Coronary Stent Healing in Cancer Patients-An Optical Coherence Tomography Perspective.

Moez Karim Aziz,Juan Lopez-Mattei,Joerg Herrmann,Heather Y Lin,Teodora Donisan,H Vernon Anderson,Donald A Molony,Bala Pushparaji,Mehmet Cilingiroglu,Cezar A Iliescu,Gerryross Tomakin,Konstantinos Marmagkiolis,Taylor Hoyt,Martin Pham,Marc D Feldman,Vlad Zaha,Dinu Valentin Balanescu,Jouke Dijkstra

doi:10.3389/fcvm.2021.665303

Abstract

Objective: This study assessed stent healing patterns and cardiovascular outcomes by optical coherence tomography (OCT) in cancer patients after drug-eluting stent (DES) placement.Background: Cancer treatment, owing to its cytotoxic and antiproliferative effects, could delay stent healing and increase stent thrombosis risk, especially when dual antiplatelet therapy (DAPT) is discontinued early for oncological treatment. OCT can assess stent endothelialization and other healing parameters, which may provide clinical guidance in these challenging scenarios.Methods: This single-center retrospective study enrolled all cancer patients who underwent OCT for assessment of vascular healing patterns after prior DES placement from November 2009 to November 2018. Primary study endpoints were stent healing parameters, including stent coverage, apposition, degree of expansion, neointimal hyperplasia heterogeneity, in-stent restenosis, stent thrombosis, and overall survival (OS).Results: A total of 67 patients were included in this study. Mean time between DES placement and OCT evaluation was 154 ± 82 days. Stent healing matched published values for DES in non-cancer patients (P ≥ 0.063). At 1 year, the OS was 86% (95% confidence interval [CI]: 78–96%) with 0% incidence of acute coronary syndrome. Advanced cancers and active chemotherapies were associated with inferior OS (P = 0.024, hazard ratio [HR]: 3.50, 95% CI: 1.18–10.42 and P = 0.026, HR: 2.65, 95% CI: 1.13–6.22, respectively), while stent healing parameters were unassociated with OS. Forty-one patients (61%) had DAPT duration ≤6 months.Conclusions: Stent healing of contemporary DES appears similar in cancer and non-cancer patients. Cardiovascular risk of cancer patients after DES placement can be managed to facilitate timely cancer therapies, as the underlying malignancy and active chemotherapy ultimately determine survival.

Highlights

30% of patients with cardiovascular disease have a current cancer diagnosis with 10% of percutaneous coronary interventions (PCI) occurring in cancer patients [1, 2]
Demographics Men Cardiovascular risk factors Smoking Hypertension Dyslipidemia Diabetes Family history of coronary artery disease History Heart failure Coronary artery disease Myocardial infarction Coronary artery bypass graft Indications for Optical coherence tomography (OCT) analysis** Abbreviated dual antiplatelet therapy (DAPT) course Shortness of breath Acute coronary syndrome Cardiomyopathy Abnormal ECG Cancer data History of chemotherapy Active chemotherapy Advanced Antiplatelet medications Remained on aspirin Remained on clopidogrel Remained on ticagrelor
Tissue factor [24], von Willebrand factor [25], and ADP [26] have been deemed common metabolites contributing to stent thrombosis and cancer pathogenesis; one would naturally expect that heightened levels of these metabolites from cancer pathogenesis would delay stent healing by contributing to stent thrombosis

Summary

Introduction

30% of patients with cardiovascular disease have a current cancer diagnosis with 10% of percutaneous coronary interventions (PCI) occurring in cancer patients [1, 2]. Discontinuing DAPT prematurely can increase stent thrombotic risk in an already prothrombotic cancer patient population. These competing concerns present a challenging dilemma of when to discontinue DAPT in cancer patients with concomitant coronary artery disease. Optical coherence tomography (OCT) has been used to guide DAPT discontinuation decisions in cancer patients [3] by offering high resolution and detailed visualization of stented coronary artery segments [4], restenosis, and other stent healing parameters [5,6,7]. Cancer treatment, owing to its cytotoxic and antiproliferative effects, could delay stent healing and increase stent thrombosis risk, especially when dual antiplatelet therapy (DAPT) is discontinued early for oncological treatment. OCT can assess stent endothelialization and other healing parameters, which may provide clinical guidance in these challenging scenarios

Methods

Results

Discussion

Conclusion