Independent Predictor Of Restenosis Research Articles

Risk Factors for Restenosis after Drug-coated Balloon Angioplasty for Complex Femoropopliteal Arterial Occlusive Disease

Currently, there exist limited data on patient outcomes following the use of drug-coated balloons (DCBs) to treat complex femoropopliteal arterial occlusive lesions. The aim of the this study is to investigate the outcomes of patient treated with DCBs and to identify the predictors of restenosis. We retrospectively investigated medical records from 120 patients (137 limbs) treated with DCBs for femoropopliteal lesions at a single center between 2013 and 2016. Primary patency, target lesion revascularization (TLR), and risk factors of restenosis were analyzed. There were 80 de novo and 57 in-stent restenosis lesions. Mean lesion length was 22.2±11.6cm. The clinical primary patency was 85.2% at 1year and 65.3% after 2years. The TLR-free survival rate was 93.0% at 1year and 87.1% after 2years. Critical limb ischemia (CLI; hazard ratio [HR] 5.80, 95% confidence interval [CI] 1.26-26.68, P=0.024) and hypercholesterolemia (HR 4.66, 95% CI 1.30-16.76, P=0.018) were identified as independent predictors of restenosis. In addition, nonuse of cilostazol and popliteal artery involvement showed trends toward an increased risk of restenosis. Treatment with DCBs showed excellent primary patency and TLR-free survival at 1 year after the procedure. However, the primary patency continuously deteriorated beyond 1 year, suggesting a late catch-up phenomenon. The risk of restenosis after treatment with DCBs was significantly associated with CLI and hypercholesterolemia.

Long-Term Outcome of Balloon Angioplasty Without Stenting for Symptomatic Middle Cerebral Artery Stenosis

A recent randomized controlled trial demonstrated that aggressive medical management was superior to angioplasty with stenting for intracranial stenosis. The purpose of this study was to assess initial and long-term outcomes of balloon angioplasty without stenting for symptomatic middle cerebral artery (MCA) stenosis. We retrospectively analyzed the clinical data of 72 patients (mean age, 58.9 years old) with 84 balloon angioplasties without stenting for high-grade (>70%) atherosclerotic stenosis of the main trunk of the MCA. All patients had experienced recurrent transient ischemic attack or minor stroke resistant to medical treatment. We assessed perioperative and long-term outcomes such as restenosis and the recurrence of strokes. The follow-up period was a median of 63 months (range, 6-171 months). Balloon angioplasty was successful in 97% of procedures. During the 30-day perioperative period, a total of 3 patients suffered from stroke (4.2%) without death. A total of 23 (31.9%) patients had restenosis at a time point that varied from 6 to 111 months. Diabetes mellitus (DM) was noted significantly more often in the restenosis group (39%) than in the nonrestenosis group (13%). Multivariate logistic regression analysis revealed DM (odds ratio, 4.84; 95% confidence interval, 1.196-19.62; P = .027) as an independent predictor of restenosis. Restenosis and DM were indicated as independent predictors of the recurrence of ischemic stroke and transient ischemic attack. Balloon angioplasty without stenting for symptomatic MCA stenosis can be performed with a high successful rate and a low risk of complications. Long-term outcome data suggest that this procedure reduces the risk of further strokes.

Monocyte Chemoattractant Protein-1 Levels and Postangioplasty Restenosis of Arteriovenous Fistulas.

Inflammation is relevant in restenosis of atherosclerotic vascular diseases, but its role in dialysis arteriovenous fistula remains unknown. In animal studies, upregulation of monocyte chemoattractant protein-1 has been shown in venous segments of arteriovenous fistula. We, therefore, aimed to investigate serial changes in circulating monocyte chemoattractant protein-1 after percutaneous transluminal angioplasty of dialysis arteriovenous fistulas and its relation to restenosis. Fifty-nine patients with dysfunctional arteriovenous fistulas that were referred for percutaneous transluminal angioplasty were enrolled prospectively between January of 2010 and July of 2012. Three of them were excluded due to percutaneous transluminal angioplasty failure or acute infection. Blood was sampled from arteriovenous fistulas at baseline, 2 days, 2 weeks, and 3 months after percutaneous transluminal angioplasty. Clinical follow-up was continued monthly for 3 months. Angiographic follow-up was arranged at the end of 3 months. Seventeen patients without significant stenosis were enrolled as the control group. Fifty-six patients completed clinical follow-up. Significant increases in monocyte chemoattractant protein-1 were observed at 2 days and 2 weeks (both P<0.001) after percutaneous transluminal angioplasty. Twenty-three (41%) patients had symptomatic restenosis. The restenosis group had a higher percentage change in monocyte chemoattractant protein-1 levels at 2 days (median =47%; interquartile range, 27%-65% versus median =17%; interquartile range, 10%-25%; P<0.001) after percutaneous transluminal angioplasty compared with the patent group. Fifty-two patients completed angiographic follow-up. A positive correlation between relative luminal loss and monocyte chemoattractant protein-1 increase at 2 days after percutaneous transluminal angioplasty was found (r=0.53; P<0.001). In multivariate analysis, postangioplasty monocyte chemoattractant protein-1 increase at 2 days was an independent predictor of restenosis. Using receiver operator characteristic analysis, >25% postangioplasty increase of monocyte chemoattractant protein-1 was significantly associated with restenosis after percutaneous transluminal angioplasty (hazard ratio, 5.36; 95% confidence interval, 1.81 to 15.8). Circulating monocyte chemoattractant protein-1 levels were elevated 2 days and 2 weeks after percutaneous transluminal angioplasty. Early postangioplasty increase of monocyte chemoattractant protein-1 level was associated with restenosis of arteriovenous fistulas.

Incidence and risk factors for restenosis, and its impact on blood pressure control after percutaneous transluminal renal angioplasty in hypertensive patients with renal artery stenosis.

Percutaneous transluminal renal angioplasty (PTA) is one of the standard treatments for renal artery stenosis (RAS). We investigated the frequency and risk factors for restenosis, and its impact on blood pressure (BP) control. A total of 175 hypertensive patients with RAS [mean age 60 years; 34% women; 30.3% fibromuscular dysplasia (FMD)] with 207 treated renal arteries were included and followed for more than 1 year without reangioplasty. Diagnosis of restenosis was based on duplex ultrasonographic findings, and data including BP and antihypertensive medication were collected consecutively. During follow-up (mean, 5.1 years), 56 patients (32.0%) developed restenosis. In multivariate Cox regression analysis, FMD was an independent predictor of restenosis (hazard ratio 2.65, P < 0.05). When divided into two groups based on FMD or atherosclerotic RAS (ARAS), the presence of previous cardiovascular disease (hazard ratio 2.84) as well as severe RAS (≥90%) (hazard ratio 3.95) in ARAS were independent predictors of restenosis (P < 0.05, respectively). At 1 year after PTA, 35 patients (20.0%) had developed restenosis. When divided into four groups on the basis of FMD or ARAS, and the absence/presence of restenosis at 1 year, the number of antihypertensive drugs was significantly lower in both FMD and ARAS patients without restenosis (P < 0.01, respectively); however, a significant difference in decrease in SBP (-31 ± 19 vs. -12 ± 25 mmHg, P < 0.05) as well as cure of hypertension (36.4 vs. 5.0%, P < 0.01) between the absence/presence of restenosis was found only in FMD patients. The frequency of restenosis after renal PTA is significant, and the presence of restenosis diminishes the benefit of its treatment, especially for FMD.

Association of increased CD8+ and persisting C-reactive protein levels with restenosis in HIV patients after coronary stenting.

The life expectancy of HIV-infected patients has recently been increasing. Although the mortality and morbidity associated with AIDS is decreasing, those associated with cardiovascular diseases and percutaneous coronary intervention (PCI) are receiving greater attention. Only limited data regarding coronary restenosis are available in these patients. In this prospective, systematic angiographic follow-up study, we enrolled HIV patients who underwent PCI for de-novo lesions and subsequent routine angiographic follow-up for 6-8 months. Angiographic restenosis was defined as stenosis of at least 50% of the in-segment area. Univariate and multivariate analyses were performed to evaluate restenosis and its predictors. Between May 2002 and March 2014, 47 patients with HIV underwent PCI in two high-volume centers in Munich, Germany. Of these patients, 41 with 131 de-novo lesions underwent invasive surveillance. One-quarter of the lesions treated subsequently presented with restenosis. Univariate analysis indicated that CD8 T-cell levels (P = 0.006), serum cholesterol (P = 0.042) and low-density lipoprotein-cholesterol (P = 0.042) levels at baseline, total number of stents (P = 0.047), and C-reactive protein level (P = 0.001) at follow-up were associated with restenosis. Multivariate analysis indicated that CD8 T-cell levels (P = 0.006) and persistent C-reactive protein elevation at 6-month follow-up (P = 0.00013) were independent predictors of restenosis. Inflammation, represented by CD8 T-cell levels, and persistent C-reactive protein elevation are independent predictors of angiographic restenosis and should therefore be closely monitored in HIV patients undergoing PCI.

Prognostic Factors for Neurologic Outcome in Patients with Carotid Artery Stenting.

Carotid artery stenting (CAS) is a valid treatment for patients with carotid artery stenosis. The long-term outcome and prognostic factors in Asian population after CAS are not clear. This study aimed to identify the prognostic factors among Asian patients who have undergone CAS. We retrospectively analyzed 246 patients with CAS. Annual carotid duplex ultrasound was used to identify restenosis. Peri-procedural complications, restenosis, neurologic outcomes, and mortality were recorded. Cox regression analyses were used to identify prognostic factors. The mean follow-up time was 49.2 months. Procedural success was achieved in 237 patients (98.3%), and protection devices were used in 208 patients (84.5%). Within 30 days of CAS, 13 (4.3% per procedure) peri-procedural complications occurred. During the follow-up period, 24 (9.7%) patients developed restenosis, and 37 (15.0%) developed ischemic strokes. In a multiple logistic regression analysis, head and neck radiotherapy [hazard ratio (HR) = 9.9, 95% confidence interval (CI), 3.38-29.1, p < .001], stent diameter (HR = 0.72, 95% CI, 0.58-0.89, p = .003), and predilatation (HR = 3.08 95% CI, 1.21-7.81, p = .018) were independent predictors for restenosis. In Cox regression analysis, hypercholesterolemia (HR = 0.25, 95% CI, 0.07-0.94, p = .04), head and neck radiotherapy (HR = 6.2, 95% CI, 1.8-21.3, p = .004), and restenosis (HR = 3.6, 95% CI, 1.1-11.18, p = .04) were predictors for recurrent ipsilateral ischemic stroke. CAS provides reliable long-term results in Asian patients with carotid stenosis. Restenosis is associated with an increased rate of recurrent stroke and should be monitored carefully following CAS. Carotid artery disease • Prognosis • Cerebrovascular disease.

Abstract 13892: Incidence and Risk Factors of Restenosis, and Its Impact on Blood Pressure Control After Percutaneous Transluminal Renal Angioplasty in Patients With Renovascular Hypertension

Background: Percutaneous transluminal renal angioplasty (PTRA) is one of the standard treatments for renal artery stenosis (RAS). Restenosis after PTRA may influence disease prognosis, but little is known about its frequency, risk factors, or impact on blood pressure control. Methods: This study included 175 renovascular hypertensive patients (mean age= 59.6 years; 33.7% women; 30.3% fibromuscular dysplasia [FMD]) with 207 treated renal arteries and were followed more than 12 months after PTRA. Data including blood pressure (BP), antihypertensive medication, and duplex ultrasonography (DUS) was collected before and 12 months, and then yearly after PTRA. Cure of hypertension was defines as a BP below 140/90mmHg without antihypertensive medication. Diagnosis of restenosis was based on DUS, by applying a renal aortic ratio &gt;3.5 in conjunction with a renal artery peak systolic velocity &gt; 250cm/s. Results: At 12 months after PTRA, the cumulative incidence of restenosis was 35 (20.0%). We divided the total patients into four groups on the basis of cause of RAS; FMD or atherosclerotic RAS (ARAS), and the absence/presence of restenosis, and found that the decrease in systolic BP (F=3.10, p&lt;0.05) as well as cure of hypertension (F=6.96, p&lt;0.01) were significantly different among the subgroups. Decrease in systolic BP (-31±19 vs -12±25mmHg, p&lt;0.05) as well as cure of hypertension (36.4 vs 5.0%, p&lt;0.01) were significantly greater in FMD patients without restenosis than those with restenosis; whereas no significant difference was found in patients with ARAS. During a median follow-up of 4.0 (IQR, 1.2-8.0) years, 56 patients (32.0%) developed restenosis. In multivariate Cox regression analysis, FMD was an independent predictor of restenosis (hazard ratio [HR] 2.65, p=0.02). We then divided total patients into two groups according to the cause of RAS, and found that statin use (HR 0.50) in FMD, and the presence of previous cardiovascular disease (HR 2.88) as well as severe RAS (≥90%) (HR 3.30) in ARAS were significant predictors of restenosis (p&lt;0.05, respectively). Conclusions: Incidence of restenosis after PTRA was higher in FMD than in ARAS among renovascular hypertensive patients. Assessment of restenosis is important for treatment success, especially for FMD.

Predictors of restenosis following contemporary subintimal tracking and reentry technique: The importance of final TIMI flow grade.

To identify predictors of restenosis after recanalization of chronic total occlusions (CTOs) with the Subintimal Tracking And Reentry (STAR) technique. STAR is associated with high rates of restenosis but the associated factors are not clear. Understanding the underlying mechanisms may be important to improve STAR outcomes and possibly other contemporary CTO recanalization techniques utilizing extensive subintimal dissection and stenting. We retrospectively analyzed 211 lesions that underwent a STAR procedure (between 2002 and 2013) with a final Thrombolysis in Myocardial Infarction (TIMI) flow grade 2 or 3. One-hundred and nineteen lesions that received drug eluting stents (DES) and underwent follow-up angiography were included in the final analysis. Of the 119 lesions treated with DES following STAR, 75 restenoses were observed (63.0%). Utilizing multivariate analysis, TIMI flow grade in the recanalized artery following stent implantation at the end of the index procedure was the only independent predictor of restenosis. Following recanalization of a CTO with STAR, final TIMI flow predicted future restenosis or reocclusion. As a bailout technique, STAR resulted in a high acute success rate with good safety and acceptable long-term results. When poor flow is observed following recanalization, and prior to stent implantation, a two-step strategy whereby a second procedure is performed at an interval to maximize coronary flow at the end of the procedure may be considered with the goal to reduce the risk of future restenosis or total vessel occlusion following STAR.

1-Year Results of the ZEPHYR Registry (Zilver PTX for the Femoral Artery and Proximal Popliteal Artery): Predictors of Restenosis.

This study sought to assess the rate and predictors of 1-year restenosis after drug-eluting stent implantation for femoropopliteal (FP) lesions in patients with peripheral arterial disease. Zilver PTX, a paclitaxel-eluting stent for FP lesions, provides superior outcomes to angioplasty and bare-metal stents in clinical trials. However, its real-world outcomes and the associated features remain unclear. This was a prospective multicenter study enrolling 831 FP lesions (797 limbs, 690 patients) treated by Zilver PTX implantation. The primary endpoint was 1-year restenosis. Secondary endpoints included major adverse limb event and stent thrombosis. Mean lesion length was 17 ± 10 cm. One-year restenosis, major adverse limb event, and stent thrombosis rates were 37%, 22%, and 2%, respectively. The generalized linear mixed model showed that lesion length ≥16 cm assessed by angiography and distal external elastic membrane area ≤27 mm(2) and minimum stent area ≤12 mm(2) assessed by intravascular ultrasound were independent risk factors for restenosis. One-year restenosis rates were 15% in cases with none of these risk factors and 50% in those with ≥2 risk factors. The current study demonstrated 1-year real-world outcomes after drug-eluting stent treatment for FP lesions, including challenging ones in clinical practice. Lesion length, external elastic membrane area, and minimum stent area were independent predictors for restenosis. (Zilver PTX for the Femoral Artery and Proximal Popliteal Artery-Prospective Multicenter Registry [ZEPHYR]; UMIN000008433).

Intravascular Ultrasound Measurements After Drug-Eluting Stent Placement in Femoropopliteal Lesions

Purpose: To investigate the relationship between postprocedure intravascular ultrasound (IVUS) findings and restenosis after placement of drug-eluting stents (DES) for femoropopliteal lesions. Methods: Between July 2012 and May 2013, DES were placed in 64 patients with 88 de novo femoropopliteal lesions. In 40 patients (mean age 74.2±9.4 years; 27 men), DES were placed in 50 lesions under IVUS guidance, and restenosis was monitored for 1 year. All patients were symptomatic (Rutherford 2–6), and 17 patients (43%) suffered from critical limb ischemia. IVUS findings after stenting were compared for patients with vs without restenosis, which was defined as a peak systolic velocity ratio >2.4 on duplex ultrasonography or >50% diameter stenosis on angiography. Results: Ten patients (14 lesions) developed restenosis, while 30 patients (36 lesions) did not. There were no significant differences in the frequency of diabetes or dialysis between the 2 groups. Female patients were predominant in the restenosis group (p<0.003). There were no significant differences of the percentage of TransAtlantic Inter-Society Consensus C/D lesions or stent edge dissection. Multivariate analysis indicated that cilostazol use [odds ratio (OR) 0.13; p=0.046], distal lumen cross-sectional area (CSA) (OR 0.86; p=0.035), and axial symmetry index (OR 0.60; p=0.045) were independent predictors of restenosis. Using receiver operator characteristic analysis, the best cutoff values of the distal lumen CSA and axial symmetry index for predicting restenosis were 17.1 cm2 and 0.6, respectively. Conclusion: IVUS guidance of DES placement in femoropopliteal lesions can offer useful predictors of restenosis at 1 year. The utility of distal lumen CSA and the axial symmetry index in the prediction of restenosis after femoropopliteal DES placement should be confirmed in a larger cohort.

24-Month Data from the BRAVISSIMO: A Large-Scale Prospective Registry on Iliac Stenting for TASC A & B and TASC C & D Lesions

To evaluate the 24-month outcome of stenting in Trans-Atlantic Inter-Society Consensus (TASC) A & B and TASC C & D iliac lesions in a controlled setting. The BRAVISSIMO study is a prospective, nonrandomized, multicenter, multinational, monitored registry including 325 patients with aortoiliac lesions. The end point is the primary patency at 24months, defined as a target lesion without a hemodynamically significant stenosis on duplex ultrasound (>50%, systolic velocity ratio >2.0). A separate analysis for TASC A & B versus TASC C & D population is performed. Between July 2009 and September 2010, 190 patients with TASC A or B and 135 patients with TASC C or D aortoiliac lesions were included. The demographic data were comparable for TASC A & B cohort and TASC C & D cohort. Technical success was 100%. Significantly more balloon-expandable stents were deployed in TASC A & B lesions, and considerably more self-expanding stents were placed in TASC C & D (P=0.01). The 24-month primary patency rate after 24months for the total population was 87.9% (88.0% for TASC A, 88.5% for TASC B, 91.9% for TASC C, and 84.8% for TASC D). No statistically significant difference was shown when comparing these groups. The 24-month primary patency rates were 92.1% for patients treated with the self-expanding stent, 85.2% for patients treated with the balloon-expandable stent, and 75.3% for patients treated with a combination of both stents (P=0.06). Univariate and multivariable regression analyses using Cox proportional hazards model identified only kissing stent configuration (P=0.0012) and obesity (P=0.0109) as independent predictors of restenosis (primary patency failure). Interestingly, as all TASC groups enjoyed high levels of patency, neither TASC category nor lesion length was predictive of restenosis. The 24-month data from this large, prospective, multicenter study confirm that endovascular therapy may be considered the preferred first-line treatment option of iliac lesions, irrespectively of TASC lesion category.

Metabolic Syndrome Predicts Restenosis After Carotid Endarterectomy

Metabolic syndrome is an independent predictor for restenosis after carotid endarterectomy (CEA).

Endovascular treatment of lesions in the below-knee popliteal artery

Endovascular interventions are increasing; however, there are little data regarding outcomes of complex interventions involving the below-knee popliteal/P3 artery. This study evaluated the short-term and long-term results and predictors of success of below-knee popliteal artery endovascular interventions. This was a retrospective review of a prospectively maintained endovascular lower extremity database of all patients with below-knee popliteal interventions from 2004 to 2012. Patient demographics, angiographic findings, interventions, primary and secondary patency, limb loss, and mortality were recorded. Analysis was performed using Kaplan-Meier life-table and multivariate analysis, with P < .05 indicating significance. There were 221 patients (56% male) with below-knee popliteal/P3 artery lesions. Mean age was 73 ± 11.2 years. Claudication was present in 22% and critical limb ischemia (CLI) in 78%. Mean lesion length was 10 ± 8.5 cm, with 45% having total occlusions. Treatment included percutaneous transluminal angioplasty (PTA) with or without a stent (47%), atherectomy (ATH) with or without PTA/stent (52%), and stenting with PTA and ATH (3%). Complications included embolization (0.4%), hematoma (2.7%), pseudoaneurysm (1.3%), and dissection (7%). Freedom from restenosis (peak systolic velocity ratio >2.4) was 65% at 1 year. Independent predictors of restenosis were CLI (hazard risk [HR], 4.4; 95% confidence interval [CI], 1.9-9.9) and stenting combined with PTA and ATH (HR, 2.7; 95% CI, 1.01-7.4). Primary assisted and secondary patencies were 95% and 85% at 1 year. ATH with PTA had lower short-term restenosis in diabetic patients compared with nondiabetic patients (95% vs 78% at 4 months). Limb loss was 18% at 4 years. Mortality was 24% at 4 years. Statin use was protective against primary restenosis (HR, 0.39; 95% CI, 0.23-0.67) and death (HR, 0.5; 95% CI, 0.28-1.0). Endovascular intervention for lesions involving the below-knee popliteal artery is a safe and effective therapy for claudication and CLI. Diabetic patients benefit most from ATH with PTA. Statin use is protective against restenosis and mortality and should be the standard of care in patients undergoing peripheral endovascular interventions.

Glycosylated hemoglobin (HBA1c) levels as follow-up for restenosis clinical outcomes after coronary artery stenting in patients with diabetes mellitus

Background Diabetes has been shown to be independent predictor of restenosis after percutaneous coronary intervention (PCI). Diabetes mellitus has been proved to be a strong risk factor for in-stent restenosis. Restenosis after stent implantation remains the “Achilles’heel” of PCI, and patients with diabetes still have poorer clinical outcomes compared to non-diabetics. 1 Objective (Aim of work) The aim of the present study is to evaluate whether the level of HbA1c as an indicator for the glycaemic control in diabetic patient is related to major cardiovascular events during the follow up in diabetic patients after percutaneous coronary intervention [(PCI) – stenting]. Methods This study included 60 patients with diabetes 41 patient on oral hypoglycemic agent and 19 patient on insulin at the time of the study. These patients included 44 male (73.3%) and 16 female (26.7%) with mean age 56.48 ± 7.8 years. All patients were subjected to stress thallium at the end of follow-up period (24 month) or at the occurrence of the cardiac events. Follow-up HbA1c were performed before stenting and every 6 month till the end of follow-up period. In the study, 30 non-diabetic patients, who underwent stenting, were enrolled as control. Results Regarding the duration of diabetes mellitus (in years), patients who had cardiac events had longer duration of DM than who did not (12.83 ± 6.8, 8.17 ± 3.3 yrs with p -value = 0.002). LDL level was lower in the patients who had no cardiac events than who did (108 ± 2.15 mg/dl, 123.67 ± 22.5 mg/dl with p -value = 0.01). While patients who had cardiac events were on shorter duration of clopidogrel than those who did not (9.7 ± 6.8 month, 16.4 ± 7.0 month with p -value ⩽ 0.01). Regarding the HbA1c levels, HbA1c in the patients with cardiac events was ⩾7% while in the none cardiac event patients was ⩽ 7% with p -value p -value Conclusion – In diabetic patients undergoing coronary artery stenting, patients with HbA1c levels ⩽7% may have lower risk of restenosis and have better clinical outcome after PCI at 2-year follow-up. – Clopidogrel may reduce the risk of restenosis in diabetic patients who underwent coronary artery stenting when used for more than 12 month or more (12–24 month).

Brave New World

Dr. Rastan and colleagues are to be congratulated for performing a well designed multicenter, prospective, randomized controlled trial comparing primary stenting with provisional stenting for moderate length (~42 mm) popliteal artery stenoses in primarily claudicators (79%) with one third having total occlusions (REF). 1 The Endovascular Treatment of Atherosclerotic Popliteal Artery Lesions - Balloon Angioplasty versus primary Stenting (ETAP) trial confirms, for what seems to be the bazillionth time, that provisional stenting, properly performed, achieves equal functional and patency outcomes as primary stenting. This has been shown for femoral lesions in multiple trials that often included lesions extending into the popliteal artery, and now it has been shown for the isolated popliteal disease. Although not reported in this paper, we would expect a cost analysis to demonstrate that provisional stenting, for appropriate indications, would be resource sparing compared to primary stenting. The popliteal segment was thought to be a hostile environment for stents due to repeated flexion, extension, and torsion at the knee joint, but this trial and others have dispelled that myth. As always there is the caveat that total occlusions, and longer more complex lesions, are more difficult to treat with endovascular techniques. This was confirmed by ETAP with a multivariate logistic regression analysis revealing that target lesion length [ 60mm lesion length; Odds ratio (OR): 0.26; Confidence interval (CI): 0.09-0.68; P=0.007], and total occlusions (stenosis versus occlusion; OR: 0.39; CI: 0.18-0.87; P=0.02) as independent predictors of restenosis.

Does Restenosis Still Hamper the Benefit of Carotid Artery Revascularization?

Both carotid endarterectomy (CEA) and carotid artery angioplasty with stenting (CAS) may offer acceptable short-term results in symptomatic or asymptomatic patients with carotid stenosis. Independent on the type of revascularization, the long-term benefit may be limited by recurrent stenosis, especially after endovascular treatment. Pathophysiological studies suggest that atherosclerotic plaque composition is an independent predictor of restenosis. Identification of certain plaque characteristics could help risk stratify patients in order to decide on the best therapy and minimize the risk of restenosis. Although currently no gold standard exists for the approach of recurrent carotid stenosis, both redo CEA and CAS seem safe therapeutic options. Limited data are available on treatment of recurrent carotid in-stent stenosis. More data are required in order to recommend the best therapy for in-stent restenosis.

TCT-616 Comparison of Long-Term Outcomes with Everolimus-Eluting- and Sirolimus-Eluting Stents in Small Coronary Artery Disease

Small vessel size remains an independent predictor of restenosis and target lesion revascularization (TLR) even in the drug-eluting stent (DES) era. It is unknown whether second-generation DES improve outcomes in this lesion subset. This study aimed to compare the long-term clinical outcomes between

Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial

In the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), the composite primary endpoint of stroke, myocardial infarction, or death during the periprocedural period or ipsilateral stroke thereafter did not differ between carotid artery stenting and carotid endarterectomy for symptomatic or asymptomatic carotid stenosis. A secondary aim of this randomised trial was to compare the composite endpoint of restenosis or occlusion. Patients with stenosis of the carotid artery who were asymptomatic or had had a transient ischaemic attack, amaurosis fugax, or a minor stroke were eligible for CREST and were enrolled at 117 clinical centres in the USA and Canada between Dec 21, 2000, and July 18, 2008. In this secondary analysis, the main endpoint was a composite of restenosis or occlusion at 2 years. Restenosis and occlusion were assessed by duplex ultrasonography at 1, 6, 12, 24, and 48 months and were defined as a reduction in diameter of the target artery of at least 70%, diagnosed by a peak systolic velocity of at least 3·0 m/s. Studies were done in CREST-certified laboratories and interpreted at the Ultrasound Core Laboratory (University of Washington). The frequency of restenosis was calculated by Kaplan-Meier survival estimates and was compared during a 2-year follow-up period. We used proportional hazards models to assess the association between baseline characteristics and risk of restenosis. Analyses were per protocol. CREST is registered with ClinicalTrials.gov, number NCT00004732. 2191 patients received their assigned treatment within 30 days of randomisation and had eligible ultrasonography (1086 who had carotid artery stenting, 1105 who had carotid endarterectomy). In 2 years, 58 patients who underwent carotid artery stenting (Kaplan-Meier rate 6·0%) and 62 who had carotid endarterectomy (6·3%) had restenosis or occlusion (hazard ratio [HR] 0·90, 95% CI 0·63-1·29; p=0·58). Female sex (1·79, 1·25-2·56), diabetes (2·31, 1·61-3·31), and dyslipidaemia (2·07, 1·01-4·26) were independent predictors of restenosis or occlusion after the two procedures. Smoking predicted an increased rate of restenosis after carotid endarterectomy (2·26, 1·34-3·77) but not after carotid artery stenting (0·77, 0·41-1·42). Restenosis and occlusion were infrequent and rates were similar up to 2 years after carotid endarterectomy and carotid artery stenting. Subsets of patients could benefit from early and frequent monitoring after revascularisation. National Institute of Neurological Disorders and Stroke and Abbott Vascular Solutions.

Glycosylated hemoglobin (HbA1c) levels and clinical outcomes in diabetic patients following coronary artery stenting

BackgroundDiabetes has been shown to be independent predictor of restenosis after percutaneous coronary intervention (PCI). The aim of the present study was to investigate whether a pre- and post-procedural glycaemic control in diabetic patients was related to major advance cardiovascular events (MACE) during follow up.MethodsWe evaluated 2884 consecutive patients including 2181 non-diabetic patients and 703 diabetics who underwent coronary stenting. Diabetes mellitus was defined as the fasting blood sugar concentration ≥ 126 mg/dL, or the use of an oral hypoglycemic agent or insulin at the time of admission. Diabetic patients were categorized into two groups based on their mean HbA1c levels for three measurements (at 0, 1, and 6 months following procedure): 291 (41.4%) diabetics with good glycaemic control (HbA1c ≤ 7%) and 412 (58.6%) diabetics with poor glycaemic control (HbA1c > 7%).ResultsThe adjusted risk of MACE in diabetic patients with poor glycaemic control (HbA1c > 7%) was 2.1 times of the risk in non-diabetics (adjusted HR = 2.1, 95% CI: 1.10 to 3.95, p = 0.02). However, the risk of MACE in diabetics with good glycaemic control (HbA1c ≤ 7%) was not significantly different from that of non-diabetics (adjusted HR = 1.33, 95% CI: 0.38 to 4.68, p = 0.66).ConclusionsOur data suggest that there is an association between good glycaemic control to obtain HbA1c levels ≤7% (both pre-procedural glycaemic control and post-procedural) with a better clinical outcome after PCI.

The impact of preprocedural hemoglobin A1c on the efficacy of sirolimus-eluting and paclitaxel-eluting stents

Several reports have shown contrary results regarding the efficacy of sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) in diabetic patients. The association between hemoglobin A1c (A1c) before coronary intervention and the midterm clinical outcomes of patients treated with these stents is unclear. The enrolled population was 415 patients with diabetes or impaired glucose tolerance (IGT) who underwent follow-up angiography after being implanted with a SES (n = 282) or PES (n = 133). The enrolled population was classified into the optimal glycemic control group (n = 213) and suboptimal glycemic control group (n = 202), and the predictors of restenosis were examined in each group. In the optimal glycemic control group, the use of PES was an independent predictor of restenosis [odds ratio (OR) 9.98, 95% confidence interval (CI) 3.08-38.9, p < 0.0001]; on the other hand, the use of SES was a positive independent predictor of restenosis prevention (OR 0.10, 95% CI 0.03-0.32, p < 0.0001). In the suboptimal glycemic control group, neither stent was predictive of restenosis. In a subanalysis, preprocedural A1c (≥7.0%) was found to be an independent predictor of restenosis in the SES group (OR 3.61, 95% CI 1.14-12.8, p = 0.03), but not the PES group. Postprocedural A1c (≥7.0%) was not an independent predictor of restenosis in either stent group. This study showed that the superiority of SES compared to PES was attenuated in the suboptimal glycemic control group. Preprocedural A1c (≥7.0%) was found to be an independent predictor of restenosis in the SES group, but not in the PES group.