Angiographic Restenosis Research Articles

Effects of probucol on restenosis after percutaneous coronary intervention: a systematic review and meta-analysis.

BackgroundRestenosis after percutaneous coronary intervention (PCI) is a remained clinical problem which limits long-term success of PCI. Although there was recognition that probucol in treating restenosis after percutaneous transluminal coronary angioplasty, the efficacy of probucol on restenosis after stent-implantation is controversial. So this meta-analysis was conducted to investigate the association between probucol and late restenosis.MethodsArticles were assessed by four trained investigators, with divergences resolved by consensus. PubMed, EMBASE, ScienceDirect and the Cochrane Central Register of clinical trials were searched for pertinent studies. Inclusion criteria were random allocated to treatment and a comparison of probucol-treated patients and control patients (not treated with lipid-lowering drug) undergoing PCI.ResultsFifteen studies with 859 subjects were analyzed. Major outcome, binary angiographic restenosis defined as >50% stenosis upon follow-up angiography, was significantly decreased with probucol treatment (RR = 0.59 [0.43, 0.80] among vessels, P = 0.0007; and RR = 0.52 [0.40, 0.68] among patients, P<0.00001). Probucol also increased the minimal luminal diameter (SMD = 0.45 [0.30, 0.61], P<0.00001) and decreased late loss upon follow-up after 6 months (SMD = -0.41 [-0.60, -0.22], P<0.0001). Moreover, there was a significantly lower incidence of major adverse cardiac events (MACE) in the probucol group than control group (RR = 0.69 [0.51, 0.93], P = 0.01).ConclusionProbucol is more than a lipid-lowering drug. It is also effective in reducing the risk of restenosis and incidence of MACE after PCI.

Impact of lesion morphology on angiographic and clinical outcomes in patients with chronic total occlusion after recanalization with drug-eluting stents: a multislice computed tomography study.

The aim of this study was to investigate the multislice computed tomography (MSCT) parameters associated with adverse outcomes after chronic total occlusion percutaneous coronary intervention (CTO-PCI) with drug-eluting stents. A total of 285 patients who underwent MSCT before CTO-PCI were analyzed. Lesion morphology was assessed with MSCT. Angiographic restenosis, reocclusion, and MACE (a composite of cardiac death, myocardial infarction, stent thrombosis, and target lesion revascularization) were analyzed. MACE was observed in 36 patients (13.6%). Occlusion length was greater (39.5 ± 19.9 mm vs. 22.3 ± 13.7 mm, p < 0.01), minimal vessel area smaller (11.2 ± 5.7 mm(2) vs. 14.5 ± 5.6 mm(2), p < 0.01), and severe calcification more common (36% vs. 12 %, p < 0.01) in the MACE group compared to the non-MACE group. We defined occluded length >25.4 mm, minimal vessel area <11.9 mm(2), which were identified by receiver operating characteristic analysis, and severe calcification as CT-derived risk factors. Angiographic restenosis (60% vs. 12% vs. 7%, p < 0.01), reocclusion (29% vs. 2% vs. 2%, p < 0.01), and MACE (43% vs. 6% vs. 3%, p < 0.01) were more common in patients with 2 or more risk factors than in those with 1 or 0. MSCT characteristics associated with adverse outcomes after CTO-PCI were occlusion length, minimal vessel area, and severe calcification. • Percutaneous coronary intervention of chronic total occlusion remains a challenge. • The parameters related to adverse outcomes after CTO-PCI have not been clarified. • MSCT can provide useful information associated with adverse outcomes after CTO-PCI.

Stratification of coronary artery disease patients for revascularization procedure based on estimating adverse effects.

BackgroundPercutaneous coronary intervention (PCI) is the most commonly performed treatment for coronary atherosclerosis. It is associated with a higher incidence of repeat revascularization procedures compared to coronary artery bypass grafting surgery. Recent results indicate that PCI is only cost-effective for a subset of patients. Estimating risks of treatment options would be an effort toward personalized treatment strategy for coronary atherosclerosis.MethodsIn this paper, we propose to model clinical knowledge about the treatment of coronary atherosclerosis to identify patient-subgroup-specific classifiers to predict the risk of adverse events of different treatment options. We constructed one model for each patient subgroup to account for subgroup-specific interpretation and availability of features and hierarchically aggregated these models to cover the entire data. In addition, we deviated from the current clinical workflow only for patients with high probability of benefiting from an alternative treatment, as suggested by this model. Consequently, we devised a two-stage test with optimized negative and positive predictive values as the main indicators of performance. Our analysis was based on 2,377 patients that underwent PCI. Performance was compared with a conventional classification model and the existing clinical practice by estimating effectiveness, safety, and costs for different endpoints (6 month angiographic restenosis, 12 and 36 month hazardous events).ResultsCompared to the current clinical practice, the proposed method achieved an estimated reduction in adverse effects by 25.0% (95% CI, 17.8 to 30.2) for hazardous events at 36 months and 31.2% (95% CI, 25.4 to 39.0) for hazardous events at 12 months. Estimated total savings per patient amounted to $693 and $794 at 12 and 36 months, respectively. The proposed subgroup-specific method outperformed conventional population wide regression: The median area under the receiver operating characteristic curve increased from 0.57 to 0.61 for prediction of angiographic restenosis and from 0.76 to 0.85 for prediction of hazardous events.ConclusionsThe results of this study demonstrated the efficacy of deployment of bare-metal stents and coronary artery bypass grafting surgery for subsets of patients. This is one effort towards development of personalized treatment strategies for patients with coronary atherosclerosis that could significantly impact associated treatment costs.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-015-0131-0) contains supplementary material, which is available to authorized users.

Plasma heparin cofactor II activity correlates with the incidence of in-stent restenosis after the intervention of arteriosclerosis obliterans in lower extremity

To explore the relationship between activity of plasma heparin cofactor II (HC II) and the incidence of in-stent restenosis aft er the intervention of arteriosclerosis obliterans in lower extremity. A total of 62 patients with arteriosclerosis obliterans in lower extremity underwent femoropopliteal stent implantation. They were divided into 2 groups: A high HC II activity group (≥100%, n=40) and a low HC II activity group (<100%, n=22). All patients filled in follow up tables and conducted body examination. Possible risk factors resulting in restenosis were collected. Patients were followed up for 6 months after femoropopliteal stent implantation. Baseline clinical characteristics were not significantly different between the 2 groups. The degree and incidence of angiographic restenosis at the end of the 6th month after the implantation in the high HC II activity group were all significantly lower than those in the low HC II activity group (P<0.05). Multivariate analysis demonstrated that high plasma HC II activity was an independent factor in reducing the incidence of angiographic restenosis (OR=0.982, P=0.048, 95%CI, 0.966, 0.998). High plasma HC II activity is an independent factor in reducing the degree of in-stent restenosis. The lower the plasma HC II activity, the severer the degree of in-stent restenosis.

A 2-year follow-up of a randomized multicenter study comparing a paclitaxel drug-eluting balloon with a paclitaxel-eluting stent in small coronary vessels the BELLO study

Background/objectivesA prospective, multi-center, randomized trial, BELLO (Balloon Elution and Late Loss Optimization), showed that the primary endpoint of in-stent (in-balloon) late loss was significantly less with drug-eluting balloons (DEB) as compared with paclitaxel-eluting stents (PES). At 6months, DEB and PES were associated with similar rates of angiographic restenosis, target lesion revascularization (TLR), and major adverse cardiac events (MACE) defined as death, myocardial infarction and target vessel revascularization. The aim of this study was to report 2-year clinical outcomes after treatment of de novo small vessel disease with DEB as compared with PES. MethodsA total of 182 patients were enrolled and randomized to treatment with DEB (n=90) in 94 lesions or PES (n=92) in 98 lesions. The study endpoint was the incidence of MACE at 2-year follow-up. ResultsTwo-year follow-up was achieved in almost all cases (97.8% in DEB group vs. 98.9% in PES group). There was a trend towards a lower incidence of MACE in the DEB group as compared with the PES group (14.8% vs. 25.3%; p=0.08). TLR rates in the DEB group were acceptable at 6months, 1year and 2years and did not differ significantly from the PES group (4.4% vs. 7.6%, p=0.37; 6.7% vs. 12.1%, p=0.23; 6.8% vs. 12.1%, p=0.25, respectively). ConclusionsOur results suggest that treatment of small vessel disease with a paclitaxel DEB is associated with a trend for improved clinical outcomes as compared with PES up to 2years. Late catch-up phenomenon requiring repeat intervention after treatment with DEB was not evident in this study.

Early (before 6 months), late (6-12 months) and very late (after 12 months) angiographic scaffold restenosis in the ABSORB Cohort B trial

The long-term follow-up of the first-in-man ABSORB Cohort B trial showed that angiographic binary restenosis can occur early, late or very late after implantation of the Absorb everolimus-eluting bioresorbable vascular scaffold (Absorb BVS). Since the mechanical support of the scaffold decreases during bioresorption, the mechanism of in-segment restenosis (ISR) of the Absorb BVS might be different from that of metallic stents. The objective of the current analysis was to review the multimodality imaging of cases with binary restenosis to elucidate the mechanism of ISR after Absorb BVS implantation. The ABSORB Cohort B trial enrolled 101 patients with a maximum of two de novo coronary lesions. At the three-year imaging and clinical follow-up, there were six cases of in-segment binary restenosis: two early ISR (<6 months), one late ISR (6-12 months) and three very late ISR (>12 months). Three of these ISR cases seemed to be induced by anatomical or procedural factors. In the other three cases, intravascular imaging (IVUS/OCT) demonstrated that the main mechanism of restenosis was significant intra-scaffold tissue growth, while the structural circularity and diameter of the scaffold were not affected. Early and late restenosis after implantation of the Absorb bioresorbable scaffold could be related to anatomical or procedural factors. In this small cohort of patients late or very late restenosis seems to be attributed to pure intra-scaffold tissue growth without extrinsic encroachment of the scaffold.

0182: Bioresorbable everolimus eluting stents in coronary arteries. Preliminary implantation data and follow up of 65 patients

Between february 2013 and april 2014, of 1450 coronary angioplaty procédures realized in our institution, 65 patients, aged 64.3 (40-94), underwent coronary artery stenting with Absorb Biovascular Scaffold (BVS) exercise angina 22 patients, acute coronary syndromes 37 (including acute myocardial infarction 5), silent ischemia 7, heart failure 2. Ten patients suffered diabètes (15%) and 14 experienced previous coronay interventions (20%). all stents have been implanted under angiographic control (except two cases including IVUS imaging) in de novo lésions through a radial approach with 6F guiding catheters following mandatory predilatation. 44 patients had single vessel desease (67%) and 21 multivessel desease. Target vessel was the left anterior descending artery in 35 cases, left circumflex in 10 and right artery in 14. 68 stents have been delivered; three patients had two BVS; 16 patients had also metallic drug eluting stents in other arteries. Side branch dilatation had to be performed in 4 patients. Implantation was successfull in all cases. No death Complications: side branch occlusion with non Q wave infarction in one case and transient ischaemic attack in one another. 58 patients left the institution the day after the procedure under conventionnal dual antiplatelet therapy. at 6.2 month (1-15) all patients were event free (100%) Three patients had angiographic control at one year and were free of restenosis; one another had 70% angiographic restenosis at the edges of the stent and underwent longer DES implantation (TLR: 1.5%). Three other patients had computed tomography scanner control at one year with no evidence of restenosis, including one case demonstrating restoration of systolic compression of the stented segment in a myocardal bridging whereas diastolic diameter was normal. at that time our preliminary data confirm the safety of the BVS device at implantation and at six months follow up.

Genetic risk of restenosis after percutaneous coronary interventions in the era of drug-eluting stents.

Our previous studies identified three single nucleotide polymorphisms (SNPs), rs419598 in the interleukin-1 receptor antagonist gene (IL1RN), rs235326 in the CD18 gene (ITGB2), and rs5918 in the platelet glycoprotein IIIa gene (ITGB3), as risk factors for restenosis after placement of bare metal stents in coronary arteries. The aim of the present study was to determine whether these SNPs remain risk factors after drug-eluting stent implantation. The study population included 2028 patients, who underwent drug-eluting stent implantation. The primary study endpoint was angiographic restenosis (diameter stenosis≥50% at the 6-month follow-up angiography) and clinical restenosis (target lesion revascularization at the 3-year follow-up). Angiographic restenosis was observed in 12.8% of the patients with genotype T/T, 14.6% with genotype T/C, and 13.0% with genotype C/C of IL1RN (P=0.60), in 13.1% of the patients with genotype C/C, 13.2% with genotype C/T, and 16.1% with genotype T/T of ITGB2 (P=0.53), and in 13.2% of the patients with genotype T/T, 14.8% with genotype T/C, and 9.6% with genotype C/C of ITGB3 (P=0.50). Clinical restenosis was present in 11.8% of the patients with genotype T/T, 12.5% with genotype T/C, and 9.9% with genotype C/C of IL1RN (P=0.63), in 13.3% of the patients with genotype C/C, 10.0% with genotype C/T, and 13.9% with genotype T/T of ITGB2 (P=0.07), and in 11.9% of the patients with genotype T/T, 12.1% with genotype T/C, and 10.2% with genotype C/C of ITGB3 (P=0.91). The SNPs rs419598 in IL1RN, rs235326 in ITGB2, and rs5918 in ITGB3, which have shown an association with restenosis after implantation of bare metal stents, were not related to restenosis after placement of drug-eluting stents.

ASSA14-12-11 Modified mini-crush versus Cullotte techniques in bifurcation lesions of left anterior descending artery: clinical and angiographic long-term outcome after implantation of drug-eluting stents

Background The best option on the treatment of coronary bifurcation lesions is a subject of considerable debate. However, recent evidence suggests that bifurcation lesions might be treated by drug-eluting stent on both branches using the mini-crush (MMC) with a low rate of major adverse cardiac event and restenosis. This retrospective study sought to assess the clinical and angiographic long-term outcome after implanting drug-eluting stents in the bifurcation lesions of left anterior descending artery (LAD) with the Cullotte and MMC technique. Methods From April 2003 to January 2013, 445 patients were consecutively treated with either MMC (MMC group, n = 141) or Cullotte (Cullotte group, n = 304). The results of in-hospital and 12-month clinical follow-up were analysed. The indexes of in-hospital, angiographic restenosis at 12-months and major adverse cardiac events (MACE) including death, myocardial infarction or any target lesion revascularisation were evaluated. Results The mean 12-month angiographic follow-up was completed in 63 patients (44.7%) of MMC group and in 118 patients (38.8%) of Cullotte group. The MMC group compared with the Cullotte group had significantly shorter operative time and lower main or side branches restenosis (hazard ratio [HR]: 0.41, 95% confidence interval [CI]: 0.20 to 0.85; p = 0.016; and HR 0.52, 95% CI 0.27–0.99; P = 0 .047, respectively). So, the MMC group compared with the Cullotte group had significantly lower revascularisation (HR 0.57, 95% CI 0.31–0.97; p = 0.023). After a propensity score adjustment, 2-year cumulative major adverse cardiac events were similar between groups (p = 0.16). Conclusions The modified mini-crush technique with DES can be safely performed giving complete coverage of the ostium of side branches and optimising side branch access. Both techniques of bifurcation treatment met high procedural success with low complication rates and similar major adverse cardiac event long-term outcome. However, the MMC minimised the stent structs in main branch, yields a lower restenosis rate at main or side branches.

Resultados Angiográficos e do Seguimento Clínico de 5 Anos Após Implante de Stents Farmacológicos com Revestimento Biodegradável em Pacientes com Alto Risco de Reestenose. Análise de Subgrupo do Estudo Randomizado PAINT

Introdução: Polímeros biodegradáveis foram desenvolvidos para reduzir a reação de hipersensibilidade associada aos polímeros duráveis dos stents farmacológicos de primeira geração, mantendo sua eficácia antiproliferativa e aumentado sua segurança. Avaliamos os resultados angiográficos de 9 meses e os resultados clínicos de longo prazo dos stents farmacológicos com polímeros biodegradáveis em pacientes com alto risco de reestenose. Métodos: Pacientes com diâmetro de referência ≤ 2,5 mm, extensão da lesão ≥ 15 mm, diabetes, ou uma combinação dessas características foram selecionados da população do estudo PAINT. Esses pacientes foram previamente randomizados e alocados para intervenção coronária percutânea recebendo os stents farmacológicos com polímeros biodegradáveis com sirolimus ou com paclitaxel ou stents metálicos, na razão 2:2:1. Resultados: Cento e setenta e oito pacientes foram tratados com stents farmacológicos com polímeros biodegradáveis (n = 142) ou stents metálicos (n = 36). No acompanhamento angiográfico de 9 meses, os primeiros mostraram menor perda tardia (0,40 ± 0,42 mm vs. 0,90 ± 0,47 mm; p < 0,01) e reestenose binária (7,4% vs. 25%; p < 0,01). No acompanhamento clínico de 5 anos, o grupo com stents farmacológicos com polímeros biodegradáveis mostrou menores taxas do desfecho combinado de morte cardíaca, infarto do miocárdio e revascularização do vaso-alvo (16,2% vs. 38,0%; p = 0,03), principalmente devido à redução da revascularização do vaso-alvo (9,9% vs. 36,1%; p < 0,01). Morte total, morte cardíaca e infarto do miocárdio não foram diferentes entre os grupos. A trombose do stent, provável ou definitiva, ocorreu em 2,8% vs. 0% (p = 0,30). Conclusões: Os stents farmacológicos com polímeros biodegradáveis eluidores de paclitaxel ou sirolimus foram eficazes na redução de reestenose angiográfica aos 9 meses e na necessidade de reintervenção por reestenose clínica em 5 anos, sem aumentar o risco de trombose do stent.

Avaliação tardia (> 10 anos) da braquiterapia intracoronária com radiação beta para restenose difusa intrastent

IntroductionUntil the development of drug‐eluting stents (DES), diffuse in‐stent restenosis (ISR) was the main limitation of bare‐metal stents in percutaneous coronary intervention (PCI). Among the different treatments available, intracoronary brachytherapy (BT) emerged as one of the most promising, although it was almost abandoned with the increasing use of DES. ObjectiveTo assess the Portuguese experience with 90Sr/90Y beta brachytherapy for the treatment of diffuse ISR regarding long‐term (>10 years) major adverse cardiac events (MACE) and angiographic restenosis. MethodsThis single‐center, retrospective, observational study included 12 consecutive patients treated between January and June 2001, mean age 58.6±9.9 years (range 43‐77 years), 11 male. All had chronic stable angina, 75% had dyslipidemia, 58% had hypertension, 50% had peripheral arterial disease, 42% had diabetes and 50% had multivessel disease. Recurrent ISR was present in half of the patients and 11 had normal left ventricular function. After balloon dilatation, BT was performed using an Sr90/Y90 (Novoste Beta‐CathTM) beta radiation source. All patients remained under dual antiplatelet therapy until scheduled nine‐month follow‐up angiography. Patients were followed for the occurrence of death (all‐cause and cardiovascular), non‐fatal myocardial infarction (MI), revascularization, stent thrombosis and angiographic restenosis. MACE were defined as the combined incidence of cardiac death, MI and urgent target vessel revascularization. ResultsIn all cases there was both clinical and angiographic success. In a mean follow‐up of 10.9±2.5 years, 19 events occurred in seven patients: death in three (25%), only one cardiac (8.3%); ST‐elevation MI in one (related to a non‐target vessel) (8.3%); and 15 revascularizations in five (42%), of which nine were of the target vessel (mainly in the first two years). There was only one case of probable stent thrombosis. Angiographic restenosis at nine months was 27% (three out of 11 patients), of which two were total occlusions. Ten‐year MACE‐free survival was 42% (5 patients). ConclusionsIntracoronary beta brachytherapy for the treatment of diffuse ISR in this small cohort of patients proved to be safe and efficacious, with no late adverse events related to intracoronary radiation.

Late results (>10 years) of intracoronary beta brachytherapy for diffuse in-stent restenosis

IntroductionUntil the development of drug-eluting stents (DES), diffuse in-stent restenosis (ISR) was the main limitation of bare-metal stents in percutaneous coronary intervention (PCI). Among the different treatments available, intracoronary brachytherapy (BT) emerged as one of the most promising, although it was almost abandoned with the increasing use of DES. ObjectiveTo assess the Portuguese experience with 90Sr/90Y beta brachytherapy for the treatment of diffuse ISR regarding long-term (>10 years) major adverse cardiac events (MACE) and angiographic restenosis. MethodsThis single-center, retrospective, observational study included 12 consecutive patients treated between January and June 2001, mean age 58.6±9.9 years (range 43–77 years), 11 male. All had chronic stable angina, 75% had dyslipidemia, 58% had hypertension, 50% had peripheral arterial disease, 42% had diabetes and 50% had multivessel disease. Recurrent ISR was present in half of the patients and 11 had normal left ventricular function. After balloon dilatation, BT was performed using an 90Sr/90Y (Novoste Beta-Cath™) beta radiation source. All patients remained under dual antiplatelet therapy until scheduled nine-month follow-up angiography. Patients were followed for the occurrence of death (all-cause and cardiovascular), non-fatal myocardial infarction (MI), revascularization, stent thrombosis and angiographic restenosis. MACE were defined as the combined incidence of cardiac death, MI and urgent target vessel revascularization. ResultsIn all cases there was both clinical and angiographic success. In a mean follow-up of 10.9±2.5 years, 19 events occurred in seven patients: death in three (25%), only one cardiac (8.3%); ST-elevation MI in one (related to a non-target vessel) (8.3%); and 15 revascularizations in five (42%), of which nine were of the target vessel (mainly in the first two years). There was only one case of probable stent thrombosis. Angiographic restenosis at nine months was 27% (three out of 11 patients), of which two were total occlusions. Ten-year MACE-free survival was 42% (5 patients). ConclusionsIntracoronary beta brachytherapy for the treatment of diffuse ISR in this small cohort of patients proved to be safe and efficacious, with no late adverse events related to intracoronary radiation.

Effect of Cilostazol Following Endovascular Intervention for Peripheral Artery Disease.

Efficacy of endovascular therapy (EVT) with nitinol stents for femoropopliteal (FP) lesions is limited by restenosis. Oral cilostazol reduces angiographic restenosis rate; however, treatment duration remains unclear. In a retrospective analysis of a multicenter database of 3471 consecutive limbs in 2737 patients (mean age: 72 ± 9 years; 61% diabetic; and 26% on regular dialysis) undergoing EVT for FP lesions between January 2004 and December 2011, we compared Kaplan-Meier estimated primary patency after EVT followed or not by cilostazol treatment. We used Cox hazard regression analysis to assess temporal association between cilostazol treatment and post-EVT restenosis. Five-year primary patency was higher in the cilostazol group than in the noncilostazol group (57% vs 47%, P < .0001). Cilostazol treatment was inversely associated with restenosis for the first 2 years following EVT (P < .05); however, no significant association was observed thereafter. Cilostazol use therefore appears efficacious in preventing restenosis up to 2 years after EVT for FP lesions.

Coronary Bifurcations: Still the Touchstone of Drug-eluting Stents and Bioresorbable Vascular Scaffolds?

Coronary bifurcation lesions that involve significant side branches represent a particularly challenging subset of target lesions for percutaneous coronary interventions. Besides the necessity for the interventional cardiologist to often perform technically demanding interventions with more procedural steps, clinical outcome following percutaneous coronary intervention has usually been somewhat inferior. For more than two decades, coronary bifurcation lesions represent a serious touchstone for both interventional cardiologists and various types of stents and vascular scaffolds. The use of first-generation drug-eluting stents (DES) has reduced the incidence of restenosis following percutaneous coronary intervention of bifurcation lesions as compared to bare metal stents. In a first, small-sized study by Colombo et al, a numerically lower rate of angiographic restenosis was seen in bifurcated lesions treated with a single DES in the main vessel. In the meantime, pooled data of the Nordic Bifurcation and the British Bifurcation Coronary studies, both using first-generation Cypher DES (Cordis; Waaren, New Jersey, United States), have clearly demonstrated at 9-month follow-up that clinical outcome is superior following a simple approach with provisional Tstenting of the side branch vs a complex approach. In addition, the Nordic Bifurcation study has shown that long-term outcome (up to 5 years) following bifurcation stenting with a simple approach was at least as good as the outcome of a complex approach. The aforementioned studies were performed with the first-generation Cypher stent that had a closed-cell design. The results of several in vitro studies and bench tests suggest that DES with different stent materials and designs may act differently in the setting of bifurcation stenting. Moreover, the coatings of various DES types show significant dissimilarities in mechanical properties, which may be relevant during kissing balloon inflations that apply a significant shear stress to the coatings of DES. Consequently, the assessment of clinical outcome

Drug-eluting balloon: Initial experience in patients with in-stent restenosis (ISR)

BackgroundIn-stent restenosis is the most important limitation of modern coronary angioplasty. Drug-eluting stents solve this problem but at the cost of late stent thrombosis and longer duration of dual-antiplatelet therapy. Drug-eluting balloon (DEB) technology is now available and offers an attractive option for treatment of restenosis. MethodsA cohort of 20 patients with in-stent restenosis after stenting were treated with a drug-eluting balloon and were followed up clinically and angiographically for 6 months. Results and conclusionProcedural success was achieved in all patients. 6 month clinical follow-up was available for all and 6 month angiographic follow up for 17 patients. On 6 month follow-up, 5 of the 20 patients had recurrence of angina and 4 patients had angiographic restenosis (2 focal, 2 diffuse). The mean Canadian Cardiovascular Society angina score improved significantly from 3.1 to 1.1. DEB offers a novel method of treatment for patients with in-stent restenosis with a good safety and efficacy profile.

Does endovascular treatment of infra-inguinal arterial disease with drug-eluting stents offer better results than angioplasty with or without bare metal stents?

A best evidence topic in vascular and endovascular surgery was developed according to a structured protocol. The question addressed was whether treatment of infra-inguinal arterial occlusive disease with drug-eluting stents (DESs) provides improved outcomes compared with bare metal stents (BMSs) or percutaneous balloon angioplasty (PTA) alone. Altogether, 136 papers were found using the reported searches, of which 5 provided the best evidence to answer the question. All papers represent either level 1 or 2 evidence. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Main outcome measures varied among the studies, and included patency, in-stent restenosis, target lesion revascularization, major adverse events, clinical improvement and limb salvage. Evidence on the comparative efficacy of DESs in femoro-popliteal arterial disease is mainly based on two randomized, controlled trials. Paclitaxel-eluting stents were evaluated in the Zilver PTX trial and demonstrated superior 2-year results to either BMSs or PTA, as indicated/shown by patency (DES vs PTA, 74.8 vs 26.5%, P < 0.01), clinical benefit (DES vs PTA, P < 0.01) and event-free survival (DES vs PTA, 86.6 vs 77.9%, P = 0.02). However, the SIROCCO trial found that the sirolimus-eluting stent did not exhibit statistically significant differences in 2-year in-stent restenosis (22.9 vs 21.1%) and target lesion revascularization (6 vs 13%) compared with the BMS. Treatment of infra-politeal arterial disease with DESs was related with superior outcomes to those of BMSs, as indicated/shown by patency, freedom from target lesion revascularization and freedom from major adverse events. Furthermore, the ACHILLES trial, the only published trial comparing the infra-popliteal DES with PTA, revealed lower angiographic restenosis (22.4 vs 41.9%, P = 0.019) and greater vessel patency (75 vs 57.1%, P = 0.025) in the DES group at 1 year. However, data related to clinical parameters in patients with critical limb ischaemia secondary to infrageniculate arterial disease, such as limb salvage and ulcer healing, are insufficient. In conclusion, treatment of infra-inguinal arterial disease with DES is safe and seems to be superior to treatment with PTA alone or BMS. The role of DES in sustained improvement in clinical outcome end-points, such as limb salvage, remains to be elucidated.

THE ‘ANGIOGRAPHIC EVALUATION OF THE EVEROLIMUS-ELUTING STENT IN CHRONIC TOTAL OCCLUSIONS’ (ACE-CTO) STUDY

There is limited data on outcomes after implantation of second generation drug-eluting stents in coronary chronic total occlusions (CTOs). Our study's aim is to evaluate the frequency of angiographic restenosis and clinical outcomes after implantation of the everolimus-eluting stent (EES) in CTOs

Angiographic result of T-stenting with small protrusion using drug-eluting stents in the management of ischemic side branch: the ARTEMIS study

The aim of this study was to examine the mid-term angiographic result of T-stenting with small protrusion (TAP) as the bailout strategy for treating coronary bifurcation lesions. From 2009 to 2012, symptomatic patients who had severe coronary bifurcation stenoses were treated with one-stent strategy using drug-eluting stents, with kissing balloon inflation performed whenever side branch (SB) impingement occurred. TAP was performed if residual diameter stenosis of SB was ≥75%, presence of ≥type B dissection or flow impairment was observed in the SB. Seventy-one patients (83% male, mean age of 61 ± 12 years) were recruited into the study. MEDINA classification 1,1,1 lesions were observed in over 60% of patients. The mean stent size and length in the main vessel (MV) and SB were 2.86 ± 0.43 and 30 ± 12, and 2.45 ± 0.26 and 16 ± 6 mm, respectively. Restudy angiography was performed on 64 (90 %) patients at 9.2 ± 3.9 months. Angiographic restenosis was observed in 8 (12.5%) patients with late lumen loss in the MV and SB being 0.22 ± 0.19 and 0.34 ± 0.37 mm, respectively. The use of TAP as the bailout technique for treating coronary bifurcation lesions is associated with good angiographic outcomes, in terms of late lumen loss and restenosis, at 9 months.

Sirolimus-eluting versus paclitaxel-eluting stents in diabetic and non-diabetic patients within sirolimus-eluting stent restenosis: Results from the ISAR-DESIRE 2 trial

Concern exists relating to potential attenuated efficacy of limus-eluting stents in patients with diabetes mellitus. In this respect diabetic patients with sirolimus-eluting stent (SES) failure requiring reintervention may be expected to derive particular benefit from a treatment-switch to paclitaxel-eluting stent (PES) implantation. The aim of the current report was to investigate outcomes of patients with SES restenosis randomized to treatment with SES (same stent strategy) or PES (switch stent strategy) in the pre-specified subgroups of patients with and without diabetes mellitus. In the setting of ISAR-DESIRE 2 trial, 450 patients with clinically significant SES restenosis were randomly assigned to receive either SES or PES. The primary end point was in-stent late loss at 6-8month follow-up angiography. Secondary endpoints were binary angiographic restenosis (diameter stenosis >50%) and target lesion revascularization (TLR), the composite of death or myocardial infarction (MI) and definite stent thrombosis at 12months. Of 450 patients enrolled, 162 (36.0%) had a diagnosis of diabetes mellitus. In patients with diabetes 86 patients were randomly assigned to SES versus 76 to PES. In patients without diabetes 139 were assigned to SES versus 149 to PES. Late loss was comparable between SES and PES both in patients with diabetes (0.38±0.59mm vs. 0.37±0.59mm; p=0.97) and without (0.41±0.67mm vs. 0.38±0.6mm; p=0.98; pinteraction=0.89). Similarly binary restenosis was comparable between SES and PES in patients with diabetes (19.0% vs. 26.0%; p=0.32) or without (18.9% vs. 17.8%; p=0.98; pinteraction=0.36). TLR, death or MI and definite stent thrombosis were also similar in SES versus PES treatment groups regardless of diabetes status. In cases of SES-restenosis, treatment with either repeat SES or switch to PES was associated with a comparable degree of efficacy, regardless of diabetic status.

Overaggressive stent expansion without intravascular imaging: impact on restenosis

ObjectiveAggressive stent expansion is required for optimal strut apposition, but risk of stent deformation, fracture and subsequent restenosis is potentially greater when performed without intravascular imaging guidance. We investigated how...