with DES in SVG lesions from March 2002 to March 2004 (DES group), as compared to 89 consecutive patients treated with bare-metal stents (BMS) in the 24 months immediately before the introduction of DES (BMS group). Major adverse cardiac events (MACE) including death, myocardial infarction, target lesion revascularization (TLR), and target vessel revascularization (TVR) were recorded in-hospital and at six-month follow-up. RESULTS: The rate of in-hospital MACE was similar between the two groups (6.6% vs. 5.6%, p = 1.0). Cumulative MACE at six months was 11.5% in the DES group and 28.1% in the BMS group (p = 0.02). The DES group had a significantly lower incidence of in-segment restenosis (10.0% vs. 26.7%, p = 0.03), TLR (3.3% vs. 19.8%, p = 0.003), and TVR (4.9% vs. 23.1%, p = 0.003). By Cox regression analysis, diabetes (hazard ratio [HR]: 3.03; 95% confidence interval [CI]: 1.33 to 6.90; p = 0.008), usage of BMS (HR: 2.53; 95% CI: 1.07 to 5.97; p = 0.03), and age of SVG (HR: 1.10; 95% CI: 1.02 to 1.19; p = 0.02) were identified as predictors of MACE at six-month follow-up. CONCLUSIONS: Compared to BMS implantation, DES implantation in SVG lesions appears safe with favorable and improved mid-term outcomes.     

A meta-analysis of randomized controlled trials appraising the efficacy and safety of cilostazol after coronary artery stent implantation

Objectives: To evaluate the impact of cilostazol on the angiographic and clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) with stents and treated with aspirin and thienopyridine. Methods: A total of 11 randomized controlled trials including 8,525 patients comparing triple antiplatelet therapy (aspirin, thienopyridine and cilostazol) with standard dual antiplatelet therapy were included in the analysis. The primary end points were in-segment late loss and angiographic restenosis at angiographic follow-up. Secondary end points included mortality, stent thrombosis, target lesion revascularization (TLR) and major adverse cardiac events (MACE). Results: Triple antiplatelet therapy was associated with a significant reduction in late loss [weighted mean difference 0.14, 95% confidence interval (CI) 0.08-0.20; p < 0.001] and angiographic restenosis [odds ratio (OR) 0.58, 95% CI 0.48-0.71; p < 0.001]. Addition of cilostazol to dual antiplatelet therapy was associated with a significant reduction in TLR (OR 0.56, 95% CI 0.41-0.77; p < 0.001) and MACE (OR 0.72, 95% CI 0.60-0.86; p < 0.001) with no differences in mortality (p = 0.29), stent thrombosis (p = 0.60) or bleeding episodes (p = 0.77). Conclusions: Cilostazol in addition to dual antiplatelet therapy appears to be effective in reducing the risk of restenosis and repeat revascularization after PCI without any significant benefits for mortality or stent thrombosis.     

Single-center randomized evaluation of paclitaxel-eluting versus conventional stent in acute myocardial infarction (SELECTION)

OBJECTIVES: To evaluate the superiority of the paclitaxel-eluting stent (PES) in reducing neointimal hyperplasia (NIH) over its corresponding bare metal stent (BMS) during primary percutaneous coronary intervention (PCI). BACKGROUND: Primary PCI with stent implantation is the repercussion strategy of choice for ST-elevation myocardial infarction (STEMI); nonetheless restenosis rate is still high. Drug-eluting stents have been proven to reduce restenosis rate in many settings, but their use during primary PCI is still controversial. METHODS: Consecutive patients with STEMI <12 hours were randomized to receive PES or BMS. The primary end-point was the percentage of the stent volume obstructed by neointimal proliferation (NIH) measured by intravascular ultrasound (IVUS) at a 7-month angiographic follow-up. Secondary end-points were binary restenosis rate and major adverse cardiac events (MACE, i.e., death, nonfatal myocardial infarction, and target lesion revascularization). RESULTS: Eighty patients with STEMI were randomized into the PES or BMS group. Patients were well matched for baseline characteristics and the index procedure was always successful. In-hospital and 1-month MACE were 2.5% per group. NIH at 7 months was 4.6% versus 20% (P< 0.01), late lumen loss 0.1 versus 1.01 mm (P = 0.01). MACE were 7.5% versus 42.5% (P = 0.001) with no difference in death and recurrent myocardial infarction rates. Late-acquired incomplete stent apposition (ISA) rate was 5.1% versus 2.7% (P = 0.65). One subacute stent thrombosis was reported in each group. CONCLUSIONS: PES was superior to its corresponding BMS in reducing NIH in the STEMI setting without any increase in early and long-term clinical adverse events.