Lesions Of Large Coronary Arteries Research Articles

Efficacy and safety of drug-coated balloon for de novo lesions of large coronary arteries: Systematic review and meta-analysis of randomized controlled trials

BackgroundDrug-coated balloon (DCB) is a novel approach to avoiding stent-related complications and has proven effective for the treatment of in-stent restenosis (ISR) and small vessels. However, its role in the treatment of de novo lesions in large vessels is less settled. AimsTo estimate the efficacy and safety of drug-coated balloon versus stent in the treatment of de novo lesions in large coronary arteries. MethodsWe searched the literature until April 2023. We judged the safety of DCB based on major adverse cardiovascular events (MACEs), cardiac death, all-cause mortality, non-fatal myocardial infarction, target lesion revascularization (TLR), and bleeding event; and efficacy according to late lumen loss (LLL), minimum lumen diameter (MLD). We conducted subgroup analyses according to stent type and whether urgent PCI was required. ResultsA total of 10 RCTs were included. Overall, LLL (mean difference (MD) = −0.19, 95 % confidence interval (CI): −0.32 to −0.06, P = 0.003) was lower in the DCB group than in the Stent arm. This effect was consistent in subgroup analysis regardless of stent type and disease type. In terms of safety indicators, there were no significant differences between DCB and stent. The subgroup analyses found that safety indicators showed no significant differences between DCB and drug-eluting stent (DES), but TLR was lower in the DCB than in the bare metal stent (BMS). Moreover, in ST-elevation myocardial infarction (STEMI), safety indicators and LLL showed no significant differences between DCB and DES, but MLD in the DCB was smaller. While in patients with excluded STEMI, MACE and TLR was lower in the DCB compared with the overall stent. ConclusionsDCB could be a promising alternative for treating de novo lesions in large coronary arteries with satisfactory efficacy and low risk, superior to BMS and not inferior to DES, with a trend toward lower late lumen loss.

Long-Term Clinical Outcomes After Percutaneous Coronary Intervention With Drug-Coated Balloon-Only Strategy in de novo Lesions of Large Coronary Arteries.

Background and ObjectivesUse of drug-coated balloon (DCB)-only strategy for revascularization of native large coronary artery lesions is on the rise. The long-term efficacy of this approach for bifurcation and non-bifurcation lesions remains unknown. We aim to assess the long-term clinical outcomes of DCB-only strategy for the treatment of de novo bifurcation and non-bifurcation lesions in large coronary arteries.MethodsThis multicenter, prospective, observational study enrolled 119 patients with de novo coronary lesions in vessels ≥2.75 mm. The primary end point was the rate of clinically driven target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction, and clinically driven target lesion revascularization (TLR). Patients were followed up for a median of 2 years.ResultsOf 119 patients with 138 lesions, 66 patients (75 lesions) had bifurcation and 53 patients (63 lesions) had non-bifurcation lesions. Average reference vessel diameter was 3.1 ± 0.3 mm, and there was no difference in bifurcation and non-bifurcation group (3.0 ± 0.3 vs. 3.1 ± 0.3mm; p = 0.27). At 2-year follow-up, the TLF occurred in five (4.2%), TLR in four (3.4%), and target vessel revascularization (TVR) in five (4.2%) cases. The frequency of TLR and TVR was higher in the non-bifurcation group (p = 0.04 and 0.02, respectively), but there were no differences in TLF between the two groups (p = 0.17). The cumulative incidence of TLF (Kaplan–Meier estimates) was also not different in the two groups (log-rank p = 0.11).ConclusionDCB-only strategy for de novo lesions in large coronary arteries appears to be safe and effective for both bifurcation and non-bifurcation lesions. Further randomized clinical trials are warranted to confirm the value of DCB-only strategy in de novo bifurcation lesions of large vessels.

СОСТОЯНИЕ КОРОНАРНЫХ АРТЕРИЙ У МУЖЧИН МОЛОЖЕ 60 ЛЕТ ПРИ ИНФАРКТЕ МИОКАРДА, ОСЛОЖНЕННОМ ОСТРЫМ ПОВРЕЖДЕНИЕМ ПОЧЕК

Relevance. The role of the coronary arteries angiographic changes severity in myocardial infarction complicated by acute kidney injury is assessed in different ways. Aim. To evaluate the features of the coronary arteries state in men under 60 years old with myocardial infarction complicated by acute kidney injury to improve prevention and outcomes. Material and methods. The study included men 19-60 years old with type I myocardial infarction. The patients were divided into two age-comparable groups: I - study group, with acute kidney injury - 25 patients; II - control, without it - 168 patients. A comparative assessment of coronary angiography indicators, also acute kidney injury and heart failure development risk analysis (ANOVA) were performed. Results. There were no differences in the compared groups in angiographic data, localization, depth of the lesion, and the frequency of the complicated course of the disease. The study group were characterized by akinesia in the middle anterior (in the studied% 100; control: 15.6%; p =0.02) and antero-septal (100 and 17.7%; respectively; p=0.04) segments , as well as the frequency of registration of chronic heart failure (72.0 and 43.2%; p=0.005) by the eighth week of myocardial infarction. Bypass surgery (absolute risk: 46.2%; relative - 4.37; p=0.0002) and unstable angina (absolute risk: 19.8%; relative - 2,46; p=0.02) in the medical history, as well as the presence of peripheral angiopathies (absolute risk: 18.9%; relative - 3.21; p=0.0008). Conclusions. Men under 60 years old with acute kidney injury in myocardial infarction were not differ in the number and extent of large coronary artery lesions from the general group. They are characterized by large in area and severity of dysfunction lesions of the anterior middle segments of the left ventricle with a higher frequency of chronic heart failure than in the general group. The anamnestic data listed above associated with coronary arteries is advisable to use in the formation of groups at high risk for the acute kidney injury development formation, as well as prognostic modeling.

Drug Coated Balloon-Only Strategy in De Novo Lesions of Large Coronary Vessels.

Objectives We analyzed the efficacy of drug coated balloons (DCB) as a stand-alone-therapy in de novo lesions of large coronary arteries. DCBs seem to be an attractive alternative for the stent-free interventional treatment of de novo coronary artery disease (CAD). However, data regarding a DCB-only approach in de novo CAD are currently limited to vessels of small caliber. Methods By means of propensity score (PS) matching 234 individuals with de novo CAD were identified with similar demographic characteristics. This patient population was stratified in a 1:1 fashion according to a reference vessel diameter cut-off of 2.75 mm in small and large vessel disease. The primary endpoint was the rate of clinically driven target lesion revascularization (TLR) at 9 months. Results Patients with small vessel disease had an average reference diameter of 2.45 ± 0.23 mm, while the large vessel group averaged 3.16 ± 0.27 mm. Regarding 9-month major adverse cardiac event (MACE), 5.7% of the patients with small and 6.1% of the patients with large vessels had MACE (p=0.903). Analysis of the individual MACE components revealed a TLR rate of 3.8% in small and 1.0% in large vessels (p=0.200). Of note, no thrombotic events in the DCB treated coronary segments occurred in either group during the 9-month follow-up. Conclusions Our data demonstrate for the first time that DCB-only PCI of de novo lesions in large coronary arteries (>2.75 mm) is safe and as effective. Interventional treatment for CAD without permanent or temporary scaffolding, demonstrated a similar efficacy for large and small vessels.

Prevention of large coronary artery lesions caused by Kawasaki disease

Appropriate therapy during the acute phase of Kawasaki disease to prevent large coronary artery lesions (CAL) has not been established. The aim of this retrospective study was to investigate the usefulness of initial intravenous immunoglobulin (IVIG) therapy with delayed administration of antiinflammatory drugs (ADs). A total of 132 pediatric patients who received IVIG therapy with delayed administration of ADs for Kawasaki disease between 2004 and 2014 were enrolled at the Department of Pediatrics, Aomori Prefectural Central Hospital. An initial IVIG regimen of 2 g/kg/day, starting on day 5, was used as first-line therapy when possible. Second-line therapy was additional IVIG therapy, and third-line therapy was an urinastatin infusion or plasma exchange. All 132 patients received 2 g/kg/day initial IVIG therapy. Seventy-four patients received aspirin and 58 patients received flurbiprofen after completion of initial IVIG infusion. Initial IVIG therapy resistance occurred in 31 of 132 patients (23%), and 10 patients (8%) received additional IVIG. One patient received urinastatin and one patient received plasma exchange as third-line therapy. Before the 30th day, the prevalence of CAL was 2% (2/132); after 30 days, it was 1% (1/132). The maximal internal CAL diameters were 4.8 mm (Z score = 6.3) among all patients. Initial single IVIG therapy with delayed administration of ADs may be useful for the prevention of large CAL caused by Kawasaki disease.

Background Factors Associated with the Complications of Coronary Artery Lesions Caused by Kawasaki Disease

Appropriate therapy during the acute phase of Kawasaki disease to prevent large coronary artery lesions (CAL) has not been established. The aim of this retrospective study was to investigate the usefulness of an initial single intravenous immunoglobulin (IVIG) therapy. In this study, I included a total of 200 pediatric patients who had received 2g/kg/day IVIG therapy for Kawasaki disease between 1999 and 2015 at the Department of Pediatrics, Aomori Prefectural Central Hospital. An initial IVIG therapy starting on day 5 was used as first-line therapy when possible. The second-line therapy was additional IVIG therapy, and the third-line therapy was an urinastatin infusion or plasma exchange. All patients received an initial single IVIG therapy with delayed or with concomitant administration of aspirin or flurbiprofen. Initial IVIG therapy resistance occurred in 48 of 200 patients (24%), and 17 patients (9%) received additional IVIG therapy. Four patients received urinastatin and one patient received plasma exchange as the third-line therapy. Before the 30th day, the prevalence of CAL was 5% (10/200); after 30 days, it was 2% (4/200). The maximal internal CAL diameter was 4.8 mm (Z score = 6.3) among all patients. Variable factors including IVIG resistance, responsiveness, and relapse of disease were associated with CAL complications. An initial single IVIG therapy may be useful for the prevention of large CAL caused by different factors of Kawasaki disease.

Impact of stent diameter and length on in-stent restenosis after drug eluting stent versus bare metal stent implantation in patients needing large coronary stents

Introduction: The advantage of drug eluting stents (DES) compared to bare metal stents (BMS) is small for the the risk of in-stent-restenosis (ISR) in short lesions of large coronary arteries. Therefore, the British National Institutes of Clinical Excellence (NICE) guidelines recommend to use BMS instead of DES in lesions 3mm diameter. However, no dedicated trial has tested this question. We analysed the impact of stent length and stent diameter on ISR in the BASKET-PROVE study population. Methods: In the multicentre randomized BASKET-PROVE study we compared BMS vs. DES regarding target vessel revascularization (TVR) rates in large coronary arteries (needing ≥3mm stents) resulting in significantly lower 2-year TVR rates in the DES group. For this retrospective subgroup analysis two experienced interventionalists blinded to stent type reviewed all angiographic films for the presence of ISR. We used a mixed-effects Cox survival model to analyse the impact of stent length and stent diameter on ISR on a basis, with ISR being defined as luminal narrowing >50% by visual assessment. Results: 2312 patients with a total of 3278 stented segments were included in the analysis (mean age 63.7±10.9 years; 24.4% female). 123 patients had at least one re-angiography during the two years follow-up due to recurrent ischemia. A total of 75 ISR in 63 patients were observed (mean age 61.9±11.1 years). ISR was significantly more frequent in segments with a BMS (5.3%) compared to segments with a DES (0.74%; HR = 6.18, p<0.001). Based on the Cox analysis, the strongest predictor of ISR was the use of a BMS (hazard ratio (HR)) 6.74; p<0.001). There was a decreased risk of ISR per 1mm increase in stent diameter (HR of 0.30, p=0.003). The HR for stent length per segment was 1.02 (p=0.02; CI= 1.0-1.04) indicating a 2% increased risk of ISR per 1mm increase in stent length. Co-factors like renal failure or diabetes mellitus had no significant effect on ISR. The HR for ISR in patients with stent diameter >3mm and stent length <15mm was not significantly different between the DES and the BMS group although the event rate in this subgroup was low (2.0% with BMS, 1.4% with DES, p=NS). Conclusion: The risk of ISR in patients receiving stents in large coronary arteries is low. Nevertheless, even in patients in need of stents ≥3.0mm, the strongest predictor of ISR was the use of a BMS. Other co-factors like renal failure or DM are not associated with ISR in this population. Alltogether, these findings challenge the restriction of NICE to use BMS instead of DES in vessels >3.0mm.

Use of Drug Eluting Stents in Long but Large Coronary Artery Lesions: Observations from the Melbourne Interventional Group (MIG) Registry

Use of Drug Eluting Stents in Long but Large Coronary Artery Lesions: Observations from the Melbourne Interventional Group (MIG) Registry

Sirolimus-Eluting vs Uncoated Stents for Prevention of Restenosis in Small Coronary Arteries

Percutaneous coronary revascularization of small vessels is associated with a high restenosis rate. Sirolimus-eluting stents reduce restenosis in simple and previously untreated lesions of large coronary arteries, but their outcomes in small vessels have not been adequately investigated. To determine whether sirolimus-eluting stents are associated with a reduced 8-month rate of angiographic restenosis in comparison with an uncoated stent. This was a randomized, multicenter, single-blind, prospective trial performed with 257 patients undergoing percutaneous coronary revascularization for ischemic heart disease, and who had a previously untreated atherosclerotic lesion located in a small segment with a diameter of 2.75 mm or less, in 20 Italian centers between August 2002 and December 2003. Patients were randomly assigned to receive a sirolimus-eluting stent (129 patients) or an uncoated stent having an identical architecture and radiographic appearance (128 patients). The primary end point was the 8-month binary in-segment restenosis rate; secondary end points included procedural success and the 8-month rate of major adverse cardiac and cerebrovascular events. The mean (SD) reference diameter of the treated segment was 2.2 (0.28) mm; the lesion length, 11.84 (6.15) mm. After 8 months, the binary in-segment restenosis rate was 53.1% (60/113) in the patients receiving an uncoated stent and 9.8% (12/123) in those receiving a sirolimus-eluting stent (relative risk [RR], 0.18; 95% confidence interval [CI], 0.10-0.32; P<.001). Fewer patients randomized to sirolimus-eluting stents experienced major adverse cardiac events (12/129 [9.3%] vs 40/128 [31.3%]; RR, 0.30; 95% CI, 0.15-0.55; P<.001) mainly because of a reduction in target lesion revascularization (9/129 [7%] vs 27/128 [21.1%]; RR, 0.33; 95% CI, 0.14-0.70; P = .002) and myocardial infarction (2/129 [1.6%] vs 10/129 [7.8%]; RR, 0.20; 95% CI, 0.01-0.93; P = .04). The use of sirolimus-eluting stents to treat atherosclerotic lesions in small coronary arteries reduces restenosis and may also reduce major adverse cardiac events.

Coronary-coronary radial artery graft for single, distal LAD lesion

Radial artery segment has been used as a coronary-coronary graft for single, distal lesion of the large left anterior descending coronary artery running well over the cardiac apex. In our opinion this technique may occasionally be an attractive approach for bypassing very distal lesions of large coronary arteries combined with regular arterial or venous grafting of the target artery if proximal stenosis is also present. The remnant of the radial artery can be used for grafting of another diseased artery (eg, the large first marginal branch of the circumflex artery in our case report).

Coronary-coronary free internal thoracic artery graft on a single, distal, left anterior descending artery lesion

A free short segment of left internal thoracic artery (ITA) has been used to bypass a single distal lesion on a large left anterior descending artery (LAD) running well over the cardiac apex. In our opinion this technique occasionally might be an attractive approach for bypassing very distal lesions of large coronary arteries (combined with regular arterial or venous grafting if there has also been proximal stenosis in the targeted artery). The proximal remnant of the left ITA can be easily used as an in situ graft.

In situ pedicle graft and coronary-coronary bypass grafting using internal thoracic artery in management of multiple lesions of the left anterior descending coronary artery

Nowadays, coronary-coronary bypass grafting (CCBG) has been applied in patients with heavily calcified ascending aorta or due to lack of graft material. We describe a case in which the patient's large left anterior descending (LAD) coronary artery, running well over the cardiac apex, presented with proximal and distal stenosis. Although the pedicled left internal thoracic artery (ITA) graft is sometimes too short for sequential bypass in cases of distal stenosis of the LAD coronary artery, we used a free, short segment of the pedicled left ITA for coronary-coronary bypass grafting. The in situ remnant of the left pedicled ITA was used to bypass the proximal LAD stenosis. The patient's postoperative course was uneventful. Predischarge angiogram (on the 9th postoperative day) showed an in situ left ITA graft as well as afree coronarycoronary ITA graft. The patient had a regularfollow-up after 3 months, and was classified as New York Heart Association (NYHA) class I. Primarily used in aorto-coronary bypass surgery (termino-terminal interposition of the saphenous vein between two parts of a resected coronary artery), CCBG was revised latter on, and from hemodynamic point of view the physiologic restoration of coronary blood flow has been confirmed CCBG might be an attractive approach for bypassing distal lesions of large coronary arteries (combined with arterial or venous grafting of targeted arteries, if proximal stenoses are also present). The proximal remnant of ITA can be used as an in situ or free graft.

Comparison of immediate and one-year outcome after coronary angioplasty of narrowing

Balloon angioplasty of small coronary artery lesions has been associated with lower success and higher complication rates than large coronary artery lesions. This study evaluates the in-hospital and 1-year outcome of the treatment of small coronary artery lesions in the modern era of interventional cardiology and compares it with the outcome of treating large coronary artery lesions. Of 1,658 patients with a single lesion treated from July 1997 to February 1998 in the National Heart, Lung, and Blood Institute (NHLBI) Dynamic Registry, there were 587 patients with small coronary artery lesions (<3 mm) and 1,071 patients with large coronary artery lesions (≥3 mm). Success, in-hospital, and 1-year outcomes between both groups were compared. Patients with lesions in small coronary arteries were more often women, insulin-treated diabetics, and had undergone more prior coronary bypass graft surgery. Conventional angioplasty alone was performed more often and angioplasty with stents was performed less often in the small coronary artery than in the large coronary artery group. Angiographic success was slightly lower in the small coronary artery group (94.2% vs 96.9%, p <0.05). Periprocedural and in-hospital complication rates were similar in both groups. Likewise, at 1-year follow-up, major adverse cardiac events including death, myocardial infarction, and coronary artery bypass graft surgery were relatively low and comparable between the 2 groups, although patients with small coronary arteries were more likely to undergo repeat revascularization (17.4% vs 13.6%, p <0.05). Treatment of lesions in small coronary arteries in the modern era is associated with high success and low complication rates, comparable to the treatment of large coronary artery lesions, although the incidence of repeat revascularization was significantly greater at follow-up even if stents were used.

Intravascular ultrasonic predictors of angiographic restenosis after long coronary stenting

The intravascular ultrasound (IVUS) criteria for stent optimization have not been determined in stenting long lesions. We evaluated the predictors of angiographic restenosis and compared it with stent lumen cross-sectional area (CSA) and stent length between short (stent length <20 mm) and long (≥20 mm) coronary stenting. IVUS-guided coronary stenting was successfully performed in 285 consecutive patients with 304 native coronary lesions. Six-month follow-up angiogram was performed in 236 patients (82.8%) with 246 lesions (80.9%). Results were evaluated using conventional (clinical, angiographic, and IVUS) methods. The overall angiographic restenosis rate was 22.8% (56 of 246 lesions) (short stent 17.6% vs long stent 32.2%, p = 0.009). Using multivariate logistic regression analysis, the independent predictors of angiographic restenosis were the IVUS stent lumen CSA (odds ratio 1.51, 95% confidence intervals 1.18 to 1.92, p = 0.001) and stent length (odds ratio 0.95, 95% confidence intervals 0.91 to 1.00, p = 0.039). The angiographic restenosis rate was 54.8% for stent lumen CSA of <5.0 mm2 (short stent 37.5% vs long stent 73.3%, p = 0.049), 27.4% for CSA between 5.0 and 7.0 mm2 (short stent 24.1% vs long stent 31.7%, p = 0.409), 10.5% for CSA between 7.0 and 9.0 mm2 (short stent 10.0% vs long stent 12.5%, p = 0.772), and 11.4% for stent lumen CSA of ≥9.0 mm2 (short stent 10.4% vs long stent 13.3%, p = 0.767) (p = 0.001). Compared with short coronary stenting, long coronary stenting is effective treatment modality to cover long lesions with comparable long-term clinical outcomes in cases of stent lumen CSA of ≥7.0 mm2. Regardless of the stent length, the most important factor determining angiographic restenosis was the IVUS stent lumen CSA in relatively large coronary artery lesions.