Lesion Length Impacts Long Term Outcomes of Drug-Eluting Stents and Bare Metal Stents Differently

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Abstract

Background

Long lesions have been associated with adverse outcomes in percutaneous coronary interventions with bare metal stents (BMS). However, the exact impact of lesion length on the short- and long-term outcomes of drug-eluting stent (DES) implantations is not as clear.

Methods and Results

This study compared the impact of lesion length on angiographic and clinical outcomes of BMS and DES in a single-center prospective registry. Lesion length was divided into tertiles. The primary endpoints were angiographically defined binary in-stent restenosis (ISR) rate and major adverse cardiac event (MACE). Of the 4,312 de novo lesions in 3,447 consecutive patients in the CAPTAIN registry, 2,791 lesions (of 2,246 patients) received BMS, and the remaining 1,521 lesions (of 1,201 patients) received DES. The mean follow-up duration was 4.5 years. The longer the lesion, the higher the ISR rate (14%, 18%, and 29%, p<0.001) and the lower the MACE-free survivals (p = 0.007) in the BMS group. However, lesion length showed no such correlation with ISR rates (4.7%, 3.3%, and 7.8%, p = 0.67) or MACE-free survivals (p = 0.19) in the DES group.

Conclusions

In our single-center prospective registry, lesion length defined in tertiles has no impact on the short-term (ISR) or long-term (MACE) outcomes of patients implanted with DES. In contrast, longer lesion correlates with higher ISR and MACE rates in BMS group.

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Most cited references 30

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Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery.

Jeffrey W Moses, Martin Leon, Jeffrey J. Popma … (2003)

Preliminary reports of studies involving simple coronary lesions indicate that a sirolimus-eluting stent significantly reduces the risk of restenosis after percutaneous coronary revascularization. We conducted a randomized, double-blind trial comparing a sirolimus-eluting stent with a standard stent in 1058 patients at 53 centers in the United States who had a newly diagnosed lesion in a native coronary artery. The coronary disease in these patients was complex because of the frequent presence of diabetes (in 26 percent of patients), the high percentage of patients with longer lesions (mean, 14.4 mm), and small vessels (mean, 2.80 mm). The primary end point was failure of the target vessel (a composite of death from cardiac causes, myocardial infarction, and repeated percutaneous or surgical revascularization of the target vessel) within 270 days. The rate of failure of the target vessel was reduced from 21.0 percent with a standard stent to 8.6 percent with a sirolimus-eluting stent (P<0.001)--a reduction that was driven largely by a decrease in the frequency of the need for revascularization of the target lesion (16.6 percent in the standard-stent group vs. 4.1 percent in the sirolimus-stent group, P<0.001). The frequency of neointimal hyperplasia within the stent was also decreased in the group that received sirolimus-eluting stents, as assessed by both angiography and intravascular ultrasonography. Subgroup analyses revealed a reduction in the rates of angiographic restenosis and target-lesion revascularization in all subgroups examined. In this randomized clinical trial involving patients with complex coronary lesions, the use of a sirolimus-eluting stent had a consistent treatment effect, reducing the rates of restenosis and associated clinical events in all subgroups analyzed. Copyright 2003 Massachusetts Medical Society

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In-stent restenosis in the drug-eluting stent era.

Roxana Mehran, E. Sanidas, George Dangas … (2010)

The introduction of the drug-eluting stent (DES) proved to be an important step forward in reducing rates of restenosis and target lesion revascularization after percutaneous coronary intervention. However, the rapid implementation of DES in standard practice and expansion of the indications for percutaneous coronary intervention to high-risk patients and complex lesions also introduced a new problem: DES in-stent restenosis (ISR), which occurs in 3% to 20% of patients, depending on patient and lesion characteristics and DES type. The clinical presentation of DES ISR is usually recurrent angina, but some patients present with acute coronary syndrome. Mechanisms of DES ISR can be biological, mechanical, and technical, and its pattern is predominantly focal. Intravascular imaging can assist in defining the mechanism and selecting treatment modalities. Based upon the current available evidence, an algorithm for the treatment approaches to DES restenosis is proposed. Copyright © 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

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Angiographic Patterns of In-Stent Restenosis : Classification and Implications for Long-Term Outcome

Roxana Mehran, George Dangas, Andrea S Abizaid … (1999)

Background —The angiographic presentation of in-stent restenosis (ISR) may convey prognostic information on subsequent target vessel revascularizations (TLR). Methods and Results —We developed an angiographic classification of ISR according to the geographic distribution of intimal hyperplasia in reference to the implanted stent. Pattern I includes focal (≤10 mm in length) lesions, pattern II is ISR>10 mm within the stent, pattern III includes ISR>10 mm extending outside the stent, and pattern IV is totally occluded ISR. We classified a total of 288 ISR lesions in 245 patients and verified the angiographic accuracy of the classification by intravascular ultrasound. Pattern I was found in 42% of patients, pattern II in 21%, pattern III in 30%, and pattern IV in 7%. Previously recurrent ISR was more frequent with increasing grades of classification (9%, 20%, 34%, and 50% for classes I to IV, respectively; P =0.0001), as was diabetes (28%, 32%, 39%, and 48% in classes I to IV, respectively; P <0.01). Angioplasty and stenting were used predominantly in classes I and II, whereas classes III and IV were treated with atheroablation. Final diameter stenosis ranged between 21% and 28% ( P =NS among ISR patterns). TLR increased with increasing ISR class; it was 19%, 35%, 50%, and 83% in classes I to IV, respectively ( P <0.001). Multivariate analysis showed that diabetes (odds ratio, 2.8), previously recurrent ISR (odds ratio, 2.7), and ISR class (odds ratio, 1.7) were independent predictors of TLR. Conclusions —The introduced angiographic classification is prognostically important, and it may be used for appropriate and early patient triage for clinical and investigational purposes.

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Author and article information

Contributors

Giuseppe Biondi-Zoccai: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Electronic): 1932-6203

Publication date Collection: 2013

Publication date (Electronic): 11 January 2013

Volume: 8

Issue: 1

Electronic Location Identifier: e53207

Affiliations

[1]Second Section of Cardiology and Percutaneous Coronary Intervention Center Department of Medicine, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan

Sapienza University of Rome, Italy

Author notes

* E-mail: hsiehic@ 123456ms28.hinet.net

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: SHC ICH. Performed the experiments: CCC MJH CYW CHL. Analyzed the data: SHC. Contributed reagents/materials/analysis tools: CCC MJH CYW CHL. Wrote the paper: SHC ICH.

Article

Publisher ID: PONE-D-12-26366

DOI: 10.1371/journal.pone.0053207

PMC ID: 3543456

PubMed ID: 23326399

SO-VID: 99b39457-b966-4bf1-926c-0b0397e1670e

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 31 August 2012

Date accepted : 27 November 2012

Page count

Pages: 7

Funding

Shang-Hung Chang was supported by a grant from Chang Gung Memorial Hospital (CMRPG350214). I-Chang Hsieh was supported by a grant from the Taiwan National Science Council (98-2314-B-182-060). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Lesion Length Impacts Long Term Outcomes of Drug-Eluting Stents and Bare Metal Stents Differently

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Abstract

Background

Methods and Results

Conclusions

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PLOS Climate

Most cited references 30

Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery.

In-stent restenosis in the drug-eluting stent era.

Angiographic Patterns of In-Stent Restenosis : Classification and Implications for Long-Term Outcome

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