Percutaneous Coronary Intervention In Small Vessels Research Articles

Incidence and Predictors of Target Lesion Failure in Patients With Lesions in Small Vessels Undergoing PCI With Contemporary Drug-Eluting Stents: Insights From the BIONICS Study

Treatment of lesions in small coronary vessels is associated with an increased risk of adverse cardiovascular events after percutaneous coronary intervention (PCI).We aimed to evaluate the outcomes of patients undergoing small-vessel PCI in the BIONICS trial and to identify predictors of stent failure. 1910 patients were randomized to treatment with the EluNIR™ ridaforolimus-eluting stent (RES) or Resolute™ zotarolimus-eluting stent (ZES). Small vessels were defined as reference vessel diameters (RVD) ≤2.5 mm. A Cox proportional hazards model was used to identify predictors of target lesion failure (TLF) through 2 years. Patients undergoing small vessel disease PCI had a higher frequency of diabetes, prior myocardial infarction (MI), and prior PCI. 2 year TLF was higher among patients with small vessels (9.7% vs. 5.9%, HR 1.7 [95% CI 1.22–2.37], p < 0.01), driven by increased rates of target vessel-MI and target lesion revascularization (TLR). Stent thrombosis at 2 years was higher among patients with small vessel disease (1.4% vs. 0.3%, HR 5.25 [95% CI 1.47–18.8], p < 0.01). 2 year TLF rates were similar in the RES and ZES patient groups (Pinteraction 0.86). In conclusion, patients undergoing PCI in small vessels have significantly worse outcomes despite the use of contemporary stents.

Results of PCI with Drug-Eluting Stents in an All-Comer Population Depending on Vessel Diameter.

Long-term outcome after percutaneous coronary intervention (PCI) depends on vessel diameter; however, there is insufficient evidence on particular drug-eluting stent (DES) types in this setting. The aim of the study was to assess long-term performance of PCI depending on stented vessel size and DES generations. This observational study from a prospective Registry of PCI with DES assessed safety (stent thrombosis) and efficacy (major adverse cardiac and cerebrovascular event (MACCE)) of the implantation of first- (DES1) or second-generation DESs (DES2) in small and large vessels. Of 699 patients included in the analysis, 337 (48%) patients underwent PCI in small vessels. PCI in small vessels, especially the left anterior descending artery (LAD) (hazard ratio (HR) 2.6, 95% confidence interval (CI) 1.5–4.5), was associated with a higher rate of MACCEs than that in large vessels (20% vs. 14%, p = 0.025) with no difference in the rate of stent thrombosis (ST). No significant difference in safety and efficacy was found between DES1 and DES2 in small vessels. For large vessels, a higher incidence of MACCEs (21% vs. 9.2%, p = 0.002) driven by a higher rate of re-PCI (15% vs. 6%, p = 0.006) and a higher rate of cumulative stent thrombosis (3.5% vs. 0.5%, p = 0.04) was shown for DES1 than DES2. In multivariate analysis, DES1 was a significant risk factor for MACCEs in large, but not in small vessels. The risk of PCI in small vessels, especially LAD, remains high independent of the type of DES. In contrast, DES2 as a modifiable variable during PCI of a large lesion might improve long-term prognosis.

Serial Angiography and Intravascular Ultrasound: Results of the SISC Registry (Stents In Small Coronaries)

The aim of this study was to evaluate the novel CardioMind Sparrow (CMS) stent (CardioMind, Inc., Sunnyvale, California) against the Multi-Link Pixel (MLP) stent (Guidant Corp., Santa Clara, California) for small vessel percutaneous coronary intervention (PCI). The CMS consists of a guidewire-based, self-expandable, ultra-thin nitinol stent with smaller profile and improved flexibility and deliverability. The performance of this novel device against a standard balloon-expandable stent for small vessel PCI has not been determined. Twenty-one patients were treated with the CMS and compared with 30 patients treated with MLP. Only single de novo lesions <14 mm in length, in native vessels of 2.0 to 2.5 mm were included. The primary goal was the comparison of quantitative coronary angiography lumen loss and intravascular ultrasound intimal hyperplasia (IH) formation between groups at 6 months. Clinical characteristics were similar between groups. The CMS cohort had smaller vessels (2.20 +/- 0.20 mm vs. 2.43 +/- 0.16 mm, p < 0.0001) and shorter lesions (10.86 +/- 3.19 mm vs. 13.12 +/- 2.79 mm, p = 0.0091). Six-month late loss was significantly lower among CMS cohort (0.73 +/- 0.57 mm vs. 1.11 +/- 0.72 mm, p = 0.038). By intravascular ultrasound, 6-month IH volume was similar between groups (1.45 +/- 0.46 mm(3)/mm vs. 1.65 +/- 1.02 mm(3)/mm, p = 0.50). However, CMS presented a mean 13.39% expansion of its volumes, resulting in a significantly lower percentage of IH volumetric obstruction (31.94 +/- 8.19% vs. 39.90 +/- 4.72%, p = 0.0005). Despite producing similar amounts of IH volume, the self-expanding CMS stent presented chronic expansion of its volumes, better accommodating the neoformed tissue and resulting in significantly lower late loss and percent of IH volumetric obstruction in comparison with the MLP stent.

Clinical and Angiographic Features of Small Vessel Stenting in the Drug‐Eluting Stent Era

This study was designed to investigate the clinical and angiographic features and procedural outcomes of small-vessel stenting in a real-world experience during the transition era between drug-eluting stents (DES) and bare-metal stents (BMS). Using one of the largest single-institutional cohorts, this study evaluated all patients who underwent percutaneous coronary intervention (PCI) from 2002 through 2005. Analysis was restricted to patients receiving a single stent or undergoing balloon-only angioplasty in a single anatomic site. Small-vessel stents (SVS) were defined as 2.00 to 2.75 mm and large-vessel stents (LVS) as 3.00 to 4.00 mm in diameter. A total of 19,580 stents were placed in 10,396 patients. Of 6208 patients fulfilling inclusion criteria, 1630 (26.3%) received SVS, and 4578 (73.7%) received LVS. The SVS group had more female (35.5% vs 26.3%, P < .001) and diabetic patients (27.9% vs 24.2%, P < .003) than the LVS group. Compared with LVS, SVS lesions were shorter (14.5 +/- 5.8 mm vs 15.7 +/- 6.4 mm, P < .0001) and more complex (66% vs 53% class B2/C lesions, P = .041). Indicators of procedural difficulty, including greater contrast volume, number of devices, total inflation time, and fluoroscopy time, were more commonly observed in the SVS group. After adjustment for confounding factors, the incidence of small treatment vessel diameter was significantly higher among the DES vs the BMS group (odds ratio [OR]: = 1.94, 95% confidence interval [CI]: 1.56-2.36). In addition to identifying distinct patient, lesion, and procedural performance characteristics, our study, one of the largest single-center experiences in small-vessel PCI, suggests that the availability of DES substantially increased the use of SVS, as opposed to balloon-only angioplasty, in this anatomically challenging setting.

Time dependent vascular and myocardial responses of a second generation, small vessel, paclitaxel‐eluting stent platform

The purpose of this study was to evaluate the time-dependent vascular and myocardial responses to a second-generation, small vessel (< or =2.5 mm) paclitaxel-eluting stent (PES) platform. Small caliber coronary vessels present complex challenges for percutaneous coronary intervention (PCI) and are associated with lower technical success and inferior long-term efficacy. A next-generation, highly deliverable PES may improve clinical outcomes in small vessels. Sixty single stents were implanted in noninjured coronary arteries in 30 domestic swine (one TAXUS Liberté small vessel PES (svPES) and one Liberté small vessel bare metal stent (svBMS) in each animal). Ten animals each were allocated to 30-, 90-, and 180-day follow-up groups; final quantitative angiography and necropsy were performed. Samples of myocardium, liver, and kidney were processed and evaluated for pathology. Radiography and either histopathology or scanning electron microscopy were performed on all the explanted stented vessels. There were no stent-related deaths or downstream myocardial pathology. Both the svPES stent and its svBMS control demonstrated complete strut tissue coverage and complete endothelialization at all timepoints, and there was no evidence of macro- or microscopic thrombus or stent fracture. Medial smooth muscle cell content was markedly reduced in all the svPES groups compared with that in the svBMS controls. The small diameter paclitaxel-eluting TAXUS Liberté stent has a safe and predictable biologic vascular response in the noninjured swine model. This device warrants further investigation targeting the currently poorly met clinical need for small vessel PCI.