Higher Risk Of Stent Thrombosis Research Articles

Peripartum Management of Dual Antiplatelet Therapy and Neuraxial Labor Analgesia After Bare Metal Stent Insertion for Acute Myocardial Infarction

A 31-year-old woman at 32 weeks' gestation presented with an ST segment elevation myocardial infarction with subsequent bare metal stent placement. A multidisciplinary team coordinated the delivery plan, including anticoagulation and delivery mode. Because the patient was at high risk for stent thrombosis, clopidogrel was discontinued after 4 weeks and bridged with eptifibatide for 7 days. Eptifibatide was stopped for induction of labor. Twelve hours after eptifibatide was discontinued, hemostatic function was assessed with thromboelastography before initiating neuraxial analgesia. A successful operative vaginal delivery was performed, followed by an uncomplicated recovery. Clopidogrel was resumed 24 hours postpartum.

Stent thrombosis in patients with chronic kidney disease

Chronic kidney disease is a strong predictor of adverse cardiac events, including death, myocardial infarction and stent thrombosis (ST), after percutaneous coronary intervention. In the past few years, the development of new therapeutic strategies (including both drugs and devices) and a more complete understanding of the pathophysiology and predictive factors of thrombosis have led to a significant reduction of this complication. Despite this, ST still remains a dramatic event due to its morbidity and mortality. Further efforts should be pursued to identify patients at high risk of ST in order to adopt a more effective preventive strategy. This review sought to examine the total weight of evidence regarding ST with the use of drug-eluting stents in patients with chronic kidney disease.

Drug-Eluting vs Bare-Metal Stents in Primary Angioplasty

Concerns have emerged regarding a higher risk of stent thrombosis after drug-eluting stent (DES) implantation, especially in the setting of ST-segment elevation myocardial infarction (STEMI). Our objective was to perform a meta-analysis using individual patient data to evaluate the long-term safety and effectiveness of DES compared with bare-metal stents (BMS) in patients undergoing primary percutaneous coronary intervention for STEMI. Formal searches of electronic databases (MEDLINE and CENTRAL) and scientific session presentations from January 2000 to June 2011. We examined all completed randomized trials of DES for STEMI. Individual patient data. Individual patient data were obtained from 11 of 13 trials identified, including a total of 6298 patients (3980 [63.2%] randomized to DES [99% sirolimus-eluting or paclitaxel-eluting stents] and 2318 [36.8%] randomized to BMS). At long-term follow-up (mean [SD], 1201 [440] days), DES implantation significantly reduced the occurrence of target-vessel revascularization (12.7% vs 20.1%; hazard ratio [95% CI], 0.57 [0.50-0.66]; P<.001, P value for heterogeneity, .20), without any significant difference in terms of mortality, reinfarction, and stent thrombosis. However, DES implantation was associated with an increased risk of very late stent thrombosis and reinfarction. The present pooled patient-level meta-analysis demonstrates that among patients with STEMI undergoing primary percutaneous coronary intervention, sirolimus-eluting and paclitaxel-eluting stents compared with BMS are associated with a significant reduction in target-vessel revascularization at long-term follow-up. Although there were no differences in cumulative mortality, reinfarction, or stent thrombosis, the incidence of very late reinfarction and stent thrombosis was increased with these DES.

PLATELET FUNCTION TESTING GUIDED USE OF PRASUGREL IN PATIENTS WITH HIGH ON-CLOPIDOGREL TREATMENT PLATELET REACTIVITY REDUCES THE RISK OF EARLY STENT THROMBOSIS

In clopidogrel treated patients undergoing PCI, high platelet reactivity (HPR) is associated with a higher risk for stent thrombosis (ST). Prasugrel may be advantageous over clopidogrel especially in HPR patients. Here, we report the results of a 5 year-experience of routine platelet function (PF)

Can the restenosis benefit of drug-eluting and bare-metal stents be predicted?

Evaluation of: Yeh RW, Normand SL, Wolf RE et al. Predicting the restenosis benefit of drug-eluting versus bare-metal stents in percutaneous coronary intervention. Circulation 124(14), 1557–1564 (2011). Drug-eluting stents (DES) reduce restenosis rates. However, there is the need for prolonged (1 year) dual antiplatelet therapy (DAT). Also, concerns have been raised regarding the higher risk of stent thrombosis, especially with the first-generation DES. Therefore, physicians and interventional cardiologists should select the use of DES or bare-metal stents (BMS), by assessing the risk of restenosis, bleeding associated with prolonged DAT and stent thrombosis in each patient. Yeh et al. propose a model predicting target vessel revascularization risk, which include only 3 factors: diabetes mellitus, lesion/stent length and vessel/stent diameter. A target vessel revascularization rate with BMS of <11% is associated with an increase in society-based costs to prevent one repeat procedure of more than US$10,000...

Bare Metal Stent Thrombosis in Patients With Acute Coronary Syndrome

Patients undergoing coronary stenting during acute coronary syndrome (ACS) are exposed to a higher risk of stent thrombosis (ST) than those undergoing elective stenting. FEW STUDIES HAVE AIMED TO IDENTIFY ST INCIDENCE AND PREDICTORS IN THIS SPECIFIC POPULATION. This single-center study enrolled 611 consecutive Tunisian patients with ACS who underwent coronary stenting with bare metal stents (BMS). The incidence of ARC (Academic Research Consortium) definite ST throughout a median 16-month follow-up period was 3.5%; it was 9.2% in patients with ST-elevation myocardial infarction (STEMI) who underwent an emergency percutaneous coronary intervention (PCI). Independent predictors were fever during PCI (hazard ratio (HR) 5.19; 95% confidence interval (95%CI) 1.69-15.95, P=0.004); premature cessation of clopidogrel (HR 2.66; 95%CI 1.02-6.97, P=0.046), resumption of smoking (after PCI) (HR 4.41; 95%CI 1.58-12.27, P=0.005), primary PCI (HR 5.02; 95%CI 1.57-16.01, P=0.006), rescue PCI (HR 6.33; 95%CI 2.08-19.34, P=0.001), reference vessel diameter <2.8mm (HR 6.96; 95%CI 2.06-23.56, P=0.002), TIMI flow grade before PCI <2 (HR 11.51; 95%CI 2.76-48.06, P=0.001) and a visible thrombus (HR 3.57; 95%CI 1.1-11.12, P=0.028). The incidence of ST in ACS patients was higher than classically described. Clopidogrel discontinuation and resumption of smoking are involved. Efforts should be made to improve patient education and secondary prevention.

Unraveling the Pharmacogenetics of Clopidogrel

Clopidogrel forms a cornerstone in the treatment of patients undergoing coronary stenting. Although the clinical effectiveness of clopidogrel has been shown repeatedly in large clinical trials, there appears to be a large interindividual response variability that influences the risk of atherothrombotic events.1,2 Studies3,4 have shown that differences in the plasma concentration of the active metabolite of clopidogrel are an important determinant of its antiplatelet effect. Although several environmental factors influence the formation of the active metabolite, most variation appears to be genetic.5 Numerous studies5–7 have shown that polymorphisms in genes encoding the cytochrome (CYP) p450 system, especially CYP2C19, influence bioactivation of clopidogrel and, hence, the risk of cardiovascular events, especially stent thrombosis. Still, polymorphic variation in CYP2C19 seems to explain only 5% to 11% of the response variability to clopidogrel, leaving variation in bioactivation of clopidogrel largely unexplained.5,8 Article see p 422 A new player in the pharmacogenetics of clopidogrel was introduced by Bouman et al,9 who identified paraoxonase-1 (PON1) as a major determinant of the bioactivation and clinical efficacy of clopidogrel in a series of elegant experiments and clinical studies among subjects from European descent. This hepatic esterase is associated with high-density lipoprotein and has antioxidative effects on low-density lipoprotein and macrophages. Bouman et al identified PON1 as the crucial enzyme for the bioactivation of clopidogrel, with its common Q192R polymorphism determining the rate of active thiol metabolite formation. In a case-cohort study among 41 cases with stent thrombosis and 71 control subjects, the Q allele was dose-dependently associated with lower PON1 activity and active metabolite concentrations in plasma, reduced platelet inhibition, and a higher risk of stent thrombosis. Q192R explained >70% of the response variability to clopidogrel. The authors corroborated their findings in a …

Perioperatives Management der antithrombotischen Behandlung bei Stent-Patienten

Perioperative management of antiplatelet treatment in patients with coronary stents remains challenging as premature discontinuation may cause thrombotic events. To date, there is a lack of evidence-based results and guidelines to recommend adequate antithrombotic drug therapy in patients at high risk of stent thrombosis who undergo noncardiac surgery. According to our clinical experience with these patients, we propose a perioperative bridging of discontinued dual antiplatelet therapy by the „off-label“ use of low molecular weight glycoprotein IIbIIIa antagonist for up to 24 hours. Patients should be monitored by a perioperative point-of-care-testing and, thus, could benefit from the individually adapted antiplatelet therapeutic issue.

Bare-Metal Stents Versus Drug-Eluting Stents for Primary Angioplasty: Long-Term Outcome

Percutaneous transluminal coronary intervention (PCI) is the most used myocardial revascularization technique for patients with coronary artery disease. Primary PCI with stent implantation is widely considered the gold standard for the treatment of ST-elevation myocardial infarction patients. Coronary stents, compared with balloon angioplasty, have reduced focal lesion restenosis. To reduce in-stent restenosis, drug-eluting stents (DES) were designed to locally release drugs inhibiting neointimal growth. Recent concerns have emerged on the potential higher risk of stent thrombosis with DES that might be even more pronounced among myocardial infarction patients. For these reasons, DES for primary PCI remains an "off-label" use. In the last several years, a number of randomized trials and registries have tested the safety and efficacy of DES in primary PCI. Data from these studies were analyzed in several meta-analyses, reasonably consistently demonstrating that the use of DES significantly decreased the need for revascularization without an increase in the incidence of death, recurrent infarction, or stent thrombosis at long-term follow-up.

Relationship between clopidogrel-induced platelet P2Y12 inhibition and stent thrombosis or myocardial infarction after percutaneous coronary intervention—A case-control study

Insufficient platelet inhibition is a major determinant of stent thrombosis (STh), although the etiology is multifactorial. On-clopidogrel platelet reactivity was investigated in patients with previous angiographically confirmed STh, myocardial infarction (MI), and controls. Using the Swedish Coronary Angiography and Angioplasty Registry, we identified patients with angiographically confirmed STh (n = 48) or MI (n = 30) while on dual antiplatelet therapy within 6 months of percutaneous coronary intervention (PCI) and matched control patients (n = 78). On-clopidogrel platelet reactivity was measured with VerifyNow P2Y12 and vasodilator-stimulated phosphoprotein (VASP) phosphorylation assay. The mean P2Y12 reaction units (PRU) was higher (246.8 ± 75.9 vs 200.0 ± 82.7, P = .001) in STh patients compared with controls. The optimal cutoff for STh was 222 PRU or higher (area under the curve 0.69, P < .0001) in a receiver operating characteristics (ROC) analysis. The cutoff level resulted in 70.2% sensitivity and 67.3% specificity. There was no significant difference in mean PRU but a higher device-reported percent inhibition (45.1 ± 23.8 vs 32.1 ± 23.2, P = .04) in patients with MI compared with controls. Results with the VASP phosphorylation assay were not related to the occurrence of STh or MI. STh was associated with high on-clopidogrel platelet reactivity measured with VerifyNow (cutoff level of PRU ≥222) but spontaneous MI in stented patients on clopidogrel treatment was not. There was, however, a substantial overlap in on-clopidogrel platelet reactivity between patients with and without on-treatment STh questioning the clinical use of platelet function testing to identify patients at high risk for STh.

Coronary stents and non-cardiac surgery: current management strategies

The care of patients with coronary stents in the perioperative period of non-cardiac surgery requires anesthesiologists, surgeons and cardiologists. The management of dual antiplatelet therapy should be handled depending on type and urgency of the surgery, the risk of bleeding, type of coronary stent implanted, time from placement and the risk of stent thrombosis. For patients identified as high risk of stent thrombosis, surgery should be planned at hospitals with cardiac catheterization facilities. These patients require postoperative monitoring and antiplatelet therapy should be restarted immediately. Stent thrombosis should be recognized early and treated aggressively with percutaneous coronary intervention.

Stents coronarios y cirugía no cardiaca: estrategias de manejo actual

The care of patients with coronary stents in the perioperative period of non-cardiac surgery requires anesthesiologists, surgeons and cardiologists. The management of dual antiplatelet therapy should be handled depending on type and urgency of the surgery, the risk of bleeding, type of coronary stent implanted, time from placement and the risk of stent thrombosis. For patients identified as high risk of stent thrombosis, surgery should be planned at hospitals with cardiac catheterization facilities. These patients require postoperative monitoring and antiplatelet therapy should be restarted immediately. Stent thrombosis should be recognized early and treated aggressively with percutaneous coronary intervention.

No association of paraoxonase-1 Q192R genotypes with platelet response to clopidogrel and risk of stent thrombosis after coronary stenting

In clopidogrel-treated patients undergoing coronary stenting, high on-treatment platelet reactivity was linked to a higher risk of stent thrombosis (ST). Platelet response to clopidogrel is significantly influenced by genetic factors. Recently published findings showed a highly significant impact of a common polymorphism (Q192R) within the paraoxonase-1 (PON1) gene on clopidogrel treatment efficacy but no influence of the CYP2C19*2 genetic variant as previously demonstrated. The aim of this study was to assess the impact of the PON1 Q192R genotype in parallel to that of CYP2C19*2 on the antiplatelet effect of clopidogrel and the risk of ST in clopidogrel-treated patients. In 1524 patients undergoing percutaneous coronary intervention, ADP-induced platelet aggregation was assessed in relation to PON1 Q192R and CYP2C19*2 genotypes. The clinical impact of genetic variants was investigated by comparing genotype frequencies of both genetic variants in a registry of 127 cases with early ST vs. an early ST-free control cohort (n = 1439). For PON1 Q192R genotypes, platelet aggregation values were similar across all genotype groups (P = 0.65). For CYP2C19*2 genotypes, significantly higher aggregation values were found in CYP2C19 wt/*2 and *2/*2 patients when compared with wt/wt allele carriers (P < 0.0001). Comparing genotype frequencies between ST cases and controls, no differences were observed for PON1 Q192R genotype distributions (P = 0.23), whereas the genotype distribution differed for CYP2C19*2 genotypes (P = 0.019). The PON1 Q192R genotype did not influence platelet response to clopidogrel or the risk of ST in clopidogrel-treated patients, whereas the CYP2C19*2 genotype impacted on both antiplatelet effect of clopidogrel and risk of coronary ST.

Rationale and design of the randomized, multicenter EREMUS trial, a study that investigates how to achieve low restenosis and early reendothelialization after percutaneous coronary interventions

Drug eluting stent (DES) use has improved clinical outcome after percutaneous coronary interventions. However, DES-treated patients may have a higher risk of stent thrombosis, mainly due to uncorrect stent deployment or lack of reendothelialization. Thus, the availabilily of different approaches with comparable efficacy to DES, but higher safety, especially in bleeding-prone patients, have to be investigated. The EREMUS is a multicenter open-label prospective randomized three-arm clinical trial that will investigate the efficacy of a paclitaxel coated balloon + an endothelial progenitor capture stent for the treatment of native coronary lesions, and compare it to a DES strategy, or the sole endothelial progenitor capture stent. An angiographic follow-up with optical coherence tomography analysis will be scheduled 9 months after index procedure. Noninferiority regarding the primary endpoint (late luminal loss) between study group and DES is hypothesized. All patients will undergo clinical follow-up until 24 months from index hospitalization. The EREMUS trial will determine whether a composite approach with a paclitaxel coated balloon + an endothelial progenitor capture stent in coronary lesions at medium-to-high risk of restenosis will achieve similar results compared to DES regarding inhibition of intrastent proliferation; complete stent strut reendothelialization, a safety issue, will also be investigated.

Why a EuroIntervention supplement on bifurcation stenting?

Where we began The first attempts to dilate a coronary bifurcation stenosis were carried out in the 1980s, with kissing balloon techniques being performed via two separate guiding catheters! This technique was associated with a poor outcome as well as high complication and restenosis rates. A broad variety of bifurcation stenting techniques were described in the 90s during the bare metal stent (BMS) era, one of the initial strategies being the placement of the famous PS 153 Cordis stent bridge in front of a side branch. Most of these techniques originated in the creative mind of Antonio Colombo in an attempt to adapt the treatment strategies to the various types of coronary anatomy. Although the use of stents increased the safety of these techniques, high restenosis and re-intervention rates were still reported. Despite the absence of randomised trials, the first clinical and bench studies on stent deployment led to the idea of using a single stent to treat a coronary bifurcation whenever possible. Since 2000, the use of drug-eluting stents (DES) has considerably decreased the risk of restenosis and re-intervention after bifurcation stenting, but this at the price of a potential higher risk of stent thrombosis as in non-bifurcated lesions. The improvement in outcome prompted the development of many new techniques which were designed to address the problem of side branch restenosis by achieving enhanced coverage of the whole bifurcation.

Is there a higher risk of stent thrombosis in bifurcation lesion or is it related to the technique?

Bifurcation lesions and bifurcation stenting have been reported to be risk factors of stent thrombosis (ST). ST is a complex process that may be the culmination of device, patient, lesion and procedural factors. The strategy of provisional SB stenting is widely accepted for suitable bifurcation lesions, and is accompanied by low rates of ST. However, it is not applicable to all patients, and in these clinical scenarios (approx. 10%), there is no consensus on the best option for elective stenting with two stents regarding the incidence of ST. Excessive metal scaffolding, such as in the classical crush technique, should be avoided. Further accumulation of long-term data from larger clinical registries and randomised studies will be needed to elucidate the best technique regarding the avoidance of ST in bifurcation treatment. Dedicated bifurcation stents tailored for each type of lesion could resolve this issue, especially the excess of metal protruding in the vessel lumen or crushed onto the wall. However, they need to be tested in upcoming and ongoing trials. Stent thrombosis (ST) is the sudden occlusion of a stented coronary artery due to thrombus formation. Despite major improvements of antiplatelet therapy, thrombotic events remain the primary cause of death after percutaneous coronary interventions (PCI). The clinical consequences of ST are frequently catastrophic and include death in 20% to 48% or major myocardial infarction (MI) in 60% to 70% of the cases. In the drug-eluting stent era, ST and especially very late ST remains a concern of coronary intervention. Bifurcation lesions and bifurcation stenting have been reported to be the risk factors for ST. ST is a complex process that may be a culmination of device, patient, lesion, and procedural factors. The exact cause of the higher risk of ST in bifurcation lesions is unknown although pathologic studies have suggested that the arterial branch points are predisposed to development of atherosclerotic plaque, thrombus, and inflammation because they are foci of low shear stress.

Antiplatelet therapy in the perioperative period

The current practice of withdrawing aspirin 7–10 days preoperatively may be dangerous in certain groups of patients. The risk of cardiovascular events increases 3-fold after aspirin withdrawal. The average time between aspirin withdrawal and the manifestation of acute coronary syndrome is 8 to 11 days. The withdrawal of clopidogrel earlier than 4–6 weeks after bare metal stent implantation or less than 12 months after drug-eluting stent implantation is very risky and poses a high risk of stent thrombosis and high perioperative mortality. Continuing aspirin perioperatively leads to a 1.5-fold increase in perioperative bleeding complications but it does not lead to a higher severity of bleeding complications or higher mortality. The article analyzes current European and American guidelines for perioperative antiplatelet treatment and suggests an algorithm based on the guidelines to help make clinical decisions.

041 Clopidogrel and proton pump inhibitors: can near patient testing help to inform dual prescription?

Clopidogrel is relatively contraindicated in patients at risk of gastrointestinal bleeding. To reduce this risk, proton-pump inhibitors (PPI) which are often co-prescribed. Many PPIs undergo hepatic metabolism by the cytochrome (CYP) P450 isoenzymes, thus CYP P450-metabolised drugs, including clopidogrel become vulnerable to drug-drug interaction. Gilard et al first highlighted the negative impact of PPIs, on the pharmacodynamic response to clopidogrel in the randomised, double-blind Omeprazole CLopidogrel Aspirin (OCLA) trial. A randomised trial of omeprazole and pantoprazole conducted by Cuisset et al also demonstrated that after 1 month, patients receiving pantoprazole had significantly better platelet response to clopidogrel than those receiving omeprazole. Population-based studies have suggested that concomitant use of PPI with clopidogrel results in significantly increased risk of adverse outcomes. Anxieties brought on by such studies have been largely allayed by the recently presented results of the COGENT trial. This major randomised controlled trial, comparing clopidogrel with omeprazole vs clopidogrel alone demonstrated no difference in the risk of cardiovascular events between groups. We assessed the impact of PPI co-prescription on clopidogrel response using a verified near patient test, prospectively in 269 patients (mean age 63±11, 85 female) admitted with high risk ACS (characterised by electrocardiographic changes of ischaemia and/or raised troponin I). Loading and maintenance of clopidogrel was as per contemporary UK practice. Eighty-eight patients were prescribed a PPI concomitantly as in-patients. Platelet response to clopidogrel in whole blood samples, taken at the time of angiography, was assessed using a VerifyNow analyser (Accumetrics, California, US). Of the 269 patients recruited, 151 (56%) proceeded to PCI, 40 (15%) underwent coronary artery bypass grafting (CABG), 78 (29%) were treated medically. The clinical endpoint was adverse clinical events (ACE) at 18 months (death, MI, repeat revascularisation, CABG, stroke or unplanned cardiovascular hospitalisation). Co-administration of PPI and clopidogrel was associated with significantly reduced clopidogrel P2Y12 activity (p=0.022) (Abstract 41 Figure 1a) but not clinical outcome (ACE, p=0.123, Abstract 41 Figure 1b). Groups were well matched for age, gender, body mass index, current smoking, presence of diabetes and hyperlipidaemia. More patients in the PPI group had suffered a previous MI (36% vs 20%, p=0.007) and had received previous PCI treatment (20% vs 8%, p=0.005). As near patient tests of clopidogrel activity find their position in the care of patients with ischaemic heart disease, physicians may wish to use this technology to test patients at high risk of stent thrombosis who are also taking medications which pose a risk of inhibiting platelet clopidogrel response.

The Relationship and Threshold of Stent Length With Regard to Risk of Stent Thrombosis After Drug-Eluting Stent Implantation

The aim of this study was to evaluate the association between the length of the stented segment and the risk of stent thrombosis (ST) after drug-eluting stent (DES) implantation and to determine the cutoff value of stent length in higher risk of ST in routine clinical practice. Despite the recommendations of full lesion coverage to prevent angiographic restenosis, the length of the stented segment has been a risk factor for DES-related ST. A total of 3,145 consecutive patients (4,667 lesions) who underwent DES implantation were analyzed. The independent association of stent length with ST and its predictive value were evaluated for a median 29.6 months (interquartile range 21.6 to 37.5 months). Stent thrombosis occurred in 68 patients (2.2%) at 3 years. The stent length/lesion was an independent predictor of ST (hazard ratio: 1.11, 95% confidence interval: 1.06 to 1.15, p < 0.001). The threshold of stent length for predicting ST was 31.5 mm (area under the receiver-operating characteristic curve: 0.746, 95% confidence interval: 0.699 to 0.793, p < 0.001), which had a sensitivity and specificity of 88.4% and 52.1%, respectively. Stent lengths >or=31.5 mm were associated with higher rates of ST (4.0% vs. 0.7%, p < 0.001), death (5.2% vs. 3.0%, p = 0.005), and myocardial infarction (2.4% vs. 0.7%, p = 0.001) at 3 years, as compared with stent lengths <31.5 mm. Length of the stented segment was independently associated with the incidence of ST and death or myocardial infarction after DES implantation. The value of stent length >or=31.5 mm is a threshold for the prediction of ST.

Efficacy and Safety of Drug-Eluting Stents in Chronic Total Coronary Occlusion Recanalization: A Systematic Review and Meta-Analysis

The aim of this study was to compare the efficacy and safety of drug-eluting stent (DES) and bare-metal stent (BMS) use in chronic total occlusion (CTO) recanalization. The long-term effectiveness and safety of DES use in CTO recanalization are unclear, and performance of randomized clinical trials in the field is complex. Major electronic information sources were explored for articles comparing outcomes with DES and BMS use among patients with CTO. Assessed clinical outcomes were death, myocardial infarction, target vessel revascularization, major adverse cardiac events, and stent thrombosis; angiographic outcomes were stent restenosis and stent reocclusion. Fourteen comparative studies were identified (a total of 4,394 patients). When compared with BMS, DES significantly reduced risk of major adverse cardiac events (relative risk [RR]: 0.45, 95% confidence interval [CI]: 0.34 to 0.60, p < 0.001) and TVR (RR: 0.40, 95% CI: 0.28 to 0.58, p < 0.001) without increasing death (RR: 0.87, 95% CI: 0.66 to 1.16, p = 0.88) or myocardial infarction (RR: 0.89, 95% CI: 0.54 to 1.46, p = 0.80). This benefit was sustained at >/=3 years of follow-up. Lower RRs for restenosis (RR: 0.25, 95% CI: 0.16 to 0.41, p < 0.001) and stent reocclusion (RR: 0.30, 95% CI: 0.18 to 0.49, p < 0.001) were also observed in the DES group. A strong trend toward a higher rate of stent thrombosis was documented in DES-treated patients (RR: 2.79, 95% CI: 0.98 to 7.97, p = 0.06). DES use in CTO recanalization is associated with significantly fewer major adverse cardiac events and fewer occurrences of target vessel revascularization, restenosis, and stent reocclusion than with BMS. Although a statistical trend toward a higher risk of stent thrombosis was observed, the use of DES in this context seems to be safe, with an overall benefit sustained in the long term.