Predictors Of Target Vessel Revascularization Research Articles

Abstract 12711: Stent Length as a Predictor of Target Vessel Revascularization in Patients Treated With Drug-Eluting Stents

Background: While several factors have been shown to increase the risk of stent thrombosis, most cases of target vessel revascularization (TVR) are due to in-stent restenosis (ISR) and have not been fully evaluated. Objectives: Our aims were to identify predictors of early and late TVR after drug-eluting stents (DES) implantation in a large prospective registry, focusing on stent length. Methods and Results: We analyzed rates of TVR according to stent length in a prospective registry of 14,447 all-comers treated with angioplasty and DES implantation in our institution. Patients were divided into quartiles according to stent length - mean 21mm - percentile 25 (Q1) 15mm, 50 (Q2) 18mm, 75 (Q3) 26mm and 100 (Q4) 32mm. At baseline patients had similar rates of diabetes mellitus, congestive heart failure and left ventricular ejection fraction. Patients in the first quartile tend to be older, more commonly of female gender, with higher rates of GFR<60, anemia, and unprotected LM angioplasty. At 4 years follow-up, rates of TVR and MACE were higher in patients with longer stents; 8.5%, 9.8%, 10.4% and 16.1% (p<0.001) and 25.3%, 26.6%, 27% and 28.4% (p=0.031); for TVR and MACE in Q1, Q2, Q3 and Q4 groups of patients; respectively. There were no significant differences in the rates of all-cause death amongst patients in different quartiles. Furthermore, at multivariate Cox-regression analysis length of stent was found to be a significant independent predictor for TVR (OR 1.25 95.0% CI 1.11 - 1.42; p<0.001). Conclusion: From the analysis of a large cohort of all-comer angioplasty patients who were treated with DES, stent length emerged as an independent predictor of TVR and MACE.

Clinical outcomes of coronary artery bifurcation disease patients underwent Culotte two-stent technique: a single center experience

BackgroundPercutaneous coronary intervention for coronary artery bifurcation disease (CABD) remains challenging. In patients of CABD with situations that two-stent strategy is needed, the culotte technique is a widely used method and also as the majority at out institution. We sought to take a look of the clinical outcomes of our culotte stenting patients.MethodsThis retrospective study analyzed 238 consecutive CABD patients who underwent culotte two-stent technique at a tertiary medical center between July 2008 and November 2015.ResultsCulotte technique was used in 238 lesions in 238 patients. Of these patients, all DES were implanted for culotte two-stent technique. Most of these patients were elderly, male gender, ACS on admission and multiple vessel disease. The bifurcation lesions were mostly located at left coronary artery (51.3%), categorized as true bifurcation lesion (92%) and calculated less than 70 degree of bifurcation angle (74.4%). During a medium 3.27-year follow up, the angle of bifurcation lesion ≥70° and body mass index were positively independent predictors for target lesion failure (TLF), diabetes mellitus was an independent predictor of target vessel revascularization, and statin therapy for hyperlipidemia, hemoglobin and EF were negatively independent factors associated to total mortality. The rates of in-hospital and total mortalities were 4.2 and 17.6%.ConclusionIn this cohort of CABD patients with most left main and left anterior descending artery lesions treated by culotte stenting, the procedural success rate was high and the intermediate clinical outcomes were acceptable. (Reviewer #1, Comment #1) Bifurcation angle (≥ 70°) is an inherently independent predictor of TLF and other two-stent strategy replaced needed to be considered in this situation.

Novel predictor of target vessel revascularization after coronary stent implantation: Intraluminal intensity of blood speckle on intravascular ultrasound.

The difference in intraluminal intensity of blood speckle (IBS) on integrated backscatter-intravascular ultrasound (IB-IVUS) across the coronary artery stenosis (i.e., ΔIBS) has been reported to negatively correlate with fractional flow reserve. Fractional flow reserve after coronary stenting is known as a predictor of target vessel revascularization (TVR). However, the relation between ΔIBS and TVR is unclear. Seven hundred and three vessels which underwent percutaneous coronary intervention with stents were screened. Vessels without IVUS-guidance and follow-up information were excluded. Intraluminal IBS values were measured using IB-IVUS in cross-sections at the ostium of the target vessel and at the distal reference of implanted stent. ΔIBS was calculated as (distal IBS) - (ostium IBS). A total of 393 vessels were included. Mean ΔIBS at postprocedure was 6.22 ± 5.65. During the follow-up period (11.2 ± 3.1 months), 24 cases (6.1%) had TVR. ΔIBS was significantly greater in the vessels with TVR than in those without (11.10 ± 5.93 vs. 5.90 ± 5.49, P <0.001). In receiver operating characteristic curve analysis, ΔIBS significantly predicted TVR (AUC 0.74, best cut-off value 8.24, P < 0.001). Multiple logistic regression analysis showed use of drug eluting stent and ΔIBS ≥ 8.24 as independent predictors of TVR. ΔIBS at postprocedure was significantly associated with TVR. IVUS may be able to predict TVR by physiological assessment with measurement of ΔIBS.

Predictors of poor clinical outcomes after successful chronic total occlusion intervention with drug-eluting stents.

The aim of this study was to identify the prognostic predictors for the worse clinical outcomes after a successful chronic total occlusion (CTO) intervention with drug-eluting stents. A total of 2334 patients in the multicenter Korean CTO registry who underwent a successful CTO intervention with drug-eluting stents (first generation, 1367, new generation, 967) were enrolled. The primary endpoint was the composite of cardiac death, myocardial infarction, and stent thrombosis.The cumulative incidence of the primary endpoint was 2.5% (median follow-up duration: 22 months). In multivariate analysis, age above 65 years [hazard ratio (HR)=1.769, 95% confidence interval (CI)=1.025-3.052, P=0.041], heart failure (HR=4.242, 95% CI=2.335-7.705, P<0.001), and diabetes (HR=1.773, 95% CI=1.043-3.012, P=0.034) were the significant predictors. The cumulative incidence of the primary endpoint was significantly higher in patients with three risk factors (19.1%) than in those with one (2.2%) or two (3.0%) risk factors (P=0.001). The cumulative target-vessel revascularization rate was 8.4%, with the significant predictors being a diffuse long lesion (HR=1.626, 95% CI=1.129-2.340, P=0.009) and at least three implanted stents (HR=1.964, 95% CI=1.301-2.965, P=0.001). Clinical parameters such as age, diabetes, and heart failure were independent predictors of the composite of cardiac death, myocardial infarction, and stent thrombosis, whereas angiographic or procedural parameters such as lesion length and number of implanted stents were predictors of target-vessel revascularization. Clinical outcomes after CTO intervention were worse in patients with multiple risk factors.

TCT-560 Novel Predictor of Target Vessel Revascularization after Coronary Stent Implantation: Intraluminal Intensity of Blood Speckle on Intravascular Ultrasound

The difference in intraluminal intensity of blood speckle (IBS) on integrated backscatter-intravascular ultrasound (IB-IVUS) between distal and proximal to the coronary artery stenosis reportedly has a correlation with fractional flow reserve (FFR). FFR value after coronary stenting is known to be a

TCT-19 Predictors of Target Vessel Revascularization after Primary Percutaneous Coronary Intervention for Acute ST-Segment Elevation Myocardial Infarction: Lessons from HORIZONS-AMI

TCT-19 Predictors of Target Vessel Revascularization after Primary Percutaneous Coronary Intervention for Acute ST-Segment Elevation Myocardial Infarction: Lessons from HORIZONS-AMI

Clinical presentation and predictors of target vessel revascularization after drug-eluting stent implantation

Drug eluting stent (DES) failure including restenosis and stent thrombosis, or disease progression may result in target vessel revascularization (TVR) but the relative contribution of these mechanisms in the DES era is not well described. We sought to examine the predictors and presentations of patients with clinically driven TVR after DES. Patients with all lesions treated with a DES in the Dynamic Registry from 2004 to 2006 were analyzed. Included were 2691 patients with 3401 lesions. Patients with and without incident clinically driven TVR at 2years were compared according to baseline clinical, procedural, and angiographic characteristics and independent predictors of TVR and target lesion revascularization (TLR) were determined by multivariate analysis. By 2-years, TVR occurred in 7.2% of patients and TLR in 3.8%, with 71.6% and 82.5% of repeat revascularization events occurring in the first year, respectively. The indication for first TVR was myocardial infarction in 18.6% (n=34), unstable angina in 42.6% (n=78), stable coronary disease in 25.7% (n=47) and other/unknown in 13.1% (n=24). Disease progression was responsible for 47% of TVR. Among patients with TLR, restenosis was the mechanism in 86.6% and stent thrombosis in 13.4%. Independent predictors of TVR included younger age, diabetes, attempted graft lesion, lesion length >30mm and prior lesion intervention. Independent predictors of TVR and TLR were similar. The incidence of clinically driven TVR is low in patients treated with DES and nearly half is attributable to disease progression, which along with the low rate of in-stent restenosis explains why the mode of presentation is often an acute coronary syndrome.

Long-term follow-up after coronary stenting with the sirolimus-eluting stent in clinical practice: results from the prospective multi-center German Cypher Stent Registry

To obtain long-term follow-up data of the sirolimus-eluting coronary stent (SES) and to determine factors associated with clinical events and target vessel revascularization (TVR). Between 2002 and 2005, 5,946 patients were treated with at least one SES. A follow-up after a median of 4.1years was obtained in 5,247 patients (88.2%). During the follow-up, death occurred in 9.2% of patients, nonfatal myocardial infarction in 5.9%, nonfatal stroke in 2.2% and MACCE (death/myocardial infarction/stroke) in 16.3%. Any TVR was performed in 20.3%. Independent predictors of MACCE were: older age (p<0.0001), renal insufficiency (p<0.0001), prior myocardial infarction (p<0.0001), diabetes mellitus (p<0.0001), cardiogenic shock (p=0.0002), three-vessel disease (p=0.0012), reduced left ventricular function (p=0.0048), target vessel=bypass graft (p=0.0122), indication for treatment=ACS (p=0.0181) and PCI before implantation (p=0.0308). Independent predictors of TVR were target vessel=coronary bypass (<0.0001), two- or three-vessel disease (p<0.0001), ostial lesions (p<0.0001), total length of SES implanted (p=0.0012) and older age being a protective factor (p=0.0187). Long-term follow-up of the SES in clinical practice showed clinical event rates that were comparable to randomized trials with a MACCE rate of 16.3% and TVR rate of 20.3%.

Synergistic increase risk of death and myocardial infarction at one year in patients with concomitant diabetes mellitus and renal failure

Aims We tested the hypothesis that in patients with acute myocardial infarction (AMI), concomitant diabetes mellitus (DM) and renal failure (RF) increases the short- and long-term risk compared to DM or RF alone. Materials and methods This registry included consecutive patients with AMI treated with percutaneous coronary intervention (PCI) who completed 1-year follow-up. The primary outcome included the rate of all causes of death, AMI, and target vessel revascularization (TVR). Results A total of 858 patients were studied in 4 groups: DM and RF, 112 (13.1%); DM alone, 145 (16.9%); RF alone, 134 (15.6%); and no DM or RF, 467 (54.4%). The DM and RF group had more cardiogenic shock, lower ejection fraction, longer hospital stay, and higher peak troponin (all p < 0.01). After multivariable adjusted analysis, the DM and RF group had higher risk of death (HR 3.35, CI 1.69–6.67; p < 0.01), AMI (HR 2.8; CI 1.15–6.83; p = 0.02), and major adverse cardiac events (HR 1.97, CI 1.23–3.13; p < 0.01) at 1-year follow-up compared to patients with no DM or RF. Conclusion The combination of DM and RF is the strongest independent predictor of death and AMI, but not a predictor of TVR. These findings should be evaluated in large prospective studies.

Coronary Stenting with the Sirolimus‐Eluting Stent in Clinical Practice: Final Results from the Prospective Multicenter German Cypher Stent Registry

Drug-eluting coronary stents (DES) have gained widespread use for the treatment of coronary artery disease. However, because of safety concerns and frequent "off-label" use data from "real life," registries are necessary to monitor indications and outcome of DES in daily clinical practice. We evaluated data from the German Cypher Stent Registry. A total of 10,894 patients treated with at least one sirolimus-eluting stent (SES) at 152 hospitals were included. Follow-up at a median of 6.4 months was available in 10,006 patients (92%). Median age was 64.8 years and 75.5% were male. Per lesion a mean of 1.09 +/- 0.41 SES were implanted with a mean length of 21.1 +/- 11.5mm. During follow-up, death rate was 1.8% and the rates of myocardial infarction or stroke were 2.1% and 0.5%. Any target vessel revascularization (TVR) was performed in 8.0% of patients. Independent predictors for death, myocardial infarction, or stroke were: cardiogenic shock, acute coronary syndromes, reduced left ventricular function, renal insufficiency, diabetes mellitus, advanced age, three-vessel disease, degree of stenosis, and prior myocardial infarction. Predictors for a TVR were: two- or three-vessel disease, target vessel = coronary bypass, advanced age, stent diameter, ostial lesions, indication in-stent restenosis, renal failure, and target vessel = left anterior descended artery. These results demonstrate that SES use in clinical practice is safe and effective. The main predictors of clinical events during follow-up are clinical parameters whereas as predictors of TVR mainly are angiographic parameters.

Abstract 3033: Predictive Factors of Target Vessel Revascularization after Drug-eluting Stent Implantation in the NHLBI Dynamic Registry

Drug-eluting stents (DES) reduce the risk of restenosis, however, the benefit may not be consistent or result in fewer repeat interventions in all patient and lesion subsets. We sought to identify the clinical presentation and predictive factors of target vessel revascularization (TVR) in unselected patients treated with DES. Patients with all lesions treated with a DES in the NHLBI Dynamic Registry were analyzed. Included were 2790 patients with 3532 target lesions. All patients were followed prospectively for at least one-year. Target vessel revascularization was defined as any repeat percutaneous coronary intervention involving the target vessel. Baseline characteristics of patients with and without subsequent TVR were compared and independent predictors of TVR were determined by multivariate analysis. Clinically driven TVR occurred in 131 patients (4.7%) and 170 lesions (4.8%). The indication for first TVR was myocardial infarction (n = 29) 22.1%, unstable angina (n = 79) 60.3%, stable angina (n = 21) 16%, other (n = 2) 1.5%. Among patients with TVR the rate of stent thrombosis at 1 year was (n = 17) 13% and 15 of these patients had TVR within 3 days of ST. Several predictors of TVR were identified (Table ) the strongest being diabetes, prior in-stent restenosis, and attempted graft lesion. Stent type, sirolimus vs. other (adjusted OR 0.96, CI 0.36 –2.57) and paclitaxel vs. other (adjusted OR 0.75, CI 0.27–2.10), was not associated with TVR. Although the rate of TVR is low in patients treated with DES, certain patient and lesion subsets predict a higher risk of TVR. Of concern, unlike historical bare metal stent restenosis, TVR events were mainly related to acute coronary syndromes. These observations highlight the need for new stent technology to prevent restenosis and stent thrombosis and more aggressive medical therapy to prevent ischemic events in high risk patients. Adjusted Odds Ratio Model For Target Vessel Revascularization

Incidence and predictors of target vessel revascularization after sirolimus-eluting stent treatment for proximal left anterior descending artery stenoses among 2274 patients fromthe prospectivemulticenter German Cypher Stent Registry

Involvement of the proximal LAD is considered an indication for coronary artery bypass graft (CABG) surgery due to the high restenosis rates associated with this location after percutaneous coronary interventions (PCI). This seems to be different, however, when using sirolimus-eluting stents, a finding if proven to be true could have a major impact on clinical decision making regarding the optimal revascularization strategy for these patients. We analyzed 2274 patients treated for proximal LAD stenoses using SES from the German Cypher Stent Registry. The incidence of TVR and other major clinical adverse events were determined and independent predictors of TVR were specified using a multiple logistic regression model. Event-free survival was achieved in 89.5% of patients. TVR was performed in 179 patients (7.9%) and the combined incidence of all cause death, myocardial infarction and TVR was 10.5% (231 patients). Independent predictors of TVR were multivessel disease (OR 1.74, 95% CI 1.16-2.62, p = 0.008), stent diameter < or = 2.75 mm (OR 1.61, 95% CI 1.10-2.40, p = 0.02) and the administration of GP IIb/ IIIa antagonists (OR 1.60, 95% CI 1.05-2.60, p = 0.03). TVR rate was as high as 11.2% for 2.5 mm SES and as low as 4.0% for 3.5 mm SES (p < 0.001 for trend test). TVR among patients treated with SES for proximal LAD stenoses is low and is related in part to operator dependent factors. Treatment with SES should be considered as an effective treatment for these patients.

Incidence and Predictors of Target Vessel Revascularization and Clinical Event Rates of the Sirolimus-Eluting Coronary Stent (Results from the Prospective Multicenter German Cypher Stent Registry)

Randomized trials have demonstrated the ability of drug-eluting stents to decrease the risk of restenosis after coronary stent implantation. However, the incidences of major cardiovascular/cerebral adverse events (MACCEs) and target vessel revascularization (TVR) during follow-up in a routine clinical setting remain to be determined. We analyzed data of the multicenter German Cypher Stent Registry. From April 2002 to March 2003, 1,726 patients at 93 hospitals who received >/=1 sirolimus-eluting coronary stent were included. Median follow-up was 6.7 months. During follow-up, death occurred in 1.2% of patients (20 of 1,726), nonfatal myocardial infarction in 2.5% (43 of 1,706), and nonfatal stroke in 0.5% (7 of 1,469). TVR was performed in 8.6% of patients, with percutaneous coronary intervention in 7.3% and coronary artery bypass grafting in 1.5%. The overall rate of MACCEs or TVR was 10.8% (186 of 1,726). Independent predictors of TVR were the target vessel being a bypass graft (odds ratio [OR] 2.43, 95% confidence interval [CI] 1.41 to 4.18, p = 0.001), management of >1 lesion during the same intervention (OR 1.75, 95% CI 1.04 to 2.96, p = 0.035), 2- or 3-vessel disease (OR 1.69, 95% CI 1.05 to 2.72, p = 0.030), and age (per decade; OR 0.82, 95% CI 0.69 to 0.98, p = 0.025). These data confirm the safety and effectiveness of using the sirolimus-eluting stent in daily clinical practice. The management of bypass grafts and multiple lesions in 1 session and the presence of multivessel disease were predictors of MACCEs or TVR.

1081-50 Predictors of target vessel revascularization after stenting coronary bifurcation lesions: Insights from a large prospective single-center database

1081-50 Predictors of target vessel revascularization after stenting coronary bifurcation lesions: Insights from a large prospective single-center database

Incidence and predictors of target vessel revascularization following percutaneous transluminal coronary angioplasty: a report from the national heart, lung, and blood institute percutaneous transluminal coronary angioplasty registry

We sought to determine the rate of target vessel revascularization (TVR) after percutaneous transluminal coronary angioplasty (PTCA) and to determine factors that predispose to its occurrence. The 10-year outcome of 2,262 patients in the National Heart, Lung, and Blood Institute PTCA Registry was analyzed to determine the incidence and characterize predictors of TVR. TVR was performed in 30.4% of patients. Male gender (relative risk [RR] 1.26; p <0.05), diabetes (RR 1.57; p <0.001), multiple discrete lesions (RR 1.38, p <0.01), diffuse lesions (RR 1.27; p <0.05), and calcium at the lesion site (RR 1.25; p <0.05) were predictors for TVR. TVR was performed early (≤1 year) in 18.3% and late (>1 year) in 12.2%. Age ≥65 years (RR 1.24; p <0.05), congestive heart failure (RR 1.70; p <0.05), acute coronary insufficiency (RR 1.28; p <0.05), and left anterior descending lesion location (RR 1.34, p <0.01) were significant predictors of early versus late TVR by multivariate analysis. Coronary artery bypass grafting (CABG) rather than PTCA was the TVR procedure in 21% of patients undergoing early TVR and 58% of those undergoing late TVR. Significant independent predictors of CABG as the TVR procedure were multivessel disease (RR 1.97; p <0.001), presence of collateral vessels (RR 1.81; p <0.05), diffuse (RR 1.89; p <0.01), or occluded (RR 1.82; p <0.05) target lesions, and a greater residual stenosis after the initial PTCA (RR 1.19; p <0.001). Age ≥65 years (RR 0.65; p <0.05) conferred a lower risk for CABG.

Coronary artery stent restenosis responds favorably to repeat interventions

One hundred sixty patients who underwent a percutaneous intervention for treatment of in-stent restenosis were evaluated on clinical follow-up to determine the predictors of reintervention, and also to compare rotational atherectomy with repeat percutaneous transluminal coronary angioplasty (PTCA) for this condition. Current smoking and saphenous vein graft location were the independent predictors of target vessel revascularization (TVR), and there was no difference in the rate of TVR between rotational atherectomy and re-PTCA.